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A  TREATISE 


THE  DISEASES 


INFANCY  AND  CHILDHOOD. 


J.   LEWIS   SMITH,  M.D., 


CLINICAL    PROFESSOR  OF  DISEASES    OF    CHILDREN,   BELLEVUE    HOSPITAL    MEDICAL    COLLEGE ;    PHYSI- 
CIAK  TO  CHARITY   HOSPITAL ;   PHYSICIAN  TO  THE  N.   Y.    FOUNDLING  ASYLUM  ;   PHYSICIAN  TO  THE 
N.  Y.    INFANT   ASVLUM;    CONSULTING    PHYSICIAN  TO  THE    DEPARTMENT   OF  CHILDREN'S  DIS- 
EASES,  BUREAU  FOR    THE    RELIEF  OF  THE  OUT-DOOR    POOR,   BELLEVUE;    CONSULTING 
PHYSICIAN  TO  THE  NURSERY  AND  CHILD'S  HOSPITAL,  COUNTRY  BRANCH;  CON- 
SULTING PHYSICIAN  TO  THE  INFANT'S  HOSPITAL,   RANDALL'S    ISLAND. 


SEVENTH   EDITION,  THOROUGHLY   REVISED. 


WITH    FIFTY-ONE   ILLUSTRATIONS. 


PHILADELPHIA: 

LEA   BROTHEHS   &  CO, 

^^AfAND  HAWKINS, 
194  Canal  Street 


5GW(p*?4-T 


Entered  according  to  Act  of  Congress,  in  the  year  1890,  by 

LEA    BROTHERS    &    CO., 

in  the  Office  of  the  Librarian  of  Congress  at  Washington.     All  rights  reserved. 


Westcott  &  Thomson, 
Slereolijpers  and  Electrotypers,  Philada. 


William  J.  Dornan, 
Printer,  Philada. 


PREFACE 


Since  the  issue  of  the  Sixth  Edition  of  this  treatise  in  1886  so  many  ad- 
ditional facts  have  come  to  light  relating  to  the  etiology,  nature,  and  treat- 
ment of  the  diseases  of  children  that  the  necessary  revision  has  produced 
virtually  a  new  book.  In  the  amount  of  information  presented,  the  work 
may  properly  be  considered  to  have  doubled  in  size,  but  this  real  growth 
has  been  accommodated  without  rendering  the  volume  inconveniently  large. 
The  author  has  been  careful  in  rewriting  to  exclude  all  obsolete  material, 
and  to  condense  the  text  to  the  limits  of  clearness.  Among  the  diseases 
treated  of  in  this  and  not  in  the  former  editions  we  may  mention  Conjunc- 
tivitis, Icterus,  Sepsis,  Umbilical  Diseases,  Hgematemesis,  Melaena,  Sclerema, 
Gidenia,  and  Pemphigus  of  the  new-born  ;  Epilepsy,  Tetany,  Appendicitis, 
Typhlitis,  and  Perityphlitis.  The  paper  on  Intubation,  by  Dr.  Joseph 
O'Dwyer,  will  be  found  interesting  and  instructive  to  those  who  perform 
this  operation,  as  well  as  to  those  who  wish  to  learn  how  to  do  it. 

In  order  to  make  the  book  in  the  highest  degree  useful  to  the  practitioner 
prevalent  and  fatal  diseases  have  been  described  at  considerable  length,  and 
special  attention  has  been  bestowed  upon  the  treatment.  Modes  of  treatment 
employed  by  physicians  of  world-wide  reputation  are  in  many  instances 
related,  and  cases  are  detailed  showing  the  effects  of  remedies.  Recent 
investigations  and  discoveries  relating  to  the  bacterial  origin  of  the  local  as 
well  as  constitutional  diseases  of  early  life  have  necessitated  many  changes 
in  the  text,  and  it  is  believed  that  all  the  important  facts  relating  to  the  dis- 
eases treated  of,  brought  to  light  by  recent  researches,  are  set  forth  in  the 

proper  chapters. 

J.  L.  S. 
New  York,  September,  1890. 


LIST   OF    ILLUSTRATIONS. 


FIG.  PAGE 

1.  Congenital  Deformity 38 

2.  Milk-Globules 48 

3.  Colostrum-Corpuscles 48 

4.  Protuberant  Abdomen  in  Rachitis 93 

5.  Acrania 97 

6.  Meningocele 99 

7.  Spina  Bitida 101 

8.  Epitlieliuni  covered  by  Spores  of  Oi'dium  Albicans 147 

9.  Spores  and  Branches  of  the  Oi'dium  Albicans 147 

10.  Skeleton  of  Congenital  Rachitis 181 

11.  Head  of  the  Rachitic  Child 192 

12.  Rachitic  Spinal  Curvature 193 

13.  Rachitic  Deformities 194 

14.  Rachitic  Deforniity  of  Chest 195 

10.  ■, 

16.  j- Pelvic  Deformities 196 

17.J 

V  Rachitic  Deformity  of  Femur 196 

19.  J 


20.1 


Deformities  of  Femur,  Tibia,  Fibula 197 

22.  Scrofulous  Dactylitis 209 

23.  Case  of  Strumous  Inflammation  of  the  Joints 216 

24.  Bronchial  Phthisis 229 

25.  Bacillus  Tuberculosis 239 

26.  Syphilitic  Dactylitis 258 

27.  Syphilitic  Teeth " 259 

28.  Partial  Collapse  of  Lung  from  Pertussis 438 

29.  Bacillus  Typhosus 457 

30.  Cerebro-Spinal  Fever 483 

31.  Rheumatic  Subcutaneous  Nodules 508 

32.  Section  of  Rheumatic  Nodule  Magnified 508 

33.  Chronic  Rheumatism 509 


vi  LIST  OF  ILLUSTRATIONS. 

FIG.  P^GE 

34.  Congenital  Hydrocephalus >        543 

35.  Congenital  Hydrocephalus 545 

36.  Acquired  Hydrocephalus 550 

37.  Tetany 559 

38.  Tetany 602 

39.  Facial  Paralysis • 630 

40.  Pseudo-Hypertrophic  Paralysis 632 

41.  Intubation  Instruments 669 

42.  Catarrhal  or  Lobular  Pneumonia 692 

43.  Catarrhal  or  Lobular  Pneumonia  of  a  More  Severe  Grade 693 

44.  Croupous  Pneumonia 695 

45.  Septic  or  Embolisraal  Pneumonia 696 

46.  Gangrene  of  the  Mouth 746 

47.  Intussusception      841 


48. 
49. 
50. 
51. 


Acarus  Scabiei 890 


CONTENTS. 


PAET  I. 

CHAPTER  I. 

PAGE 

Infancy  and  Childhood 33 

CHAPTER   n. 
Care  of  the  Mother  in  Pregnancy 35 

CHAPTER  III. 

Mortality  of  Early  Life:   Its  Causes  and  Prevention 39 

CHAPTER  IV. 

Weight,  Growth,  Lactation 43 

Wet-Nursing :  its  Advantages  and  Hindrances ;  Physical  Conditions  rendering  it 
Improper — Colostrum — Human  Milk — Modification  of  Milk  in  Consequence 
of  the  Diet — Modification  of  Milk  from  its  Retention  in  the  Breast — Modifica- 
tion of  Milk  by  Age  and  by  Mental  Impressions — Modification  of  Milk  by  the 
Catamenial  Fiuiction,  Pregnancy,  and  Other  Causes — Effect  of  Medicines  on 
tlie  Mother's  Milk — Differences  in  Women  as  regards  Quantity  and  Quality  of 
Milk — Rules  in  regard  to  Suckling — Scantiness  of  Milk  :  its  Causes  and  Treat- 
ment. 

CHAPTER  V. 

Selection  of  a  Wet-Nurse 59 

CHAPTER  VI. 

Course  of  Wet-Xursing — Weaning 62 

CHAPTER  VII. 
Quantity  of  Food  Required  in  Infancy  and  Childhood 64 

CHAPTER   VIIL 

Artificial  Feeding 72 

vii 


viii  CONTENTS. 


CHAPTER   IX, 

PAGE 

Bathing,  Clothing,  Sleep,  Exercise 80 


CHAPTER  X. 

Diagnosis  of  Infantile  Diseases 85 

General  Observations — Features,  External  Appearance  of  the  Head,  Trunk,  and 
Limbs  in  Disease— Attitude— Movements — The  Voice— Respiratory  System — 
Circulatory  System — Animal  Heat — Digestive  System — Nervous  System. 

CHAPTER   XI. 
Therapeutics ...      95 


PAET  II. 

DISEASES  OF  THE  NEW-BORN. 

CHAPTER  I. 

Malformations 97 

Acrania — Incomplete  Brain — Meningocele,  Encephalocele,  Hydrencephalocele 
— Spina  Bifida — Congenital  Abnormalities  in  the  Circulatory  System — Mal- 
formations of  the  Heart — Cyanosis — Caput  Succedaneum — Cephalfematoma. 

CHAPTER  II. 

Diseases  of  the  New-born 118 

Inflammation  of  the  Sterno-Cleido-Mastoid  Muscle— Mammary  Glands— Mas- 
titis— Conj  unctivitis — Umbilical  Vegetations — Umbilical  Hemorrhage. 

CHAPTER  III. 

Diseases  of  the  New-born  {Continued) 132 

Icterus  Neonatorum — Sepsis  of  the  New-born — Thrush. 

CHAPTER   IV. 

H^matemesis  and  MeljENA  Neonatorum 150 

Diarrhoea  of  the  New-born — Constipation  of  the  New-born. 

CHAPTER  V. 

Tetanus  Neonatorum 159 

Sclerema  Neonatorum— (Edema  Neonatorum — Pemphigus  Neonatorum. 


CONTENTS.  IX 


PART   111. 

CONSTITUTIONAL  DISEASES. 

SECTION    I. 
DIATHETIC   DISEASES. 
CHAPTER   I. 
Eachitis 


PAGE 

179 


CHAPTER  II. 
Scrofula 205 

CHAPTER  III. 
Tuberculosis 221 

CHAPTER  IV. 
Syphilis 251 

SECTION    II. 

ERUPTIVE  FEVERS. 

CHAPTER  I. 

Measles 263 

CHAPTER  II. 
Scarlet  Fever 2*1 

CHAPTER  III. 

ROTHELN 228 

CHAPTER   IV. 
Variola — Varioloid ^^^ 

CHAPTER  V. 
Vaccinia ^^^ 

CHAPTER   VI. 
Varicet,la 2^2 


X  CONTENTS. 


CHAPTER  VII. 

PAGE 

Diphtheria 356 


CHAPTEE  VIII. 
Pertussis 431 

CHAPTEE  IX. 
Mumps 445 

SECTION    III. 

OTHER  GENERAL  DISEASES. 

CHAPTEE  I. 

Intermittent  Fever 449 

CHAPTER  II. 
Eemittent  Fever  .   .   .' 454 

CHAPTEE  III. 
Typhoid  Fever 456 

CHAPTEE  IV. 
Cerebro-Spinal  Fever 470 

CHAPTEE  V. 
Acute  Eheumatism 503 

CHAPTEE  VI. 
Erysipelas 512 


PAET  IT. 

SECTION    I. 

DISEASES  OF  THE  CEEEBRO-SPINAL   SYSTEM. 

CHAPTER  I. 

MicROCEPHALUs— Atrophy  of  Brain 522: 


CONTENTS.  xi 


CHAPTER   II. 

PAGE 

Hypertrophy  of  Brain 523 


CHAPTER  III. 
Thrombosis  in  the  Cranial  Sinuses  (Phlebitis) 527 

CHAPTER  IV. 
Congestion  of  the  Brain 531 

CHAPTER  V. 

Intracranial  Hemorrhage  (Meningeal  Hemorrhage,  Cerebral  Hem- 
orrhage)   534 

CHAPTER   VI. 
Congenital  Hydrocephalus 542 

CHAPTER  VII. 

Acquired  Hydrocephalus 548 

CHAPTER  VIII. 
Meningitis  (Tubercular  and  Non-Tubercular) 551 

CHAPTER   IX. 
Spurious  Hydrocephalus 566 

CHAPTER  X. 
Eclampsia 570 

CHAPTER    XI. 
Epilepsy 578 

CHAPTER  XTI. 

Internal  Convulsions  (Spasm  of  the  Glottis;  Laryngismus  Stridulus)    590 

CHAPTER   XIII. 
Tetany 597 

CHAPTER   XIV. 
Chorea 608 


xii  CONTENTS. 


CHAPTER  XV. 

PAGE 

Paralysis 621 


CHAPTEE  XVI. 
Poliomyelitis  Acuta  Anterior 624 

CHAPTER  XVII. 
Facial  Paralysis , 630 

CHAPTER  XVIII. 
Psei-do-Hypertrophic  Paralysis 631 

CHAPTER   XIX. 

Diseases  of  the  Spinal  Cord  and  its  Coverings 634 

CHAPTER  XX. 

Congestion  of  the  Spinal  Cord  and  its  Membrane 635 

CHAPTER    XXI. 

Vertebral  Caries 637 


SECTION   II. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

CHAPTER  I. 
CORYZA 641 

CHAPTER   II. 

Laryngitis •    •    644 

Catarrhal  Laryngitis — Spasmodic  Laryngitis. 

CHAPTER   III. 

MEMBRANOrS  CrOUP   (DIPHTHERITIC   CrOUP  ;    TrUE  CrOUP) 650 

CHAPTER  IV. 

Intubation 667 

Tracheotomy. 

CHAPTER  V. 
Bronchitis 677 


CONTENTS.  xiii 


CHAPTER    VI. 

PAOE 

Atelectasis 687 

CHAPTER   VII. 

Pneumonia 690 

Catarrhal  Pneumonia — Croupous  Pneumonia — Septic  or  Embolismal  Pneumonia 
— Cheesy  Pneumonia. 

CHAPTER   VIII. 
Pleurisy 704 

CHAPTER  IX. 
Nervous  Cough 737 


SECTION   III. 

DISEASES  OF  THE  DIGESTIVE  APPAEATUS. 

CHAPTER  I. 

Simple  Stomatitis,  Ulcerous  Stomatitis,  Follicular  Stomatitis    ....    739 
Simple  or  Catarrhal  Stomatitis — Ulcerous  Stomatitis — Aphthous  Stomatitis. 

CHAPTER  II. 
Gangrene  of  the  Mouth 744 

CHAPTER  III. 

Dentition 750 

Second  Dentition. 

CHAPTER  IV. 

Catarrhal  Pharyngitis,  Peripharyngeal  Abscess,  CEsophagitis   ....    756 

CHAPTER  V. 

Indigestion,  Congestion  of  Stomach,  Gastritis,  Follicular  Gastritis, 

Diphtheritic  Gastritis,  Gastro-Malacia 765 

CHAPTER  VI. 
Gastro-Intestinal  Bacteria 77& 

CHAPTER  VII. 
Simple  Diarrhcea 781 

CHAPTER  VIII. 

Intestinal  Catarrh  of  Infancy  (Entero-Colitis) 785 

Cholera  Infantum,  or  Choleriform  Diarrhoea. 


xiv  CONTENTS. 


CHAPTEE  IX. 

PAGE 

Enteritis  and  Colitis  in  Childhood 808 


CHAPTEE  X. 
Constipation 811 

CHAPTEE  XI. 
Intestinal  Worms 822 

CHAPTEE  XII. 
Intussusception 837 

CHAPTEE  XIII. 
Appendicitis,  Typhlitis,  Perityphlitis 856 

SECTION    IV. 

DISEASES  OF  THE  GENITO-URINAEY  OEGANS. 

Uric-Acid  Infarctions — Enuresis— Calculi;  Dysuria;  Cryptorchia — Vulvitis  .    .    .    866 

SECTION   V. 
SKIN  DISEASES. 

CHAPTEE   I. 

Erythematous  Diseases 877 

Erythema — Eoseola — Urticaria. 

CHAPTEE  II. 

Papular  Diseases 882 

Strophulus, 

CHAPTEE  in. 
Eczema 883 

Scabies. 


THE 


DISEASES  OF  CHILDREN. 


PART  I 


CHAPTER     I. 
INFANCY  AND  CHILDHOOD. 

Infancy  and  childhood  are,  in  certain  respects,  the  most  important  and 
interesting  periods  of  life.  To  the  physiologist  they  are  especially  interest- 
ing, because  they  are  the  periods  of  development  and  of  greatest  functional 
activity  ;  to  the  pathologist,  because  in  them  many  diseases  occur  which  are 
rarely  or  never  observed  in  the  other  periods,  or  which  present  in  these  periods 
peculiar  features  ;  to  the  physician  and  vital  statistician,  because  in  them 
there  are  the  greatest  amount  of  sickness  and  largest  number  of  deaths. 

Infancy  extends  from  birth  to  the  age  of  two  and  a  half  years,  or 
till  the  completion  of  first  dentition.  In  infancy  the  organs  are  delicately 
organized,  containing  a  large  proportion  of  water,  and  hence  are  easily 
injured.  In  this  period  the  brain  is  rapidly  developed — more  so  than  any 
other  organ ;  animal  matter  pi'edominates  in  the  bones  ;  the  arteries  are  rel- 
atively large,  the  muscles  small ;  the  superficial  veins  are  small.  Fat  is 
absent  from  the  inteinor  of  the  body,  but  abundant,  in  well-nourished  infants, 
underneath  the  integument.  The  skin  is  delicate,  and  its  temperature  not 
much  below  that  of  the  blood.  At  birth  it  has  a  reddish  hue  and  is  covered 
with  soft,  fine  hairs  (lanugo).  The  reddish  hue  gradually  fades  into  the 
healthy  tint  of  infancy,  and  the  hairs  fall  out.  In  the  first  two  months  the 
sweat-glands  have  little  functional  activity,  sensible  perspiration  being  quite 
rare.  Subsequently,  perspiration  is  freer,  and  in  certain  diseased  states 
(rachitis,  etc.)  is  abundant.  The  sebaceous  glands  in  the  first  half  of  infancy 
are  active,  particularly  upon  the  scalp,  producing  often  a  pale-yellow  incrusta- 
tion con.?isting  of  sebaceous  matter  and  epidermic  cells. 

The  secretions  from  the  mucous  surfaces  commence  at  an  early  period. 
At  birth  the  surface  of  the  digestive  tube  is  covered  with  more  or  less 
mucus,  often  in  considerable  quantity.  The  meconium  is  not  considered, 
as  formerly,  to  be  a  product  of  intestinal  secretion.  It  consists  of  flat 
epithelial  cells,  fine  hairs,  oil-globules,  crystals  of  cholesterin,  and  brownish 
or  yellowish  masses  of  coloring  matter,  probably  from  the  liver.  It  is  sup- 
3  33 


34  INFANCY  AND   CHILDHOOD. 

posed  that,   witli   the   exception   of  the   coloring  matter,   the   meconium   is 
derived  mainly  from  the  amniotic  fluid  which  the  foetus  has  swallowed. 

The  most  wonderful  change  occurring  in  the  system  at  birth,  through 
the  exigencies  of  the  new  life,  is  that  in  the  circulation.  The  flow  of  blood 
being  interrupted,  thrombi  form  in  the  umbilical  vein  and  arteries  and  in 
the  ductus  arteriosus  and  ductus  venosus,  and  these  vessels  gradually  atrophy, 
becoming  finally  shrivelled  but  permanent  cords.  I  have  many  times  at 
autopsies  removed  the  plug  from  the  ductus  arteriosus  when  death  had 
occurred  as  late  as  the  third  week.  The  foramen  ovale  closes  slowly.  I 
have  ordinarily  found  it  open  till  near  the  end  of  the  first  half  year,  but 
the  valve  covers  fully  the  aperture,  so  that  there  is  no  detriment  to  the 
circulation.  Both  the  pulse  and  respiration  are  more  frequent  during 
infancy  than  childhood,  and  are  more  accelerated  by  moral  and  physical 
causes. 

The  stomach  has  a  smaller  relative  size  and  emesis  is  more  readily  caused 
than  in  the  adult.  The  liver  is  large,  occupying  at  birth  nearly  half  of  the 
abdominal  cavity,  but  it  grows  smaller  in  successive  months.  The  appetite 
is  good  and  digestion  active,  so  that  hunger,  when  appeased,  soon  returns. 
The  thymus  gland,  at  birth  about  the  size  of  an  unexpanded  lung,  slowly 
atrophies,  but  it  does  not  totally  disappear  till  after  infancy. 

The  kidneys,  distinctly  lobulated  at  birth,  gradually  change  their  form, 
so  as  to  present  in  the  last  part  of  infancy  nearly  the  shape  of  the  organ  in 
the  adult.  The  renal  secretion  commences  early,  even  before  birth.  The 
kidneys  seldom  undergo  degenerative  changes  as  in  the  adult,  but  they  are 
liable  to  congestions  and  inflammations.  During  the  first  month,  and  espe- 
cially the  first  fortnight,  crystals  of  uric  acid  and  the  urates  are  often  found 
in  the  urine  in  a  state  of  apparent  health,  causing  more  or  less  fretfulness  in 
their  elimination,  staining  the  diaper,  and  not  infrequently  being  arrested  in 
the  tubules  of  the  pyramids,  where  they  can  be  seen  as  pink-colored  spots  or 
lines  (uric-acid  infarction).  These  deposits  of  uric  acid  and  the  urates  may 
even  occur  in  the  foetus,  producing  obstruction  and  inflammation  of  the  renal 
tubes.  Congenital  cystic  degeneration  of  the  kidneys  is,  in  the  opinion  of 
Virchow,  due  to  them.  In  early  infancy  the  senses  are  imperfectly  devel- 
oped, the  eyes  being  attracted  only  by  bright  objects  and  the  sense  of  hear- 
ing afi"ected  only  by  loud  noises.  Sleep  is  the  normal  state  in  the  first  weeks 
of  life :  as  the  age  of  the  infant  increases,  less  and  less  sleep  is  required  ; 
but  the  oldest  infants  need  more  than  children  and  several  hours  more  than 
adults. 

The  new-born  infant  is  apparently  destitute  of  mental  faculties.  It  seeks 
the  breast  by  instinct,  and  it  exhibits  no  perception  or  reflection.  The  loud 
cries  with  which  it  commences  its  existence  are  not  from  anger  or  sufi"ering ; 
they  appear  to  be  normal,  like  the  act  of  nursing,  and  providentially  designed 
in  order  to  expand  the  lungs.  It  is  not  till  the  close  or  near  the  close  of  the 
first  month  that  the  gray  substance  of  the  brain  begins  to  appear — the  prob- 
able seat  of  the  mind  and  the  source  of  all  mental  phenomena.  Perception 
and  curiosity  are  early  manifested.  The  infant,  as  Edmund  Burke  has 
remarked,  is  constantly  seeking  new  objects  for  its  amusement,  rejecting  old 
playthings  for  such  as  possess  more  novelty.  Reflection,  a  higher  faculty 
of  the  mind,  appears  at  a  later  period.  The  mind  and  the  bodily  organs  in 
infancy  are,  in  a  high  degree,  impressionable.  Anger  is  excited  by  trivial 
causes,  but  is  easily  appeased,  and  the  various  functions  in  the  system  are 
disturbed  by  agencies  which  in  youth  or  manhood  would  have  no  appreciable 
eff"ect. 

Childhood  extends  from  infancy  to  the  age  of  fifteen  years  or  puberty. 
It  is  a  period  of  great  physical  activity  and  of  rapid  growth.     The  functions 


THE  MOTHER  IN  PREGNANCY.  35 

of  the  various  organs  are  performed  with  more  moderation  than  in  infancy, 
and  are  less  iVeijuently  deranged.  The  volume  of  the  brain  continues  to 
increase  rapidly,  and  it  becomes  tirmer  tluin  in  infancy.  It  is  estimated  that 
by  the  seventh  year  the  weight  of  this  organ  has  doubled.  The  mind  now 
exerts  a  controlling  influence  over  the  actions  of  the  individual.  The 
digestive  organs  have  changed,  so  that  solid  food  is  required.  Most  of  the 
glandular  organs  are  less  active  than  in  the  greater  part  of  infancy,  and 
some  of  them,  as  the  liver,  are  relatively  smaller.  The  pulse  and  respiration 
gradually  become  less  frequent  as  the  child  advances  in  age. 


CHAPTER    II. 

CARE  OF  THE  MOTHER  IN  PREGNANCY. 

The  frequency  of  miscarriages  and  stillbirths,  and  the  large  number  of 
ill-formed  and  puny  infants  born  to  a  precarious  and  short  existence,  render 
imperative,  on  the  part  of  the  mother,  a  strict  observance  of  the  laws  of 
health,  and  an  avoidance  of  all  exciting  or  perturbating  influences  during 
the  time  when  the  foetus  is  being  developed.  The  diet  should  be  plain  and 
easily  digested,  but  nutritious.  There  is  often  a  craving  in  pregnancy  for 
unusual  articles  of  food.  These  may  sometimes  be  allowed  within  certain 
limits,  provided  that  they  are  such  as  do  not  derange  the  stomach.  Meats 
and  animal  broths,  together  with  vegetables  and  farinaceous  food,  should  con- 
stitute the  ordinary  diet  and  should  be  taken  at  regular  intervals. 

Daily  exei'cise,  never  violent,  but  moderate  and  gentle,  is  requisite.  No 
exercise  is  better,  none  safer,  and  more  likely  to  contribute  to  cheerfulness 
and  healthy  functional  activity  of  the  organs,  than  the  ordinary  household 
duties.  Lifting  heavy  weights  or  work  which,  like  washing  and  ironing, 
causes  great  and  continued  action  of  the  abdominal  muscles,  should  be 
avoided.  Such  exercise  is  highly  injurious,  and  it  may  produce  premature 
labor.  Exercise  in  the  open  air  on  foot  or  by  an  easy  conveyance  conduces 
to  the  health  of  the  mother  and  the  growth  and  development  of  the  foetus. 
On  the  other  hand,  rapid  riding  over  rough  roads  is  one  of  the  most  dangerous 
modes  of  exercise.  It  has  been  known  to  destroy  the  foetus,  which  up  to 
that  time  had  been  apparently  vigorous.  When  such  a  result  occurs  there 
is  probably  more  or  less  detachment  of  the  placenta. 

It  being  a  matter  of  the  utmost  importance  that  the  health  of  the  mother 
should  continue  good  during  gestation,  any  disease  which  she  may  have  in 
this  period,  and  which  aff"ects  her  nutrition  or  the  character  of  her  blood, 
should  be  promptly  cured  if  practicable,  and  with  the  least  possible  reduc- 
tion of  the  vital  powers.  Intermittent  fever,  occurring  during  gestation, 
should  never  be  allowed  to  continue.  It  seriously  retards  foetal  develop- 
ment and  may  produce  miscarriage.  Unless  it  be  controlled  by  proper  meas- 
ures, the  off"spring,  though  born  at  term,  is  puny  and  emaciated.  Syphilis  in 
the  pregnant  woman  also  requires  treatment.  This  disease,  readily  trans- 
mitted from  the  mother  to  the  foetus  through  the  ovum  or  the  uterine  circu- 
lation, may  be  eradicated  by  antisyphilitic  treatment  of  the  mother,  or  at 
least  so  modified  that  the  infant  is  born  vigorous  and  healthy. 

The  pregnant  woman  should  avoid  all  causes  of  undue  mental  excite- 
ment. This  is  almost  as  necessary  as  the  avoidance  of  great  physical  exer- 
tion.    There  is,  during  pregnancy,  unusual  susceptibility  to  mental  impres- 


36         CARE  OF  THE  MOTHER  IN  PREGNANCY. 

sions,  and  this  should  be  borne  in  mind  not  only  by  the  woman  herself, 
but  by  those  who  associate  with  her. 

Strong  emotions,  whether  of  joy,  sorrow,  or  anger,  affect  primarily  the 
nervous  system,  but  indirectly  most  of  the  organs  of  the  body.  Observa- 
tions have  long  established  the  fact  that  such  emotions  influence  the  state 
and  functions  not  only  of  the  digestive  and  glandular,  but  also  of  the  mus- 
cular, organs,  as  the  heart  and  uterus.  Physicians  are  familiar  with  cases 
in  which  vivid  mental  impressions  produced  uterine  contractions,  and  even 
miscarriage,  or  have  disturbed  the  catamenial  function.  Therefore,  the 
associations  and  cares  of  pregnant  women  should  be  such  as  conduce  to 
cheerfulness  and  equanimity. 

It  is  the  popular  belief  and  the  belief  of  many  physicians  that  vivid 
mental  impressions  sometimes  have  a  direct  effect  on  the  development  of 
the  foetus.  Many  cases  are  on  record  in  which  infants  were  born  with  marks 
or  deformities  corresponding  in  character  with  objects  which  had  been  seen  and 
had  made  a  strong  impression  on  the  maternal  mind  at  some  period  of  gestation. 
Whether  the  mind  of  the  mother  exerts  a  controlling  influence  on  the  form 
and  color  of  the  foetus  is  a  subject  of  great  interest  to  the  psychologist  as 
well  as  the  physiologist  and  physician,  since  it  involves  no  less  a  question 
than  the  power  and  scope  of  the  human  mind.  Violent  emotions,  it  is  admit- 
ted, may  affect  directly  most  of  the  important  organs  in  the  system.  They 
may  derange  the  liver,  causing  jaundice,  accelerate,  or  for  a  moment  suspend, 
the  heart's  action,  stimulate  the  kidneys,  causing  diuresis,  or  even  the  intesti- 
nal follicles,  causing  watery  evacuations.  But  with  all  these  organs  the  brain 
is  connected  by  nerves  which  anatomy  reveals.  On  the  other  hand,  the  mother 
and  foetus  have  a  distinct  existence  as  regards  their  nervous  systems,  and  even 
their  blood.  Still,  the  multitude  of  facts  which  have  accumulated  justify  the 
belief  that  deformity  or  other  abnormal  development  of  the  foetus  is,  at  times, 
due  to  the  emotions  of  the  mother.  Some  of  the  cases  related  by  Dr.  White- 
head in  his  work  on  hereditary  diseases  are  very  striking  and  difficult  to 
explain  on  the  ground  of  coincidence.  I  have  met  the  following  cases  :  An 
Irish  woman  of  strong  emotions  and  superstitions  was  passing  along  a  street 
in  the  first  months  of  her  gestation,  when  she  was  accosted  by  a  beggar,  who 
raised  her  hand,  destitute  of  thumb  and  fingers,  and  in  "  God's  name  "  asked 
for  alms.  The  woman  passed  on,  bat  reflecting  in  whose  name  money  was 
asked,  felt  that  she  had  committed  a  great  sin  in  refusing  assistance.  She 
returned  to  the  place  where  she  had  met  the  beggar,  and  on  different  days, 
but  never  afterward  saw  her.  Harassed  by  the  thought  of  her  imaginary 
sin,  so  that  for  weeks,  according  to  her  statement,  she  was  made  wretched  by 
it,  she  approached  her  confinement.  A  female  infant  was  born,  otherwise 
perfect,  but  lacking  the  fingers  and  thumb  of  one  hand.  The  deformed 
limb  was  on  the  same  side  as,  and  it  seemed  to  the  mother  to  resemble 
precisely,  that  of  the  beggar.  In  another  case  which  I  met  a  very  similar 
malformation  was  attributed  by  the  mother  of  the  child  to  an  accident  occur- 
ring to  a  near  relative  which  necessitated  amputation  during  the  time  of  her 
gestation.  I  examined  both  of  these  children  with  defective  limbs,  and  have 
no  doubt  of  the  truthfulness  of  the  parents.  In  May,  1868,  I  removed  a 
supernumerary  thumb  from  an  infant  whose  mother,  a  baker's  wife,  gave  me 
the  following  history  :  No  one  of  the  family  and  no  ancestor,  to  her  know- 
ledge, presented  this  deformity.  In  the  early  months  of  her  gestation  she 
sold  bread  from  the  counter,  and  nearly  every  day  a  child  with  double  thumb 
came  in  for  a  penny  roll,  presenting  the  penny  between  the  thumb  and  the 
finger.  After  the  third  month  she  left  the  bakery,  but  the  malformation  was 
so  impressed  upon  her  mind  that  she  was  not  surprised  to  see  it  reproduced 
in  her  infant.     Mrs.  S ,  AVest  Fiftieth  street,  New  York,  when  in  the 


MATERNAL  IMPRESSIONS.  37 

seventh  week  of  gestation  saw  a  child  with  fingers  united,  so  that  they  resem- 
bled the  pahn  of  the  hand  extended.  She  was  much  excited  at  the  appear- 
ance, and  clutched  the  window-sill  with  such  force  as  to  cause  abrasion  of 
the  fingers.  The  malforijiation  of  the  child  made  a  deep  and  lasting  impres- 
sion on  her  mind,  and  her  child,  born  at  term,  had  the  index,  middle,  and  ring 
fingers  of  the  left  hand  webbed  and  ending  with  the  first  phalanges,  while  the 

little  finger  was  normal.      Mrs.  D ,  Eighth  avenue,  New   York,  seven 

months  before  the  birth  of  her  child,  when  visiting  at  a  distance,  accident- 
ally broke  the  plate  of  a  full  set  of  upper  teeth.  The  line  of  fracture  was 
antero-posterior  and  through  the  centre  of  the  plate.  Being  away  from  home, 
she  was  much  annoyed  by  the  accident,  and  retained  the  fragments  of  the 
plate  in  sifu  by  pres.sure  with  the  tongue.  As  she  could  not  open  her  mouth 
without  the  plate  falling  out,  except  it  was  retained  by  pressure  with  the  tongue, 
her  mind  was  dwelling  almost  constantly  on  the  accident  during  the  few  days 
of  her  visit.  Her  boy,  born  seven  months  subsequently,  had  a  hare-lip  and 
cleft  palate.  The  mother  stated  that  the  deficiency  in  the  lip  and  palate  cor- 
responded precisely  to  the  location  of  the  fracture  in  the  plate.  Dr.  Greenley 
relates  five  similar  cases  in  which  infants  at  birth  presented  marks  or  arrested 
development  corresponding  in  appearance  with  objects  which  produced  strong 
mental  impressions  in  the  mothers  (Amer.  Prac.  and  JVews,  Oct.  29,  1887). 

Dr.  William  A.  Hammond  of  Washington,  in  an  interesting  paper  on  the 
"Influence  of  the  Maternal  Mind,"  etc.  (^Quarterly  Journal  of  Fht/aiolofjlcal 
Medicine^  January,  1868),  says:  "The  chances  of  these  instances,  and  oth- 
ers which  I  have  mentioned,  being  due  to  coincidence  are  infinitesiraally  small, 
and  though  I  am  careful  not  to  reason  upon  the  principle  of  post  hoc,  ergo 
PROPTER  HOC,  I  cannot,  nor  do  I  think  any  other  person  can,  no  matter  how 
logical  may  be  his  mind,  reason  fairly  against  the  connection  of  cause  and 
effect  in  such  cases.  The  correctness  of  the  facts  can  only  be  qu-estioned ; 
if  these  be  accepted,  the  probabilities  are  thousands  of  millions  to  one  that 
the  relation  between  the  phenomena  is  direct."  Professor  Dalton  also  says 
(Human  Phyuologij)  :  "  There  is  now  little  room  for  doubt  that  various  deform- 
ities and  deficiencies  of  the  foetus,  conformably  to  the  popular  belief,  do  really 
originate  in  certain  cases  from  nervous  impressions,  such  as  disgust,  fear,  or 
anger,  experienced  by  the  mother."  The  observations  on  which  this  belief 
is  based  relate  both  to  man  and  the  lower  animals.  A  very  strong  argument 
in  its  support  is,  as  Professor  Hammond  remarks,  the  popular  opinion,  which 
dates  back  to  the  time  of  Jacob  (Genesis  xxx.).  An  almost  universal  sen- 
timent, running  through  centuries,  is  rarely  wholly  fallacious.  It  has  some 
truth  for  its  foundation,  especially  when,  as  in  this  instance,  the  subject  is 
one  of  observation. 

If  maternal  emotions  affect  the  development  of  the  exterior  of  the  foetus, 
as  observations  show  and  physiologists  admit,  the  presumption  is  strong  that 
they  may  affect  also  the  proper  development  and  adjustment  of  the  parts  of 
the  brain,  an  organ  so  complex  and  delicate,  and  may  therefore  give  rise  to 
idiocy.  Dr.  Seguin  (Idiocy  and  its  Treatment,  etc.,  New  York,  1866)  thus 
remarks  on  this  point :  "  Impressions  will  sometimes  reach  the  foetus  in  its 
recess,  cut  off  its  legs  or  arms,  or  inflict  large  flesh  wounds  before  birth,  .... 
from  which  we  surmise  that  idiocy  holds  unknown  though  certain  relations 
to  maternal  impressions  as  modifications  to  placental  nutrition." 

In  volume  i.  of  the  Cyclopscxlia  of  Diseases  of  Children  (Philadelphia, 
1889)  Dr.  W.  C.  Dabney  has  published  the  statistics  of  90  cases  showing 
that  both  mental  and  bodily  defects  in  the  infant  sometimes  result  from  vivid 
mental  impressions  in  the  mother  during  the  early  months  of  her  gestation. 
These  cases  ai'e  mostly  collated  from  recent  medical  literature,  and  many  of 
them  are  striking  instances  showing  the  effect  of  maternal  impressions  in 


38 


CARE  OF  THE  MOTHER  IN  PREGNANCY. 


Fig.  1. 


causing  malformations  in  the  foetus,  not  only  in  the  human  race,  but  also  in 
quadrupeds.  Dr.  Dabney  also  relates  the  remarkable  statement  of  Baron 
Larrey,  that  92  enceinte  women  who  had  experienced  the  extreme  mental  and 
physical  suffering  of  the  siege  of  Landau  in  1793  brought  forth  infants  with 
the  following  result:  born  dead,  16;  born  alive,  but  dying  in  ten  months, 
33 ;  born  idiotic,  8 ;  born  with  bones  ununited  or  in  a  fragmentary  state,  2. 
It  is  an  interesting  fact  that  abnormalities  of  structure  occurring  from 
whatever  cause  are  sometimes  propagated  to  descendants.  Dr.  Carpenter 
and  others  relate  instances  among  the  lower  animals,  and  similar  instances 
of  transmission  have  now  and  then  been  observed  in  the  human  race.  Thus, 
in  the  issue  of  Nature  for  March  7, 1878,  it  is  stated  on  the  authority  of  M. 
Lenglen,  a  physician  of  Arras,  that  a  certain  M.  Gamelon  in  the  last  century 
had  two  thumbs  on  each  hand  and  two  great  toes  on  each  foot :  this  peculiar- 
ity did  not  appear  in  the  son,  but  it  reappeared  in  the  three  succeeding  gene- 
rations, so  that  some  of  the  great- 
great-grandchildren  possessed  it  in  as 
marked  a  degree  as  their  ancestors. 

In  view  of  such  important  facts 
the  duty  of  the  pregnant  woman  is 
rendered  the  more  imperative  to  avoid 
the  presence  of  disagreeable  and  un- 
sightly objects,  as  well  as  all  causes 
of  excitement,  and  to  remove,  as  soon 
as  possible,  vivid  and  unpleasant  im- 
pressions by  quiet  diversion  of  the 
mind. 

The  disastrous  results  upon  the 
foetus  of  severe  injuries  received  by 
the  mother  are  well  known  to  the 
profession,  for  premature  labor  and 
death  of  the  child  or  feebleness  from 
its  prematurity  are  common  results 
of  such  accidents.  In  rare  instances 
the  child  may  be  so  injured  as  to  be 
deformed  for  life,  as  in  the  following 

interesting  case:  Richard  L ,  aged 

six  years,  came,  in  January,  1877,  to 
the  children's  class  in  the  Bureau  for 
the  Relief  of  the  Out-door  Poor.  The 
following  history  was  obtained  :  On 
November  27,  1870,  one  month  before  the  birth  of  Richard,  the  mother  fell 
heavily  on  the  ice  when  stepping  from  a  city  car.  Uterine  hemorrhage 
resulted,  which  continued  more  or  less  freely,  producing  marked  pallor,  till 
her  confinement,  which  occurred  December  23d.  The  position  of  th  e  child 
in  utero  was  crosswise,  but  nothing  untoward  occurred  in  the  delivery.  Imme- 
diately after  its  birth,  when  it  was  being  washed  by  the  nurse,  a  blister  about 
one  inch  in  diameter  was  observed  on  the  right  side  of  the  thorax,  located 
about  one  inch  below  and  two  and  a  half  inches  externally  to  the  nipple.  A 
cicatrix  resulted,  which  now  marks  the  site  of  the  sore.  When  the  blister 
healed  the  child  seemed  entirely  well,  and  nothing  more  was  thought  of  the 
unusual  occurrence  of  an  intra-uterine  vesication  till  nearly  half  a  year  had 
elapsed,  when  the  thorax  below  the  nipple  and  at  the  site  of  the  cicatrix  was 
observed  to  be  depressed,  and  the  depression  has  continued  to  the  extent 
indicated  in  the  woodcut. 

The  ribs  at  the  point  of  depression  are  found  to  be  widely  separated ;  the 


MORTAIJTY  OF  EARLY  LIFE.  39 

rib  below  being  puslied  downwaid  so  as  to  form  one  side  of  the  triangle,  its 
cartilage  the  second  side,  and  the  rib  above  the  hypothenuse.  The  distance 
of  the  perpendicular  line  passing  from  the  costo-chondral  articulation  of  the 
lower  rib  to  the  upper  rib,  or  the  hypothenuse,  is  two  and  a  half  inches  by 
measurement.  The  depression  in  this  triangular  space  evidently  resulted 
gradually  from  the  wide  separation  of  the  ribs,  and  the  consequent  loss  of 
resiliency  in  the  thoracic  vvalls  in  the  space  destitute  of  bony  support.  The 
child  lay  crosswise  in  xite.ro.  and  it  seems  probable  that  the  injury  was  pro- 
duced by  the  pressure  of  its  arm  against  the  ribs  during  the  fall.  Cases  like 
the  above,  and  the  graver  cases  in  which  foetal  life  is  sacrificed  or  the  child 
is  born  to  a  puny  and  uncertain  existence  from  prematurity,  show  the  very 
great  importance  of  a  quiet  and  regular  life  on  the  part  of  one  who  is  about 
to  become  a  mother;  for  bodily  injuries,  like  unpleasant  sights,  occur  when 
least  expected. 


CHAPTER    III. 

MORTALITY   OF   EAELY   LIFE:    ITS  CAUSES  AND  PREVENTION. 

No  fact  is  better  known  in  the  profession  than  that  the  first  years  of  life 
constitute  the  period  of  greatest  mortality. 

In  England,  where  there  is  an  accurate  registration  of  births  and  deaths, 
statistics  show  fifteen  deaths  in  every  hundred  infants  in  the  first  yeai-  of  life, 
and  between  four  and  five  deaths  in  the  first  month  Statistics  on  the  Con- 
tinent correspond  with  those  in  England  as  regards  the  periods  of  greatest 
mortality.  Quetelet  says  :...."  There  die  during  the  first  month  after  birth 
four  times  as  many  children  as  during  the  second  month  after  birth,  and 
almost  as  many  as  during  the  entirety  of  the  two  years  that  follow  the  first 
year,  although  even  then  the  mortality  is  high.  The  tables  of  mortality 
prove,  in  fact,  that  one-tenth  of  children  born,  die  before  the  first  month  has 
been  completed." 

In  this  country,  in  consequence  of  deficient  registration  of  births,  the 
percentage  of  deaths  to  births  cannot  be  accurately  ascertained.  In  this 
city  53  per  cent,  of  the  total  number  of  deaths  occur  under  the  age  of  five 
years,  and  26  per  cent,  under  the  age  of  one  year.  According  to  the  census 
of  1865,  there  were  in  New  York  City  95,020  children  under  the  age  of  five 
years,  and  during  the  five  years  ending  with  1865,  49,000  children  five  years 
old  and  under  had  died.  Therefore,  according  to  these  statistics,  more  than 
one-third  of  all  the  infants  born  in  this  city  die  under  the  age  of  five  years. 
An  error,  however,  occurs  from  the  fact  that,  while  the  death-statistics  were 
complete,  it  is  known  there  were  more  children  in  the  city  than  were  embraced 
in  the  census  returns.  Still,  it  may,  I  think,  be  safely  stated  that  one-fourth 
of  the  children  born  in  this  city  die  before  the  age  of  five  years. 

In  less-crowded  cities  and  the  rural  districts  it  is  known  that  the  percent- 
age of  deaths  in  the  first  years  of  life  to  the  total  number  of  deaths  is  con- 
siderably less  than  in  New  York  Cit}^,  but  it  is  nevertheless  large. 

As  the  child  advances  toward  puberty  the  liability  to  sickness  and  death 
gradually  diminishes,  but  even  the  last  years  of  childhood  present  a  con- 
siderably larger  percentage  of  deaths  to  the  population  than  does  youth  or 
manhood. 

The  causes  of  this  great  mortality  of  infants  and  children,  and  the  means 
of  diminLshino-  it.  deserve  careful  consideration. 


40  MORTALITY   OF  EARLY  LIFE. 

Some  of  the  causes  which  conspire  to  produce  it  are  to  a  considerable 
extent  unavoidable.  Such  are  congenital  vices  of  formation  of  internal 
organs.  Many  of  the  internal  malformations  necessarily  occasion  an  early 
death.  Cases  of  anencephalus,  most  cases  of  congenital  hydrocephalus,  of 
spina  bifida,  of  cyanosis,  are  fatal  before  the  close  of  infancy.  These  defects 
of  formation  we  cannot  detect  before  birth,  and  their  causes  are  often  obscure. 
Some  of  them  seem  to  result  from  inflammation,  believed  to  be,  occasionally, 
syphilitic,  developed  at  some  period  of  foetal  existence.  Other  internal  mal- 
formations are  attributable  to  perturbating  influences  operating  temporarily 
on  the  mother  during  gestation.  But  in  a  large  proportion  of  cases  we  can- 
not assign  the  cause.  Obviously,  only  partial  success  can  attend  our  efforts 
as  regards  prevention  in  these  cases,  and  almost  no  success  as  regards  the  use 
of  remedial  measures. 

Another  obvious  cause  of  the  great  mortality  of  early  life  is  natural  fee- 
bleness of  system,  especially  in  infancy.  The  younger  the  patient  prior  to 
the  middle  period  of  life,  the  sooner  are  the  vital  powers  exhausted  by  dis- 
ease. Hence  a  larger  proportion  of  infants  succumb  to  the  same  malady 
than  children,  and  a  larger  proportion  of  children  than  adults.  This  state- 
ment is  true  of  infancy  and  childhood  in  general.  It  is  a  law  in  nature,  and 
cannot  be  changed  by  art.  But  there  are  many  infants  born  with  hereditary 
disease  or  a  strong  predisposition  to  disease  through  a  fault  which  is,  in  a 
degree,  curable,  in  the  system  of  one  or  both  parents ;  as,  for  example,  the 
syphilitic,  scrofulous,  or  tubercular  diathesis.  Parents  seriously  affected  by 
such  diseases  cannot,  without  corrective  treatment,  have  healthy  off"spring. 
Their  children  are  among  the  first  to  droop  and  die,  either  directly  from  the 
inherited  disease,  or  from  feebleness  of  constitution  which  such  disease  entails, 
and  which  renders  them  an  easy  prey  to  other  diseases.  The  duty  of  the 
physician  as  regards  such  parents  is  obvious.  He  may,  by  therapeutic  and 
hygienic  measures,  secure  a  more  healthy  progeny,  and  so  far  as  he  can  do 
this  he  aids  in  diminishing  the  infantile  mortality.  He  may  sometimes,  by 
timely  measures  directed  to  the  infant,  establish  a  better  state  of  health. 

The  subject  of  hereditary  disease  is  one  of  great  interest  and  importance, 
especially  as  regards  the  city  population.  Inherited  affections  are  less  com- 
mon in  the  country,  but  in  the  city  they  contribute  largely  to  the  number  of 
deaths  in  early  life. 

Another  important  cause  of  the  great  mortality  of  children  is  the  fact 
that  they  are  peculiarly  liable  to  certain  severe  and  fatal  maladies.  I  allude 
particularly  to  the  acute  infectious  diseases,  which,  as  a  rule,  occur  but  once, 
and  that  in  childhood.  Some  of  them,  as  scarlet  fever,  greatly  increase  the 
number  of  deaths.  They  extend  and  become  epidemic  through  the  inter- 
course of  children.  We  are  constantly  witnessing  in  New  York  the  spread 
of  the  acute  contagious  diseases,  especially  of  whooping  cough,  measles,  scar- 
let fever,  and  diphtheria,  through  the  schools.  Measures  employed,  thus  far, 
by  boards  of  health  or  other  local  authorities  to  prevent  the  dissemination  of 
these  and  kindred  diseases  have  been  but  partially  successful,  except  in  regard 
to  smallpox.  In  the  large  public  schools  especially  these  maladies  are  most 
frequently  contracted,  and  from  them  they  radiate  over  the  school  districts ; 
for  if,  as  is  now  common,  at  least  in  New  York  City,  a  child  comes  to  school 
wearing  clothes  which  at  home  have  lain  in  a  room  where  a  brother  or  sister 
was  sick  with  diphtheria  or  scarlet  ffever,  or  if  he  enter  the  class  with  a  mild 
pertussis  or  measles,  certain  of  his  classmates  will  probably  return  home 
infected  with  the  virus  of  the  disease.  The  same  remarks  are  applicable, 
though  with  less  force,  to  private  schools.  From  both  such  schools  I  have 
over  and  over  again  witnessed  the  dissemination  not  only  of  the  maladies 
mentioned,  but  also  of  the  milder  infectious  diseases,  as  mumps  and  varicella. 


CAUSES  OF  INFANTILE  MORTALITY.  41 

The  Health  Board  of  New  York  City  has  recently,  by  stringent  enactments 
regulating  the  schools,  accomplished  much  in  suppressing  this  source  of  the 
infectious  diseases. 

In  hospitals  and  asylums  for  children  much  can  be  done  to  prevent  the 
occurrence  of  the  infectious  diseases  by  strict  surveillance  and  prompt  isola- 
tion of  all  suspicious  cases.  Without  such  care  scarcely  a  year  pas.ses  in 
which  these  institutions  are  not  scourged  by  one  or  more  of  these  diseases. 
Much  has  been  said  of  the  crowding  of  families  in  tenement-houses  so  com- 
mon in  New  York  and  other  large  cities,  by  which  a  large  number  of  children 
are  brought  under  one  roof,  of  the  uncleanliness  of  person  and  apartment  to 
which  it  leads,  and  of  the  insufficient  air  and  space  which  it  allows  to  each. 
But  one  of  the  strongest  objections,  in  my  opinion,  to  the  present  plan  of 
building  and  crowding  tenement-houses  is  the  facility  which  it  affords  for  the 
spread  of  the  contagious  diseases  of  childhood ;  and  it  is  in  such  houses,  as 
shown  by  statistics,  that  these  maladies  are  the  most  frequent  and  fatal.  The 
much-needed  enactments  or  regulations  in  relation  to  the  construction  and 
occupancy  of  such  houses  would,  among  other  salutary  effects,  greatly  dimin- 
ish the  death-rate  from  the  infectious  maladies. 

Over  the  most  loathsome,  and  formerly  the  most  fatal,  malady  of  man- 
kind— namely,  smallpox — we  now  have,  or  can  have,  complete  control  by 
statutory  enactments  enforcing  vaccination.  It  is  only  by  carelessness  or 
the  lack  of  sufficiently  stringent  regulations  relating  to  the  matter  that  small- 
pox is  not  "  stamped  out."  Again,  some  of  the  most  fatal  inflammatory 
diseases  of  life  occur  chiefly  in  childhood,  as  croup  and  capillary  bronchitis. 
These  and  kindred  diseases  can  only  be  prevented  by  proper  hygienic  man- 
agement on  the  part  of  families,  and  the  circulation  of  tracts  or  other  means 
calculated  to  educate  families  in  reference  to  the  management  of  children 
cannot  fail  to  diminish  the  number  of  cases  of  such  inflammations,  and,  con- 
sequently, of  the  deaths  from  them. 

Another  obvious  and  important  cause  of  the  mortality  of  early  life  is  the 
antihygienic  condition  or  state  in  which  many  children  live,  in  consequence 
of  the  poverty  or  gross  negligence  of  parents. 

Residence  in  insalubrious  localities,  personal  and  domiciliary  uncleanliness, 
exposure  without  proper  protection  to  vicissitudes  of  weather,  are  fertile 
causes  of  sickness  and  death.  Hence  one  reason  for  the  great  infantile 
mortality  among  the  city  poor,  who  live  in  damp  and  dark  alleys  and  in 
crowded  and  filthy  tenement-houses,  breathing  night  and  day  an  atmosphere 
loaded  with  noxious  gases.  All  physicians  are  aware  how  the  most  fatal 
diseases,  such  as  Asiatic  cholera,  cholera  infantum,  diphtheria,  and  typhus 
fever,  seek  the  quarters  of  the  city  poor,  and  what  terrible  havoc  they  make 
there.  All  are  aware,  also,  what  wonderful  recoveries  result  when  feeble  and 
attenuated  infants,  gradually  sinking  with  chronic  diseases,  induced  in  great 
measure  by  the  foul  air,  are  transferred  from  such  localities  to  the  pure  air 
of  the  country. 

Careless  management  of  young  children  as  regards  dress  increases  greatly 
the  liability  to  local  diseases,  such  as  commonly  occur  from  exposure  to  cold. 
These  are  inflamniatory  aff'ections  seated  chiefly  upon  the  mucous  surfaces,, 
but  sometimes  in  parenchymatous  organs.  Adults,  aware  of  the  efi"ect  of 
sudden  change  of  temperature  from  warm  to  cold  or  of  exposure  to  currents 
of  air,  protect  themselves  by  additional  clothing.  Such  precautionary  meas- 
ures are  often  lacking  in  the  management  of  young  children,  and  hence  one 
cause  of  their  great  liability  to  local  afi'ections,  both  of  the  respiratory  and 
digestive  organs. 

Routh,  in  his  excellent  treatise  on  Infant  Feeding,  says :  "  Among  the 
most  pernicious  influences  to  young  children,  however,  we  may  include  cold ; 


42  MORTALITY  OF  EARLY  LIFE. 

tlie  change  of  temperature  from  45°  to  four  or  five  below  zero,  as  before 
stated,  producing  an  increase  of  mortality  in  London  alone  of  three  to  five 
hundred.  As  out  of  100  deaths,  however,  from  all  specified  causes,  nearly 
24  occur  to  children  under  one  year,  and  36  to  children  under  five,  the  great 
increase  of  mortality  to  children  by  cold  is  thus  at  once  made  obvious. 
Indeed,  it  is  a  household  word  among  us,  which  takes  its  origin  from  the 
Registrar-General's  returns,  that  a  very  cold  week  always  increases  the 
mortality  of  the  very  young  and  the  very  aged." 

Lastly,  a  very  important  cause  of  mortality  in  early  life  is  the  use  of 
improper  food.  In  infants  artificial  feeding  in  place  of  the  aliment  which 
nature  has  provided  for  them,  and  in  children  the  use  of  innutritious  or  indi- 
gestible articles  of  diet,  give  rise  to  diarrhoeal  maladies,  emaciation,  and  death 
in  numerous  instances.  Sometimes,  also,  defective  alimentation  is  the  cause 
of  scrofulous  or  tuberculous  ailments,  and  sometimes  it  gives  rise  to  a 
cachexia  or  feebleness  of  system  which,  without  engendering  any  positive 
disease,  renders  those  thus  affected  less  able  to  support  disease  induced  by 
other  causes.  A  committee,  of  which  Professor  Austin  Flint,  Jr..  was  chair- 
man, appointed  in  1867  to  revise  the  "  dietary  table  of  the  children's  nurseries 
on  Randall's  Island,"  states,  with  much  truth  and  force :  "  Children  .... 
are  not  capable  of  resisting  bad  alimentation,  either  as  regards  quantity, 
quality,  or  variety.  At  that  age  the  demands  of  the  system  for  nourishment 
are  in  excess  of  the  waste,  the  extra  quantity  being  required  for  growth  and 
development.  If  the  proper  quantity  and  variety  of  food  be  not  provided, 
full  development  cannot  take  place,  and  the  children  grow  up,  if  they  sur- 
vive, into  puny  men  and  women,  incapable  of  the  ordinary  amount  of  labor 
and  liable  to  diseases  of  various  kinds." 

Improper  feeding,  like  other  causes  of  mortality,  is  much  more  injurious, 
much  more  frequently  the  cause  of  death,  in  the  city  than  in  the  country. 
Statistics  in  Europe,  as  well  as  this  side  of  the  Atlantic,  establish  this  fact. 
It  is  in  infancy,  and  especially  in  the  first  year,  that  the  use  of  unwholesome 
food  entails  the  most  serious  consequences.  No  artificially-prepared  food  is 
a  good  substitute  for  the  mother's  milk,  and  hence  artificial  feeding  of  the 
infant,  unless  under  the  most  favorable  circumstances,  results  disastrously. 
In  the  country,  where  salubrious  air  and  sunlight  conspire  to  invigorate  the 
system,  where  a  robust  constitution  is  inherited,  and  where  cow's  milk,  fresh 
and  of  the  best  quality,  is  readily  obtained,  lactation  is  not  so  necessary  for 
the  well-being  of  the  infant ;  but  in  the  city  its  importance  cannot  be  too 
strongly  urged. 

The  foundlings  of  cities  afi'ord  the  most  striking  and  convincing  proof  of  the 
advantages  of  wet-nursing.  In  some  cities  foundlings  are  wet-nursed,  while 
in  others  they  are  dry-nursed,  and  the  result  is  always  greatly  in  favor  of  the 
former.  Thus,  on  the  Continent,  in  Lyons  and  Parthenay,  where  foundlings 
are  wet-nursed  almost  from  the  time  that  they  are  received,  the  deaths  are 
33.7  and  35  per  cent.  On  the  other  hand,  in  Paris,  Rheims,  and  Aix,  where 
the  foundlings  were  wholly  dry-nursed,  at  the  date  of  the  statistics  their 
deaths  were  50.3,  63.9,  and  80  per  cent. 

In  New  York  City  the  foundlings,  amounting  to  several  hundred  a  year, 
were  formerly  dry-nursed,  and,  incredible  as  it  may  appear,  their  mortality 
with  this  mode  of  alimentation  nearly  reached  100  per  cent.  Now  wet-nurses 
are  employed  for  a  portion  of  the  foundlings,  with  a  much  more  favorable 
result.  Several  years  ago,  before  the  New  York  Foundling  Asylum  existed, 
the  foundlings  of  New  York  were  taken  care  of  by  the  pauper  women  of  the 
almshouse,  and  the  medical  board  of  Charity  Hospital  assigned  me  to  the 
service  in  the  almshouse.  Foundlings  were  received  nearly  every  day,  and 
were  given  cow's  milk  prepared  by  these  pauper  women.     Incredible  as  it 


WEIGHT  OF  INFANT.  43 

may  seem,  the  deaths  corresponded  with  the  admissions :  only  one  infant  was 
pointed  out  that  hud  survived  the  first  luilf  year  in  tlie  almshouse. 

These  facts,  to  which  others  might  be  added  from  the  experience  of 
European  cities,  show  the  imjDortance  of  wet-nursing  as  a  means  of  reducing 
infantile  mortality  in  the  cities.  What  has  been  stated  as  regards  the  result 
of  artificial  feeding  of  foundlings  is  true,  in  great  measure,  in  reference  to 
all  city  infants.  The  ill-eifect  of  artificial  feeding  is  well  known  in  this  city, 
and  it  is  the  common  practice  in  families  to  employ  a  hired  wet-nurse  if,  for 
any  reason,  the  mother's  milk  is  insufiicient. 

When  the  infant  has  reached  the  age  at  which  it  is  proper  to  wean,  the 
digestive  organs  are  less  frequently  deranged  by  errors  of  diet.  More  sub- 
stantial food,  and  considerable  variety  in  it,  nuxy  now  be  not  only  safely 
allowed,  but  are  required  by  the  wants  of  the  system.  In  infancy,  there- 
fore, the  mortality  is  largely  increased  by  improper  diet,  while  in  childhood 
the  diet  is  a  much  less  common  cause  of  death. 


CHAPTER    IV. 

WEIGHT,  GEOWTH,  LACTATION. 

Dr.  K.  Parker,  resident  physician  0/  the  New  York  Infant  Asylum 
when  these  observations  were  made,  weighed,  immediately  after  birth,  170 
infants — 89  male  and  81  female — born  consecutively  and  at  term,  with  the 
following  result : 

Average  male  weight 7  lbs.  11  oz. 

"        female    "        7  "       4  " 

Fifty  of  these,  who  were  wet-nursed  and  apparently  well  taken  care  of,  were 
weighed  when  one  week  old,  with  the  following  result : 

Increase  of  weight  in :    ...  32  cases. 

Loss  of  weight  in 13     " 

Average  gain 4bj\  oz. 

"        lo-ss       3J      " 

Greatest  gain .  12        " 

"        loss 6        " 

AVERAGE  GAIN. 

From  birth  to  age  of  4  months  (25  cases) 4  lbs.  8|  oz. 

"      3  to    6  months  (6  cases) 3    "   3J-   " 

"      6  to    9      "  "  2    "   7f    " 

"      9  to  12      "  "  1    "  15.i   " 

It  is  desirable  that  the  infant  as  soon  as  it  requires  nutriment  should 
receive  breast-milk.  If  it  be  fed  for  a  few  days  with  the  bottle  or  spoon, 
it  may  be  difficult  finally  to  induce  it  to  take  the  breast ;  therefore  it  is  well 
to  determine  early  whether  the  mother  will  be  able  to  wet-nurse  her  infant, 
so  that,  if  unable,  suitable  provision  may  be  made. 

The  matter  of  determining  beforehand  the  capability  of  the  mother  for 
wet-nursing  has  been  investigated  by  Dr.  Donne  of  Paris,  and  in  his  treatise 
on  Moflin-s  and  In/ants  he  describes  the  mode  in  which  it  may  be  ascertained. 
The  desired  information,  in  his  opinion,  may  be  acquired  by  examining  the 


44  WEIGHT,   GROWTH,   LACTATION. 

colostrum,  which  is  secreted  in  small  quantity,  in  the  last  months  of  gesta- 
tion, and  which  can  be  squeezed  from  the  breast  in  sufficient  quantity  for 
inspection. 

In  some  women,  according  to  Dr.  Donne,  the  colostrum  is  so  scanty  that 
only  a  drop  or  half  a  drop  can  be  obtained  from  the  nipple  by  careful  pres- 
sure. This  will  be  found  by  the  microscope  to  contain  but  few  milk-glob- 
ules, ill  formed,  and  a  few  granular  bodies,  such  as  the  colostrum  ordinarily 
contains.  Such  women  almost  invariably  furnish  poor  milk  and  in  small 
quantity.  In  other  women  the  colostrum  is  abundant,  but  thin,  resembling 
gum-water ;  it  lacks  the  yellow  streaks  and  viscous  character  of  ordinary 
colostrum,  and  it  flows  readily  from  the  nipple.  The  milk  of  such  women 
is  sometimes  scanty,  sometimes  abundant,  but  it  is  watery  and  deficient  in 
nutritive  principles.  In  a  third  class  of  women  the  colostrum  is  pretty  abun- 
dant, and  it  contains  yellowish  streaks  of  more  or  less  consistence,  which  are 
found  to  be  rich  in  milk-globules  of  good  size.  Women  furnishing  such 
colostrum  in  the  last  weeks  of  gestation  will  have  sufficient  milk  and  of 
good  quality.     These  latter  women  make  the  best  wet-nurses. 

Wet-Nursing:  its  Advantages  and  Hindrances;  Physicai^ 
Conditions  rendering  it  Improper. 

During  the  first  year  of  the  infant's  life  the  natural  mode  of  alimenta- 
tion— that  by  the  mother's  milk — should  always  be  recommended,  except 
in  those  instances  in  which  mothers  are  incapacitated  by  physical  ailments 
or  mental  derangement.  The  practice  common  in  New  York,  and  probably 
in  other  cities,  of  employing  wet-nurses  in  the  belief  that  suckling  their 
infants  deprives  mothers  of  social  enjoyments  and  by  the  drain  upon  the 
system  impairs  their  general  health,  should  be  discouraged.  Wet-nursing 
by  the  mother,  if  properly  regulated,  with  sufficient  undisturbed  sleep  at 
night,  and  with  the  maintenance  of  good  appetite  and  digestion,  does  not 
impair  her  health,  but,  on  the  other  hand,  tends  to  promote  her  physical 
well-being.  But  there  are  unavoidable  conditions  which  render  wet-nursing 
by  the  mother  injudicious  or  impossible.  These  will  be  considered  here- 
after. 

The  primipara  often  experiences  difficulty  in  wet-nursing  in  consequence 
of  a  depressed  state  of  the  nipple.  It  is  not  sufficiently  prominent  to  be 
readily  grasped  by  the  mouth,  and  after  ineffectual  attempts  the  infant 
becomes  fretful  when  applied  to  the  breast,  and  perhaps  for  a  time  refuses 
it  altogether.  Multiparas  occasionally  experience  the  same  inconvenience, 
but  it  is  not  common  when  there  has  once  been  successful  lactation.  By 
calmness  and  perseverance  on  the  part  of  the  mother  the  nursling  can  usually 
be  made  to  seize  the  nipple  in  the  course  of  a  week. 

Depression  of  the  nipple  is,  to  a  certain  extent,  the  result  of  pressure 
upon  it  by  the  dress  during  gestation.  The  state  of  the  nipples  should 
indeed,  in  those  who  have  never  suckled,  receive  early  attention,  even  before 
the  birth  of  the  infant.  Tightness  of  dress  around  the  breast,  as  also  upon 
every  part  of  the  body,  should  be  avoided,  and  from  time  to  time  gentle 
traction  should  be  made  upon  the  nipple  if  it  be  depressed.  It  may  be 
drawn  out  by  the  fingers  of  the  mother  several  times  each  day,  or  by  a 
common  breast-pump,  or  by  suction  with  a  tobacco-pipe,  the  edge  of  the 
bowl  having  been  smoothed.  Occasionally,  in  these  cases  of  depressed  nip- 
ple the  mother,  fatigued  and  discouraged  by  her  frequent  ineffectual  attempts 
to  induce  the  infant  to  nurse,  becomes  feverish  and  excited,  so  that  the  quan- 
tity of  her  milk  is  sensibly  diminished.  The  physician  should  assure  her,  as  he 
usually  can  with  confidence,  that  in  a  few  days,  as  the  baby  becomes  a  little 


WET-NURSING.  45 

stronger,  there  will  be  no  difficulty  in  its  nursing.  Some  women  are  unre- 
mitting in  their  endeavors  to  procure  nursing.  This  should  be  forbidden, 
since  the  lack  of  sleep  and  the  nervousness  which  such  constant  endeavor 
produces  tend  to  defeat  the  object  which  they  have  in  view,  by  diminishing 
the  secretion  of  milk.  Sufficient  sleep,  freedom  from  anxiety,  and  no  more 
frequent  application  of  the  infant  to  the  breast  than  is  required  in  success- 
ful lactation  should  be  enjoined.  Occasionally,  we  can  best  succeed  in  pro- 
curing lactation  under  these  circumstances  of  discouragement  by  the  aid  of 
another  infant  older,  more  vigorous,  and  better  able  to  seize  the  nipple.  An 
exchange  of  infants  a  few  times  may  remedy  the  difficulty. 

Occasionally,  suckling  is  rendered  difficult  and  painful  by  too  long  delay 
before  applying  the  infant  to  the  breast.  When  the  mother  has  rested  a  few 
hours  after  her  confinement — about  six  in  ordinary  cases — lactation  may  com- 
mence. There  is  at  first  but  very  little  milk,  often  only  a  few  drops,  but  the 
secretion  is  promoted  by  nursing,  so  that  the  requisite  amount  is  sooner 
obtained  than  when  the  infant  is  kept  from  the  breast  till  the  second  or  third 
day.  If,  as  some  physicians  advise,  suckling  be  deferred  till  the  breasts  are 
full  and  tender,  and  if,  as  is  often  the  case  with  primiparae,  the  nipples  are 
also  tender,  many  mothers  lack  the  fortitude  required  to  allow  their  infants 
to  obtain  a  sufficient  amount  of  milk.  Excoriated  and  fissured  nipples  con- 
stitute a  serious  impediment  to  wet-nursing.  They  are  ver}"^  sensitive  on  pres- 
sure, and  are  long  in  healing.  They  are  fully  described  in  works  which  relate 
to  female  diseases,  and  their  treatment  pointed  out.  Occasionally,  fissured 
nipples  do  harm  to  the  infant  by  the  blood  which  escapes  and  is  swallowed 
with  the  milk.  A  case  is  related  in  which  positive  indigestion  was  caused 
in  this  way,  the  infant  vomiting,  after  each  nursing,  milk  mixed  with  blood. 
The  local  hindrances  to  lactation  described  above  can  in  most  instances  be 
relieved  in  the  course  of  a  few  weeks.  To  what  extent  menstruation  and 
pregnancy  are  detrimental  to  the  nursing,  and  therefore  contraindicate  lacta- 
tion, will  be  considered  in  another  section. 

There  is  occasionally  a  constitutional  state  of  the  mother  which  necessi- 
tates either  the  employment  of  a  hired  wet-nurse  or  weaning.  This  is  the 
case  when  there  is  a  strong  tendency  to  tuberculosis.  If  the  complexion  be 
pallid,  the  system  at  all  emaciated,  and  suckling  be  attended  by  more  or  less 
exhaustion,  and  if  with  fair  trial  of  wine  and  tonics  no  improvement  follow, 
the  physician  is  justified  in  forbidding  further  attempts  at  wet-nursing.  If, 
under  such  circumstances,  an  hereditary  tendency  to  tuberculosis  exist,  it  is 
his  duty  positively  to  interdict  nursing.  The  opinion  of  the  physician  in  such 
a  matter  should  be  formed  after  mature  deliberation.  There  are  many  women 
who,  suffering  temporarily  from  illness  and  discouraged,  are  ready  at  once  to 
abandon  their  infants  to  the  care  of  others  with  the  least  encouragement  on 
the  part  of  the  physician  to  do  so,  but  who,  by  attention  to  their  own  health, 
and  especially  by  taking  more  sleep,  soon  recover  from  their  depression  and 
become  good  wet-nurses.  On  the  other  hand,  night-sweats,  a  cough,  and  pro- 
gressive decline  in  health  show  the  need  of  immediate  suspension  of  wet- 
nursing. 

Sometimes  women  prior  to  pregnancy  present  indubitable  evidence  of 
tuberculosis,  but  by  the  improved  general  health  which  attends  pregnancy 
the  disease  is  temporarily  arrested.  Such  women  should  never  suckle  their 
infants.  If  they  do,  they  soon  lose  all  that  was  gained  and  the  disease 
advances  rapidly.  These  objections  to  wet-nursing  in  such  a  state  of  health 
apply  to  the  mother.  There  are  also  objections  as  regards  the  infant.  The 
milk  of  those  in  decidedly  infirm  health  is  deficient  in  nutritive  principles. 
Their  infants,  therefore,  are  ill-nourished,  and  if  they  have  inherited  a  pre- 
■disposition   to  tuberculosis  there  is  great  danger  that  this  disease  will  be 


46  WEIGHT,    GROWTH,   LACTATION. 

developed  in  them;  whereas  with  healthy  wet-nursing  even  a  strong  predis- 
position may  remain  latent.  M.  Donne  relates  the  following  instructive  cases, 
which  show  the  danger  which  sometimes  attends  suckling  and  the  imperative 
necessity  which  may  arise  of  discontinuing  it:  "A  very  light-complexioned 
young  mother,  in  very  good  health  and  of  a  good  constitution,  though  some- 
what delicate,  was  nursing  for  the  third  time,  and,  as  regarded  the  child, 
successfully.  All  at  once  this  young  woman  experienced  a  feeling  of 
exhaustion.  Her  skin  became  constantly  hot;  there  were  cough,  oppression, 
night-sweats  ;  her  strength  visibly  declined,  and  in  less  than  a  fortnight  she 
presented  the  ordinary  symptoms  of  consumption.  The  nursing  was  immedi- 
ately abandoned,  and  from  the  moment  the  secretion  of  milk  had  ceased  all  the 
troubles  disappeared."  '"A  woman  of  forty  years  of  age  ....  having  lost, 
one  after  another,  several  children,  all  of  whom  she  had  put  out  to  nurse, 
determined  to  nurse  the  last  one  herself.  ....  This  woman,  being  vigorous- 
and  well  built,  was  eager  for  the  work,  and,  filled  with  devotion  and  spirit, 
she  gave  herself  up  to  the  nursing  of  her  child  with  a  sort  of  fury.  At 
nine  months  she  still  nursed  him  from  fifteen  to  twenty  times  a  day. 
Having  become  extremely  emaciated,  she  fell  at  once  into  a  state  of  weak- 
ness from  which  nothing  could  raise  her,  and  two  days  after  the  poor  woman 
died  of  exhaustion." 

A  very  similar  case  recently  occurred  in  my  practice.  A  young  and 
healthy  woman  from  the  country,  suckling  her  second  infant,  on  coming  to 
the  city  lived  in  a  dark  and  very  imperfectly  ventilated  room  on  the  first  floor 
and  in  the  rear  of  a  crowded  tenement-house.  She  soon  lost  her  appetite,, 
but  continued  suckling  for  three  months,  when  she  became  so  anaemic  and 
feeble  that  she  was  compelled  to  seek  medical  advice.  She  died  without  local 
disease,  notwithstanding  the  most  nutritious  diet  and  free  use  of  stimulants 
and  tonics. 

Constitutional  syphilis  in  the  mother  does  not  contraindicate  wet-nursing. 
It  is  probable  that  the  infant  also  has  it.  The  mother  should  take  antisyph- 
ilitic  I'emedies,  which  will  eradicate  the  disease  in  herself,  and  also,  if  it  be 
present,  in  the  infant.  Febrile  affections  also  do  not  in  general  contraindicate 
wet-nursing.  They  may,  however,  for  a  time  diminish  the  quantity  of  milk 
or  impair  its  quality.  If,  however,  the  mother  be  in  a  critical  state  or  much 
reduced,  whatever  the  disease,  suckling  should  cease.  Whether  or  not  the 
infant  should  be  taken  from  the  breast  if  the  mother  be  suffering  from  one 
of  the  essential  fevers  depends  on  the  severity  of  the  malady  and  the  degree 
of  her  exhaustion.  Twice  I  have  known  newly-born  infants  to  be  suckled  by 
mothers  while  the  latter  had  scarlet  fever,  without  contracting  it,  but  suffer- 
ing immediately  afterward  from  protracted  and  severe  eczema.  In  rural 
localities,  where  artificially-fed  infants,  as  a  rule,  do  well,  it  might  be  best  to 
wean  if  the  mother  have  such  a  disease ;  but  in  the  city  eczema  is  less  dan- 
gerous than  the  diarrhoeal  affections  which  early  weaning  is  likely  to  entail. 
In  most  cases  of  typhus  and  typhoid  fevers  weaning  or  procuring  a  wet- 
nurse  is  necessary,  on  account  of  the  depression  of  the  vital  powers  which 
these  diseases  produce.  Mothers  with  organic  diseases,  of  whatever  kind,, 
which  impair  the  general  health  or  diminish  the  appetite,  should  never  be 
allowed  to  wet-nurse  their  infants.  Wet-nursing  under  such  circumstances  is 
likely  to  aggravate  the  disease,  and  the  milk  which  such  mothers  furnish, 
even  if  sufficient  in  quantity,  is  deficient  in  nutritive  properties. 

Inflammatory  affections,  unless  of  a  dangerous  character,  do  not  ordinarily 
interfere  with  wet-nursing,  except  that  the  quantity  of  milk  is  somewhat  dimin- 
ished. In  severe  inflammation  it  maybe  so  necessary  to  husband  the  strength 
or  to  keep  the  patient  perfectly  quiet  that  suckling  her  infant  would  be  inju- 
dicious.    It  should  then  be  transferred  to  a  wet-nurse  or  weaned.     Inflam- 


WET-NURSING.  47 

mation  of  the  breast  often  presents  an  impediment  to  lactation.  It  is  a 
common  and  painful  affection,  suspending  or  greatly  diminishing  the  secretion 
of  milk  in  the  affected  gland.  Wet-nursing  should  cease  as  soon  as  there  are 
evident  signs  of  inflammation,  unless  it  be  limited  to  a  small  part  of  the 
gland.  General  heat  of  th^  breast,  with  tenderness  and  induration  extend- 
ing over  a  considerable  part  of  it,  indicates  the  need  of  the  immediate 
removal  of  the  infant  from  it.  Suckling  must  be  restricted  to  the  unaffected 
side.  It  is  often  the  case  that  the  volume  of  the  inflamed  gland  is  con- 
siderably increased  from  the  afflux  of  blood  to  it  and  from  the  interstitial 
exudation,  while  it  contains  little  or  no  milk,  and  attempts  at  suckling  under 
such  circumstances  are  injurious  to  the  mother  as  well  as  to  the  infant.  The 
cause  of  the  swelling  should  be  explained  to  the  mother,  who  commonly 
attributes  it  to  the  accumulation  of  milk,  and  worries  herself  and  the  infant 
by  attempts  to  make  it  nurse.  As  the  inflammation  abates  by  resolution,  or 
more  commonly  by  suppuration,  and  the  normal  secretion  returns,  the  first 
milk,  which  is  usually  thick  and  stringy,  should  be  rejected,  after  which  the 
infant  may  nurse  as  usual.  Occasionally,  the  abscess  which  has  formed  in 
the  breast  connects  with  a  lactifei'ous  tube,  so  that  pus  may,  on  suction, 
escape  from  the  nipple.  If  this  occur,  of  course  nursing  should  be  inter- 
dicted until  pure  milk  is  obtained.  Pus  in  the  milk  can  sometimes  be 
detected  by  the  naked  eye.  It  presents  a  yellowish  or  greenish  color,  occur- 
ring in  streaks  when  not  intimately  mixed  with  the  milk.  When  it  is  inti- 
mately mixed  and  in  small  quantity,  it  cannot  be  detected  by  the  naked  eye, 
but  the  microscope  reveals  the  pus-globules.  M.  Donne  relates  a  case  in 
which  he  discovered  these  globules  by  the  microscope,  although  there  were 
at  first  no  other  evidences  of  an  abscess,  and  doubts  were  expressed  in  refer- 
ence to  the  accuracy  of  his  observation.  Finally,  an  abscess  pointed  and 
discharged. 

Sometimes  when  the  inflammation  abates  the  secretion  does  not  return, 
and,  worse  still,  occasionally  the  inflammation  has  occurred  so  near  the  nipple 
that  the  lactiferous  tubes  are  permanently  closed  by  it,  so  that,  though  milk 
form  in  the  breast,  there  is  no  escape  for  it.  Thenceforth  only  one  breast  can 
be  used. 

If  erysipelas  occur  in  the  mother,  the  infant  should  be  immediately  taken 
from  her  breast  and  from  her  arms.  If  this  disease  should  not  be  communi- 
cated to  the  infant  through  the  milk  or  through  fissures  in  the  nipple,  of 
which  there  is  danger,  still  the  milk  usually  undergoes  such  a  change  in  con- 
sequence of  the  erysipelas  as  to  endanger  the  health  of  the  child.  Thus,  one 
of  the  wet-nurses  in  the  New  York  Infant  Asylum  sickened  with  severe  facial 
ery.sipelas  on  the  24th  of  April,  1875,  eight  days  after  the  death  of  her  baby. 
She  was  wet-nursing  a  foundling,  aged  seven  weeks,  at  the  time  of  the  com- 
mencement of  the  erysipelas,  and,  as  it  was  verj^  important  that  her  milk 
should  be  preserved  for  the  coming  hot  months,  it  was  deemed  best  to  allow 
the  nursing  to  continue,  the  infant  being  placed  in  a  crib  at  a  little  distance 
as  soon  as  it  dropped  the  nipple.  On  the  27th  the  baby  was  troubled  with 
diarrhoea.  April  28th  its  morning  temperature  was  101°,  and  that  of  the 
evening  103°,  the  diarrhoea  continuing.  It  was  now  removed  entirely  from 
the  breast  and  was  given  artificial  food.  On  the  29th  there  was  a  decided 
general  icteric  hue  of  the  infant's  surface,  which  continued  till  its  death  on 
May  1st.  The  stools  numbered  about  eight  daily  till  April  30th,  when  they 
ceased.  The  record  which  I  preserved  does  not  state  whether  there  was 
vomiting,  but  it  had  probably  been  slight  on  account  of  the  speedy  prostra- 
tion. Death  occurred  from  exhaustion.  At  the  autopsy  from  half  an  ounce 
to  one  ounce  of  pus  was  found  in  the  peritoneal  cavity,  newly-formed  fibrin 
was  observed  upon  the  spleen   and  liver,  and  the  peritoneum  generally  had 


48  WEIGHT,   GROWTH,  LACTATION. 

lost  much  of  its  lustre :  a  careful  microscopic  examination  of  the  liver  and 
its  ducts,  made  by  Dr.  Heitzmann,  revealed  no  anatomical  change  which 
would  explain  the  icteric  hue,  and  it  seemed  probable  that  this  was  due 
to  the  altered  state  of  the  blood.  The  mucous  membrane  of  the  intestines 
exhibited  vascular  streaks  and  its  follicles  were  distinct.  The  lesions,  there- 
fore, indicated  intestinal  catarrh.  Nothing  unusual  was  observed  in  the  heart 
and  lungs  of  the  infant.  Its  life  had  been  apparently  sacrificed  by  the 
unhealthy  nursing. 

Colostrum. 

The  milk  secreted  during  gestation,  and  immediately  after  the  birth  of 
the  infant,  ordinarily  differs  in  its  gross  appearance,  as  well  as  chemical  and 
microscopical  characters,  from  that  which  is  subsequently  secreted.  It  is 
termed  Colostrum.  It  has  a  turbid  and  yellowish  appearance,  and  is  some- 
what viscid.  It  is  decidedly  alkaline,  and  undergoes  lactic-acid  fermentation 
more  readily  than  common  milk,  and  it  also  contains  more  solid  matter.  It 
has  an  excess  of  fat,  of  salts,  and,  according  to  Simon,  also  of  sugar.  It 
appears  from  Simon's  analysis  that  the  solid  matter  of  colostrum  is  about  17 
per  cent.,  while  that  of  the  ordinary  breast-milk  is  about  11  per  cent. 

Examined  by  the  microscope,  the  colostrum  is  seen  to  contain  oil-globules 
and  a  viscid  substance  which  often  assumes  an  ovoid  or  globular  form,  but 
which  also  exists  in  irregular  masses  of  considerable  size.  This  substance 
has  been  thought  by  some  to  be  mucus,  but  it  is  dissolved  by  acetic  acid  and 
potash  and  is  tinged  yellow  by  a  watery  solution  of  iodine.  It  is  therefore 
to  be  regarded  as  albuminous.  Imbedded  in  this  substance  are  oil-globules, 
which  are  for  the  most  part  of  small  size,  while  the  free  oil-globules  of 
colostrum  are  larger  than  those  occurring  in  healthy  milk.  The  viscid  sub- 
stance, with  the  imprisoned  oil-globules,  constitutes  what  has  been  designated 
the  "  colostrum-corpuscles."  Some  have  erroneously  considered  the  "  colos- 
trum-corpuscles "  to  be  compound  granular  cells.  The  compound  granular 
cell  or  corpuscle  is  a  cell  which  has  undergone  fatty  degeneration.  It  is  dis- 
tended with  oil-globules  to  perhaps  twice  or  thrice  its  normal  size.  On  the 
other  hand,  examinacion  of  the  "  colostrum-corpuscles  "  fails  to  detect  a  cell- 
wall,  and  the  large  and  irregular  size  of  some  of  these  corpuscles  negatives 
the  idea  that  they  are  cells.  The  oil-globules  contained  in  the  viscid  substance 
are  more  readily  acted  on  by  ether  than  are  the  free  oil-globules. 

The  colostrum  is  replaced  by  milk  of  the  normal  character  in  six  to  eight 
days,  sometimes  as  early  as  the  third  or  fourth  day  after  delivery.     In  excep- 

FiG.  2.  Fig.  3. 


©■"^^aso 


Milk-globules.  Colostrum-corpuscles. 

tional  instances  the  colostrum  does  not  disappear  for  several  weeks,  and  it 
may  reappear  at  any  time  subsequently  as  a  consequence  of  derangement  of 


HUMAN  MILK.  49 

the  system  or  from  disease.  It  is  assimilated  with  difficulty  by  the  digestive 
organs  of  the  infant,  producing  usually  a  laxative  eflect.  It  therefore  aids 
in  the  removal  of  the  meconium,  and,  being  a  normal  secretion,  it  is  to  be 
regarded  as  beneficial  in  the  first  week  of  the  infant's  life.  Continuing  longer 
than  the  first  week,  its  effect  is  deleterious.  It  produces  evident  derange- 
ment of  the  digestive  organs,  and  the  infant  that  habitually  nurses  it  never 
thrives.  It  has  diarrhoea  or  vomiting,  becomes  more  or  less  emaciated,  and 
suffers  from  colicky  pains.  Sometimes  an  extreme  degree  of  exhaustion  is 
reached  before  the  cause  is  suspected,  for  if  the  milk  be  pretty  abundant  the 
admixture  of  colostrum  with  it  cannot  be  detected  by  the  naked  eye.  The 
microscope  alone  reveals  it.  The  following  is  an  interesting  example  of  this 
fact:  In  1868  an  infant  six  weeks  old  was  brought  to  me  with  the  following 
history :  The  mother  had  for  several  years  been  troubled  with  dyspeptic 
symptoms,  but  had  otherwise  been  in  good  health.  The  infant  at  birth  was 
fleshy  and  strong,  but  after  the  first  week  it  had  never  thrived  like  other 
infants.  It  nursed  regularly,  and  the  quantity  of  milk  was  apparently  suf- 
ficient, but  it  vomited  as  soon  as  it  ceased  nursing ;  it  was  much  emaciated 
and  the  bowels  were  habitually  constipated.  The  digestive  organs  of  the 
infant  had  been  in  this  unhealthy  state,  with  little  variation,  from  the  first 
week,  and  it  was  very  evident,  from  the  emaciation  and  exhaustion,  that  it 
must  soon  perish  unless  some  change  were  eff"ected.  The  milk  of  the  mother 
presented  the  usual  appearance  to  the  naked  eye,  but  under  the  microscope 
colostrum-corpuscles  were  observed.  A  wet-nurse  was  immediately  obtained, 
and  from  that  moment  the  gastro-intestinal  symptoms  disappeared,  with  a 
rapid  recovery.  This  case  shows  at  once  the  evil  eff'ects  of  the  colostrum 
and  the  need  of  a  microscopic  examination  of  the  milk  whenever  the  nursling 
suff"ers  from  indigestion. 

Human  Milk. 

Foster  says  that  •'•  milk  is  the  result  of  the  activity  of  certain  protoplasmic 
cells  forming  the  epithelium  of  the  mammary  gland.  So  far  as  we  know,  the 
fat  is  formed  in  the  cell  through  a  metabolism  of  the  protoplasm.  Micro- 
scopically, the  fat  can  be  seen  to  be  gathered  in  the  epithelium-cell  in  the 
same  way  as  in  a  fat-cell  of  the  adipose  tissue,  and  to  be  discharged  into  the 
channels  of  the  gland  either  by  a  breaking  up  of  the  cells  or  by  a  contractile 
extrusion  very  similar  to  that  which  takes  place  when  an  amoeba  ejects  its 
digested  food."  Foster  likewise  states  that  there  is  also  evidence  that  the 
casein  and  sugar  are  formed  from  the  protoplasm  in  the  mammary  cells,  and 
not  by  appropriation  of  the  casein  and  sugar  introduced  into  the  system  in 
the  food.  Therefore,  if  the  food  contain  no  fat,  casein,  or  sugar,  still  these 
substances  are  produced  by  the  cell-agency  in  the  mammary  gland  (Archiv 
fiir  Ph7/s.,  1886,  539). 

The  specific  gravity  of  human  milk  is  about  1032.  It  has  been  carefully 
analyzed  by  diff"erent  chemists  with  nearly  the  same  result.  The  following 
table,  prepared  by  MM.  Vernois  and  Becquerel,  gives  the  proportion  of  the 
various  ingredients  in   1000  parts: 

Water 889.08 

Sugar 43.64 

Casein  and  extractive 39.24 

Butter 26.66 

Salts  (ash) 1.38 

1000.00 

Recently,   Prof.   x\lbert  R.    Leeds   has  analyzed  forty-three   samples   of 
healthy  human  milk,  with  the  following  results  : 
4 


50  WEIGHT,   GROWTH,  LACTATION. 

Average.  Minimum.  Maximum. 

Specific  gravity 1.0317  1.030  1.0353 

Water 86.766  83.34  89.09 

Total  solids  .    • 13.234  10.91  16.66 

Total  solids  not  fat 9.221  6.57  12.09 

Fat 4.013  2.11  6.89 

Milk-sugar 6.997  5.40  7.92 

Albuminoids 2.058  0.85  4.86 

Ash 0.21  0.13  0.35 

It  is  seen  that  the  constituents  of  healthy  human  milk  vary  considerably 
in  diflferent  women,  especially  the  albuminoids,  which  are  the  nutritive  part. 
Leeds  found  all  the  samples  alkaline  except  one,  which  was  neutral.  The 
heat-producing  constituents,  the  carbohydrates,  fat,  and  sugar  vary  less  than 
the  albuminoids.  Although  human  milk  seems  thinner  than  cow's  milk,  it 
nevertheless  contains  more  solids  and  less  water,  and  has  a  greater  specific 
gravity.  Milk-sugar  is  its  largest  solid  constituent.  Both  the  sugar  and  the 
fat  are  in  greater  proportion  than  in  cow's  milk,  while  the  amount  of  albu- 
minoids is  much  less.  A  very  important  difference  between  woman's  milk 
and  cow's  milk  is  in  the  casein — not  only  in  the  quality,  but  quantity.  The 
casein  of  cow's  milk  coagulates  in  large,  firm  masses,  digested  with  difficulty 
by  the  infant,  and  its  quantity  is  nearly  five  times  greater  than  that  in  human 
milk,  as  we  see  by  the  following  analysis  of  Prof.  Leeds.  Leeds  found  the 
average  specific  gravity  of  cow's  milk  1029 : 


Mean. 

Water 87.09 

Total  solids 12.91 

Fat 3.90 

Milk-sugar     ....    6.04 

Casein 0.63 

Albumen 1.31 

Albuminoids  .        .    .    1.94 
Ash 0.49 

Milk,  being  the  sole  food  of  early  infancy,  contains  all  the  nutritive  prin- 
ciples which  are  required  for  the  growth  and  repair  of  the  diff"erent  tissues. 
Most  of  the  salts  which  occur  in  the  tissues  exist  primarily  in  the  milk. 
Phosphate  of  lime,  phosphate  of  magnesium,  phosphate  of  the  peroxide  of 
iron,  chloride  of  potassium,  and  chloride  of  sodium,  known  to  exist  in  cow's 
milk,  are  believed  to  occur  also  in  human  milk.  Epithelial  cells  are  some- 
times present,  derived  from  the  lining  membrane  of  the  lactiferous  tubes. 

Modification  of  Milk  in  Consequence  of  the  Diet. 

The  relative  proportion  of  the  different  ingredients  of  the  milk  varies 
according  to  the  diet.  If  the  diet  be  poor,  the  amount  of  water  increases 
and  that  of  butter  and  casein  diminishes.  Lehmann  says  (^Phys.  Chemistry, 
vol.  ii.  p.  65)  :  "  From  experiments  made  on  bitches  it  would  appear  that  a 
vegetable  diet  renders  the  milk  richer  in  butter  and  sugar,  while  the  solid 
constituents  are  augmented  when  a  sufficient  quantity  of  mixed  food  is  given. 
Peligot  found  the  milk  of  an  ass  most  rich  in  casein  when  the  animal  had 
been  fed  on  beet-root,  while  it  was  richest  in  butter  when  the  food  had  con- 
sisted of  oats  and  lucerne.  Boussingault  found  the  milk  of  a  cow  richer  in 
casein  when  the  animal  had  been  fed  on  potatoes  than  when  other  food  was 
taken.  Reiset  found  that  the  milk  of  cows  which  were  at  grass  was  much 
richer  in  butter  than  when  the  animals  had  stood  all  night  in  their  stall  with- 


WomavJs  Milk. 

Coijds  Milk. 

Minimum. 

Maximum. 

Mean. 

Minimum. 

Maximum 

83.69 

90.90 

87.41 

80.32 

91.50 

9.10 

16.31 

12.59 

8.50 

19.68 

1.71 

7.60 

3.66 

1.15 

7.09 

4.11 

7.80 

4.92 

3.20 

5.67 

0.18 

1.90 

3.01 

1.17 

7.40 

0.39 

2.35 

0.75 

0.21 

5.04 

0.57 

4.25 

3.76 

1.38 

12.44 

0.14 

? 

0.70 

0.50 

0.87 

MODIFICATION  OF  MILK  BY  AGE,  ETC.  ol 

out  food  ;  but  Playfair  found,  on  the  contrary,  that  the  quantity  of  butter  in 
the  milk  increased  during  the  night  as  much  as  during  tlieir  stall-feeding,  but 
that  the  quantity  of  butter  in  the  milk  was  considerably  diminished  by  the 
motion  of  the  animals  in  the  fields."'  Simon  made  the  following  analysis  of 
the  milk  of  a  poor  woman.  She  was  suddenly,  during  the  period  of  lactation, 
deprived  of  the  means  of  support,  so  that  her  food  was  insufficient  in  quantity 
and  of  poor  quality.  The  amount  of  her  milk  was  not  diminished  by  priva- 
tion, but  the  solid  constituents  were  reduced  to  80  parts  in  1000.  After  this, 
for  a  time,  her  diet  was  nutritious  and  abundant,  the  quantity  of  milk  was 
increased,  and  the  solid  constituents  amounted  to  119  parts  in  1000.  Her 
diet  was  again  reduced,  with  a  reduction  of  the  solid  elements  to  98  in  1000, 
and  at  a  later  period  the  diet  was  again  nutritious,  with  an  increase  of  the 
solid  elements  to  126.  The  chief  variation  observed  in  the  milk  of  this 
woman  was  in  the  amount  of  butter. 


Modification  of  Milk  from  its  Retention  in  the  Breast. 

M.  Peligot  has  clearly  demonstrated  that  the  longer  milk  is  retained  in 
the  breast  the  more  watery  it  becomes.  This  is  explained  on  the  supposition 
that  the  solid  portion  is  first  absorbed.  Therefore,  the  milk  is  richer  the  more 
frequently  it  is  removed  from  the  breast.  A  similar  fact,  which  has  the  same 
explanation,  has  long  been  known — namely,  that  the  first  milk  taken  fi'om  the 
breast  is  thinnest,  while  that  which  flows  last  is  richest.  That  first  removed 
has  remained  longest  in  the  gland,  while  that  which  comes  last  is  but  recently 
secreted. 

A  knowledge  of  this  fact  is  of  considerable  practical  importance.  The 
milk,  as  M.  Donne  has  shown,  may  be  too  rich,  so  as  to  cause  indigestion, 
with  more  or  less  enteralgia,  in  the  infant.  Some  nurslings,  if  the  milk  be 
too  rich  and  abundant,  reject  a  part  of  it  by  vomiting,  but  others  do  not,  and 
suffer  the  consequence  in  derangement  of  the  digestive  organs.  For  such 
cases  the  remedy  is  to  give  the  breast  less  frequently,  by  which  a  less  amount 
of  milk  is  taken  and  milk  of  a  poorer  quality.  On  the  other  hand,  if  th-ere 
be  poverty  of  the  milk  and  the  infant  be  insufficiently  nourished,  the  milk  is 
more  nutritious  if  the  nursing;  be  at  short  intervals. 


Modification  of  Milk  by  Age  and  by  Mental  Impressions. 

The  composition  of  milk  varies  also  according  to  the  age  of  the  infant. 
Simon  analyzed  the  milk  of  a  woman  at  intervals  for  the  period  of  about  six 
months.  In  this  case  the  amount  of  casein  at  first  was  small,  but  the  quan- 
tity increased  during  the  two  months  succeeding  delivery,  after  which  it  was 
nearly  stationary.  A  similar  increase  was  observed  in  reference  to  the  saline 
substances.  The  sugar,  on  the  other  hand,  diminished  in  quantity  as  the 
infant  grew  older,  its  maximum  amount  being  in  the  first  and  second  months. 
The  quantity  of  butter  in  the  milk  varies  from  day  to  day  more  than  the 
other  elements. 

Many  observations  have  been  published  which  show  that  the  composition 
of  the  milk  may  be  materially  changed  by  mental  impressions.  The  infant 
has  died  suddenly  in  the  act  of  nursing  after  his  mother  had  been  violently 
excited.  Such  a  case  is  related  by  Tourtnal.  The  infant  ceased  nursing, 
gasped,  and  died  in  the  mother's  lap.  In  other  cases  convulsions  have 
occurred.  MM.  Becquerel  and  Vernois  made  the  chemical  analysis  of  the 
milk  of  a  woman  in  a  state  of  nervous  excitement,  and  found  that  the  solid 

'  Animal  Chem.,  Sydenham  Soc.'s  trans.,  vol.  ii.  p.  55. 


52  WEIGHT,   GROWTH,  LACTATION. 

constituents  were  diminished  to  91  parts  in  1000,  the  most  marked  diminu- 
tion being  in  the  butter,  which  was  only  about  5  parts.  In  a  case  related  by 
Parmentier  and  Deyeux  the  milk  became  watery  and  viscid,  and  remained  so 
till  the  nervous  attacks  from  which  the  patient  suflFered  had  ceased.  Dairy- 
men are  well  aware  how  ill-treatment  and  the  separation  of  the  calf  from  the 
cow  diminish  the  milk  which  she  yields.  A  new  milkman  seldom  obtains  as 
much  milk  as  one  with  whom  the  cow  is  familiar.  Bouchut,  alluding  to  the 
influence  of  the  moral  affections  on  the  secretion  of  milk,  makes  the  follow- 
ing remark,  the  truth  of  which  most  mothers  will  acknowledge  :  '•  It  is  also  a 
fact  that  the  sight  of  the  nursling,  the  idea  of  seeing  it  at  the  breast,  and  the 
joy  which  certain  mothers  thence  experience,  exercise  a  moral  influence  over 
the  secretion  of  the  milk  entirely  independent  of  their  will.  They  feel  the 
draught  of  milk  as  soon  as  they  behold  their  child  or  think  of  it  too  deeply ; 
and  in  a  woman  who  saw  her  child  fall  to  the  ground  the  flow  of  milk  ceased, 
and  did  not  reappear  until  the  child,  having  quite  recovered,  attempted  to 
take  the  breast." 

Rotch  states  that  a  primipara  of  an  excitable  and  nervous  temperament 
was  in  a  marked  degree  anxious  and  despondent  in  reference  to  her  infant, 
which  she  was  wet-nursing.  The  infant  began  to  suffer  from  indigestion,  so 
that  the  mother's  milk  was  analyzed  with  the  following  result:  water,  89.17  ; 
fat,  0.62 ;  sugar,  5.80 ;  albuminoids,  4.21  ;  ash,  0.20.  This  marked  varia- 
tion from  normal  milk  was  apparently  due  to  the  emotions  of  the  mother. 
A   wet-nurse   was  procured  and  the  infant  did  well. 

Modification  of  Milk  by  the  Oatamenial  Function,  Preg- 
nancy, AND  Other  Causes. 

The  catamenia  reappear  in  most  women  before  the  close  of  lactation,  often 
by  the  fifth  or  sixth  month  after  delivery.  If  this  function  be  re-established 
in  the  normal  manner — that  is,  without  any  derangement  of  the  system,  with- 
out pain  or  undue  profuseness — no  unfavorable  result  ordinarily  occurs  with 
the  infant.  On  the  other  hand,  if  the  mother  suffer  any  disturbance  of  the 
system  or  if  the  menses  be  profuse,  the  lacteal  secretion  may  be  so  changed 
that  the  infant  is  injuriously  affected  by  it.  The  symptoms  produced  are 
those  of  indigestion,  such  as  abdominal  pains,  more  or  less  vomiting,  and 
diarrhoea.  This  result  is,  however,  in  my  experience,  quite  exceptional.  In 
rare  instances  more  dangerous  symptoms  occur  in  the  infant.  A  case  has 
been  reported  to  me  in  which  at  each  catamenial  period  the  nursling  was 
seized  with  convulsions. 

Charles  Marchand  found  in  three  chemical  analyses  of  the  milk  during 
menstruation  a  diminution  of  2  to  4  parts  in  the  butter,  of  2  to  5  parts  in 
the  sugar,  and  a  diminution  in  the  casein  and  albumen  of  2  to  5  parts.  This 
seems  but  a  trifling  change  when  we  recollect  that  human  milk  in  the  state 
of  health  contains,  according  to  the  analysis  of  M.  Robin  and  others,  25  to 
37  parts  of  butter,  37  to  49  parts  of  sugar,  and  29  to  39  parts  of  casein  in 
1000  of  milk.  Rotch  has  made  the  following  analyses  of  the  milk  of  two 
women  during  the  catamenia.  Their  infants  exhibited  symptoms  of  indi- 
gestion during,  but  not  before  or  after,  the  catamenial  flow : 

First  Case.  Second  Case. 

Fat 0.62  1.37 

Sugar , 5.80  6.10 

Albuminoids 4.21  2.78 

Ash .20  _ai5 

Solids 10.83  10.40 

Water 89.17  89.60 

(Cyclop,  of  Diseases  of  Children,  1889.) 


MODIFICATION  OF  MILK  BY  THE  CATAMENIAL  FUNCTION.     53 

In  these  two  instances  the  albuminoids  were  increased.  But  even  if  the 
infant  suffer  from  indigestion  during  the  catamenial  period,  its  duration  is  so 
short  and  the  milk  so  soon  returns  to  its  normal  state  that  the  occurrence  of 
the  catamenia  does  not  indicate  the  need  of  weaning  if  the  infant  be  under 
the  age  of  ten  months.  But  if  the  menses  reappear  with  regularity  when 
the  infant  has  attained  the  age  of  ten  or  twelve  months,  they  should  be  con- 
sidered as  designed  to  supersede  the  secretion  of  milk,  which,  indeed,  usually 
begins  to  diminish.  Weaning  is  then  proper.  If  the  menses  return  early  in 
the  period  of  lactation  and  give  rise  to  symptoms  in  the  infant  in  consequence 
of  the  altered  quality  of  the  milk,  it  is  best  to  allow  but  little  nursing  during 
the  catamenia,  and  to  employ  artificial  feeding  instead  until  the  flow  of  blood 
ceases. 

The  change  produced  in  the  milk  by  pregnancy  is,  in  general,  more  inju- 
rious to  the  nursling  than  that  caused  by  the  reappearance  of  the  menses. 
The  milk  of  the  pregnant  woman  frequently  contains  more  or  less  of  the 
viscid  substance  which  characterizes  colostrum.  Still,  the  milk  of  pregnancy 
does  not  ordinarily  derange  the  digestive  function  as  much  as  colostrum  in 
the  first  weeks  of  lactation,  for  pregnancy  rarely  occurs  till  after  the  infant 
is  five  or  six  months  old,  when  the  organs  of  digestion  are  less  readily  dis- 
turbed. The  injurious  effect  of  pregnancy  on  the  infant  is  shown  by  vomit- 
ing or  diarrhoea,  by  restlessness  and  occasional  abdominal  pains ;  in  fine,  by 
symptoms  of  indigestion.  In  many  cases,  however,  these  symptoms  do  not 
occur,  and  the  infant,  though  nursing  regularly,  continues  to  thrive.  No 
doubt,  as  a  rule,  the  nursling  should  be  weaned  when  there  are  clear  evi- 
dences of  pregnancy,  but  under  certain  circumstances  weaning  is  injudicious. 
T  have  on  different  occasions  been  called  to  infants  in  midsummer  dangerously 
sick  with  diarrhoeal  attacks  induced  by  this  cause.  These  infants  were  per- 
haps doing  well  or  suffering  but  little  from  indigestion,  when  the  mothers, 
suspecting  themselves  pregnant,  at  once  withdrew  them  from  the  breast,  and 
cholera  infantum  or  a  kindred  disease  was  the  result.  No  infant  in  the  city 
should  be  weaned  in  the  hot  months.  It  is  much  safer,  though  there  be 
indubitable  signs  of  pregnancy,  that  it  continue  nursing  till  the  cold  weather. 
The  better  method  is,  however,  under  such  circumstances  to  employ  a  wet- 
nurse  or  to  remove  the  infant  to  the  country  and  wean  it  there.  In  cold 
weather  it  is  usually  safe  to  wean  an  infant  in  the  city  after  it  has  reached 
the  age  of  five  or  six  months. 

Sometimes  a  young  mother  devotes  herself  uni'emittingly  to  the  care  of 
her  infant,  giving  it  the  breast  every  hour  or  oftener  through  the  day  and 
frequently  through  the  night.  She  gives  the  infant  little  rest,  and  has  but 
little  herself.  This  devotion,  praiseworthy  as  it  is,  is  nevertheless  very 
injurious  to  both  parties  concerned.  The  rule  should  be  repeated  and  remem- 
bered, that  while  an  infant  may  nurse  hourly  during  the  first  month,  except 
in  the  hours  which  the  mother  requires  for  sleep,  in  which  it  should  not  nurse 
more  than  once  or  twice,  after  the  first  month  nursing  should  be  restricted  to 
intervals  of  two  hours  till  the  third  or  fourth  month,  and  in  older  infants, 
with  greater  capacity  of  the  stomach,  to  intervals  of  three  or  four  hours. 
Too  frequent  nursing  produces  indigestion  with  its  usual  fretfulness  and 
diarrhoea,  and  it  deprives  the  mother  of  the  mental  composure  and  rest  which 
are  required  for  successful  lactation  ;  but  the  more  the  infant  fi'ets,  in  many 
instances,  the  oftener  the  mother  applies  it  to  the  breast,  which  only  increases 
the  indigestion.  Worriment  and  lack  of  sleep  tend  not  only  to  diminish  the 
milk,  but  also  to  impair  its  quality. 

Venereal  excesses  have  a  very  injurious  effect  on  the  character  of  the 
milk.  In  our  remarks  on  the  hygienic  treatment  of  the  summer  diarrhoea  of 
infants  we  allude  to  authenticated  cases  in  which  excesses  of  this  kind  caused 


54  WEIGHT,   GROWTH,  LACTATION. 

fatal  intestinal  catarrh  in  the  nurslings.  Again,  the  relative  proportion  of 
the  ingredients  in  the  milk  may  habitually  vary  from  the  normal  without  any 
assignable  cause,  so  as  to  be  injurious  to  the  infant.  Habitual  ill-health,  as 
from  phthisis,  anaemia,  syphilis,  or  severe  nervous  disorder,  sometimes  so 
aflFects  the  secretion  of  milk  as  to  render  it  unsuitable  for  the  infant.  It  may 
cause  a  reappearance  of  the  colostrum,  like  that  immediately  after  parturition. 

Effect  of  Medicines  on  the  Mother's  Milk. 

This  important  subject  has  been  investigated  by  Fehling  (^Arch.  f.  Gyn., 
xxvii.  p.  332  ;  Jour,  de  Med.,  July  31,  1887).  According  to  him,  one  to  two 
grammes  of  salicylate  of  sodium,  taken  by  a  woman  who  is  wet-nursing,  may 
be  in  part  recovered  in  the  child's  urine.  Rheumatism  in  the  nursing  child 
may  therefore  be  treated  by  the  ordinary  doses  of  this  agent  administered  to 
the  mother.  Rheumatism  occurs  more  frequently  in  the  nursing  infant  than 
is  commonly  supposed,  since  its  symptoms  as  regards  the  joints  are  usually 
mild  and  likely  to  be  overlooked,  and  it  often  causes  endocarditis  and  per- 
manent valvular  disease  when  its  presence  is  not  suspected  and  no  physician 
is  called.  SchaefFer  relates  the  case  of  an  infant  born  with  rheumatism. 
Iodide  of  potassium  also,  says  Fehling,  given  to  the  mother,  can  be  detected 
in  large  quantity  in  the  infant's  urine.  We  have  Fehling's  authority  for  the 
following  statements :  After  applying  iodoform  to  perineal  lacerations,  iodine 
was  found  in  the  milk  and  urine  of  the  mother,  but  no  apparent  harm  has 
resulted  from  applying  iodoform  to  wounds  or  sores  in  the  nursing  mother. 
Mercury  taken  by  the  mother  did  not  appear  in  the  milk,  and  the  same  was 
true  of  acetic,  hydrochloric,  and  citric  acids.  Therefore  acid  foods  probably 
do  not  render  the  milk  acid.  Laudanum  given  by  the  mouth  in  no  instance 
caused  drowsiness  in  the  infant,  and  morphia  given  hypodermically  did  not, 
as  a  rule,  affect  the  child.  On  the  other  hand,  atropine  taken  by  the  mother 
caused  dilation  of  the  infant's  pupils.  Hydrate  of  chloral  taken  by  the 
mother  did  not  affect  the  child.  The  effect  on  the  nursing  child  of  medi- 
cines administered  to  the  mother  needs  further  investigation.  The  observa- 
tions relating  to  it  published  in  the  journals  are  as  yet  too  meagre  for  the 
valid  and  reliable  deductions  which  are  required  by  the  profession  to  ensure 
safe  and  proper  medication  of  nursing  women. 

Differences  in  Women  as  regards  Quantity  and  Quality 

OF  Milk. 

There  is  a  great  difference  in  different  women  as  regards  the  quantity  and 
quality  of  their  milk,  and  even  the  mode  in  which  it  is  secreted.  The  best 
wet-nurses  are  usually  robust  without  being  corpulent.  Their  appetite  is 
good,  and  their  breasts  are  distended  from  the  number  and  large  size  of  the 
blood-vessels  and  milk-ducts.  There  is  but  a  moderate  amount  of  fat  around 
the  gland,  and  tortuous  veins  are  observed  passing  over  it.  Such  nurses  do 
not  experience  a  feeling  of  exhaustion  and  do  not  suffer  from  lactation. 

The  nutriment  which  they  consume  is  equally  expended  in  their  own  sus- 
tenance and  the  supply  of  milk.  There  are  other  good  wet-nurses  who  have 
the  physical  conditions  which  I  have  described,  but  whose  breasts  are  small. 
Still,  the  infant  continues  to  nurse  till  it  is  satisfied,  and  it  thrives.  The  milk 
is  of  good  quality,  and  it  appears  to  be  secreted  mainly  during  the  period  of 
wet-nursing.  Other  mothers  evidently  decline  in  health  during  the  time  of 
nursing.  They  furnish  milk  of  good  quality  and  in  abundance,  and  their 
infants  thrive,  but  it  is  at  their  own  expense.  They  themselves  say,  and 
with  truth,  that  what  they  eat  goes  to  milk.     They  become  thinner  and  paler, 


SCANTINESS  OF  MILK.  55 

are  perhaps  tioubled  with  palpitation,  and  are  easily  exhausted.  They  often 
find  it  necessary  to  wean  before  the  end  of  the  usual  period  of  wet-nursing. 
There  is  another  class  whose  health  is  habitually  poor,  but  who  furnish  the 
usual  quantity  of  milk  without  the  exhaustion  experienced  by  the  class 
which  [  have  just  describeil.  The  milk  of  these  women  is  of  poor  quality. 
It  is  abundant,  but  watery.  Their  infants  are  pallid,  having  soft  and  flabby 
fibre.     All  these  kinds  of  wet-nurses  are  met  in  practice. 

Occasionally,  a  considerable  part  of  the  inilk  is  lost  by  oozing  from  the 
breast.  This  sometimes  occurs  in  robust  women,  but  is  more  frequently  asso- 
ciated with  weakness.  It  is  then  due  to  a  relaxed  state  of  the  orifices  of  the 
milk-ducts.  Galactorrhoea,  as  the  excessive  secretion  and  flow  of  milk  are 
designated,  is  said  to  be  often  associated  with  a  menorrhagic  diathesis ;  that 
is,  women  whose  menses  have  been  profuse  are  apt  to  have  too  abundant  a 
flow  of  milk,  corresponding  with  the  menorrhagia.  It  is  said  that  galactor- 
rhoea is  also  apt  to  occur  in  those  who  are  subject  to  discharges  from  parts 
which  sustain  no  immediate  relation  to  the  breast,  as  in  cases  of  hemorrhoidal 
flux,  diabetes  insipidus,  etc.  Excitement  or  irritation  of  the  uterus  or  ovaries 
may  serve  as  an  exciting  cause  of  galactoi'rhoea  in  those  predisposed  to  it,  and 
excessive  suckling  may  have  the  same  effect. 

Rules  in  regard  to  Suckling. 

Newly-born  infants  should  be  applied  to  the  breast  about  twelve  times  in 
twenty -four  hours.  The  suckling  should  be  mostly  in  the  day-time,  and  only 
once  or  twice  during  the  hours  required  by  the  mother  for  sleep.  After  the 
third  or  fourth  week  the  infant  should  take  the  breast  at  intervals  of  two 
hours  during  the  day-time,  and  only  once  during  the  seven  or  eight  hours  of 
sleep  which  the  mother  must  have  in  order  that  her  health  be  preserved  and 
her  milk  be  of  good  quality.  A  healthy  infant  empties  the  breast  in  ten  to 
fifteen  minutes  of  nursing,  when  it  should  be  removed,  and  if  in  good  condi- 
tion it  falls  asleep,  and  may  not  awaken  until  the  next  suckling,  or  if  it 
remain  awake  it  is  cheerful  and  contented.  It  is  a  fact  not  generally  known 
by  the  laity  that  frequent  nursing — as,  for  instance,  every  half  hour — renders 
the  milk  too  concentrated.  It  increases  the  solid  constituents  above  the  nor- 
mal. On  the  other  hand,  if  the  infant  be  applied  to  the  breast  at  long  inter- 
vals, the  proportion  of  solids  in  the  milk  is  diminished  below  the  average,  and 
the  water  is  in  a  corresponding  degree  increased.  Knowledge  of  this  fact  has 
its  practical  application.  A  mother  with  a  fretful  infant,  having  indigestion, 
usually  applies  it  often  to  the  breast,  and  her  milk  in  consequence  becomes 
too  concentrated  and  is  digested  with  difiiculty.  In  order  that  the  ingredients 
in  the  milk  be  in  the  proper  proportion  for  healthy  digestion,  not  only  should 
the  mother  lead  a  quiet  life,  with  regular  meals  of  plain  but  nutritious  food, 
but  suckling  should  be  at  intervals  of  about  two  or  three  hours. 

Scantiness  of  Milk:  its  Causes  and  Treatment. 

Though  the  amount  of  breast-milk  which  the  infant  requires  is  less  than 
was  estimated  by  Cumming,  still  insufficiency  of  this  secretion  is  not  uncom- 
mon, especially  in  cities.  According  to  the  statistics  of  Drs.  Merei  and 
Whitehead,  among  healthy  mothers  there  is  insufficiency  in  16.5  per  cent., 
while  among  mothers  in  feeble  health  the  percentage  is  46.6.  In  treating 
of  this  subject  in  the  following  pages  reference  is  not  had  to  those  cases  in 
which  there  is  temporary  diminution  of  milk  from  acute  diseases  or  other 
perturbating  causes,  but  to  those  cases  in  which  there  is  habitual  scantiness. 

One  cause  of  scanty  secretion  of  milk  is  a  life  of  privation  or  of  daily 


56  WEIGHT,   GROWTH,  LACTATION. 

work,  which  necessitates  separation  from  the  infant.  Insufficient  food  may 
render  the  milk  more  watery,  as  has  already  been  stated,  or  it  may  cause 
diminution  in  its  quantity.  The  mother  thus  situated  is  pallid.  She  is  sub- 
ject to  palpitation  and  attacks  of  faintness.  Her  condition,  indeed,  is  that 
of  anaemia.  Working  women  have  scantiness  of  milk,  not  only  in  conse- 
quence of  hardships,  but  also  because  they  are  usually  separated  for  hours 
from  their  infants.  Age  is  also  a  cause  of  scantiness  of  milk.  Mothers  at 
the  age  of  forty  years  ordinarily  furnish  less  milk  than  between  twenty  and 
thirty.  Those  who  have  not  borne  children  till  late  in  life,  and  whose  mam- 
mary glands  have  therefore  long  been  inactive,  have  less  milk  than  those  who 
commence  bearing  children  at  the  usual  period. 

Kouth  speaks  of  hyperaemia  as  a  cause  of  defective  lactation.  "  This  is 
a  variety,"  says  he,  "  which  I  have  chiefly  observed  among  hired  wet-nurses 

selected  from  the  poorer  classes  and  admitted  into  wealthier  families 

When  feeding  at  the  expense  of  a  master  or  mistress  the  amount  they  devour 
often  surpasses  all  moderate  imagination.  They,  in  fact,  gormandize.  If  in 
such  instances  a  wet-nurse  be  given  all  she  asks  for,  she  will  be  found  often 
to  eat  quite  as  much  as  any  two  men  with  large  appetites ;  and  as  a  result  she 
becomes  gross,  turgid,  often  covered  with  blotches  or  pimples,  and  generally 
too  plethoric  to  fulfil  the  duties  of  her  position.  The  plethora,  as  first 
induced,  is  of  the  sthenic  variety,  but  it  soon  assumes  an  asthenic  character, 
and  as  the  immediate  result  the  breast  no  longer  secretes  its  quantity  of 
milk.  There  may  be  good  milk  secreted,  but  it  is  in  small  quantity,  and  this 
quantity  diminishes  daily.  The  breast  may  also  enlarge,  but  it  is  from  a 
deposition  of  fatty  tissue  in  and  about  it.  as  in  other  parts  of  the  body.  The 
veins  on  the  surface  become  less  apparent — always  a  bad  feature  in  a  suckling 
breast — till  finally  the  flow  of  milk  ceases  altogether." 

Atrophy  of  the  breast  from  the  employment  of  iodine  or  from  long  disuse 
is  also  a  cause  of  insufficiency  of  milk. 

It  is  so  necessary  for  the  health  and  development  of  the  infant  that  the 
milk  should  be  in  proper  quantity  as  well  as  quality  that  it  is  best  in  a  work 
of  this  kind  to  consider  the  treatment  of  insufficient  secretion,  and,  on  the 
other  hand,  of  excessive  secretion  and  loss  of  milk,  or  galactorrhoea  ;  and  first 
of  insufficient  or  scanty  secretion. 

The  most  efficient  mode  of  increasing  the  lacteal  secretion  is  that  which 
is  also  natural — namely,  suction  from  the  nipple.  There  are  many  cases  on 
record  in  which  this  has  produced  the  flow  of  milk  in  women  who  have  never 
borne  children,  and  even  in  men.  Baudelocque  mentions  the  case  of  a  girl 
eight  years  old  who  suckled  her  brother  for  a  month,  and  cases  at  the  opposite 
extreme  of  life  have  been  reported — one  of  a  woman  of  seventy  years  who 
wet-nursed  a  grandchild  twenty  years  after  her  last  confinement. 

The  following  case,  which  was  under  my  observation,  is  interesting  in  this 

connection  :  Lizzie  S was  confined  with  her  first  child  on  May  30,  1876. 

When  the  baby  was  a  few  days  old,  and  before  she  had  left  the  bed,  she  had 
inflammatory  symptoms  which  proved  to  be  due  to  pelvic  cellulitis.  Its 
course  was  tedious  ;  her  milk  diminished,  and  its  secretion  soon  ceased.  On 
or  about  the  first  of  August  she  began  to  sit  up,  and  on  August  11th  she 
was  admitted  into  the  Sixty-first  street  branch  of  the  Infant  Asylum,  pale 
and  wasted,  but  with  returning  appetite.  She  had  no  mammary  secretion  for 
eleven  weeks,  and  her  breasts  were  small  and  flabby.  She  had  two  fistulous 
openings,  one  vaginal  and  the  other  low  down  in  the  back,  near  the  lower  end 
of  the  sacrum  or  the  coccyx.  The  baby  was  in  a  fair  condition,  having  been 
wet-nursed  by  other  women.  Experiences  in  this  and  other  institutions  show 
that  infants  having  breast-milk  do  far  better  and  are  much  more  likely  to 
live  than  those  without  breast-milk,  and  the  mother  was  therefore  advised  by 


SCANTINESS   OF  MILK.  57 

one  of  the  managers — himself  a  physician — to  suckle  her  baby,  although 
there  was  not  a  drop  of  milk  in  her  breast  and  nursing  had  been  suspended 
eleven  weeks.  To  the  surprise  of  the  mother  and  of  the  nurses  in  the 
house — to  whom  the  procedure  seemed  very  ridiculous — milk  began  to  appear 
in  a  few  days.  The  mother  left  the  institution  October  8th,  but  before  her 
departure  she  was  able  to  furnish  perhaps  two-thirds  the  quantity  of  milk 
which  her  infant  required.  This  case  affords  practical  illustration  of  the  fact 
that  frequent  suckling  is  the  most  efficient  galactagogue.  Mothers  sometimes, 
having  little  breast-milk,  suckle  their  babies  at  long  intervals,  and  finally, 
discouraged  at  the  unproductive  state  of  their  breasts,  resort  to  weaning, 
when  by  patience  and  more  frequent  use  of  their  breasts  they  might  become 
good  wet-nurses.  In  the  cities  and  during  the  summer  season,  in  which  breast- 
milk  is  so  much  required,  the  history  of  cases  like  the  above,  and  the  more 
remarkable  cases  in  which  men  and  grandparents  have  had  secretion  of  milk 
and  have  suckled  infants,  should  induce  the  physician  to  withhold  his  consent 
to  premature  weaning,  which  the  disheartened  mother  is  apt  to  suggest,  unless 
indeed  he  perceives  other  reasons  for  weaning  apart  from  scantiness  of  milk. 

Travellers  among  barbarous  nations  or  tribes  have  often  observed  these 
cases  of  unnatural  lactation.  Humboldt  saw  a  man  thirty-two  years  old 
who  gave  the  breast  to  his  child  for  five  months,  and  Captain  Franklin  in 
the  Arctic  regions  met  a  similar  case.  Dr.  Livingstone  in  his  African  trav- 
els says  that  he  has  examined  several  cases  in  which  a  grandchild  has  been 
suckled  by  a  grandmother,  and  equally  remarkable  instances  of  wet-nursing 
occur  among  the  negroes  of  the  Southern  and  Middle  States.  Professor 
Hall  presented  to  his  class  in  Baltimoi'e  a  male  negro,  fifty-five  years  old, 
who  wet-nursed  all  the  children  of  his  mistress.  In  these  cases  of  abnormal 
lactation,  so  far  as  we  have  accurate  records  of  them,  it  is  ascertained  that 
the  breasts  were  torpid,  and  even  sometimes,  as  in  old  people,  atrophied,  till 
the  nursing  commenced.  Titillation  or  pressing  of  the  nipple  caused  an  afflux 
of  blood  to  the  gland  and  developed  its  functional  activity,  so  that  milk  was 
produced  for  the  sustenance  of  the  nursling.  Therefore,  in  case  of  scanty 
secretion  of  milk  the  mother  may  increase  the  quantity  by  applying  the 
infant  often  to  the  breast.  If,  dissatisfied  with  the  small  amount  of  nutri- 
ment which  it  receives,  it  refuse  to  make  the  necessary  suction,  any  other 
mode  of  gentle  traction  or  pressure  may  be  employed  in  addition.  The  occa- 
sional employment  of  another  infant  or  a  pup,  milking  the  breast  with  the 
thumb  and  fingers,  or  the  gentle  suction  of  a  breast-pump,  aids  in  stimulat- 
ing the  secretion.  Forcible  rubbing  or  traction  of  the  breast  defeats  the  pur- 
pose for  which  it  is  employed.  It  produces  too  much  irritation  and  tender- 
ness. The  best  mode  of  stimulation  is  by  nursing,  as  it  is  the  natural  mode, 
and  the  eff"ect  of  the  infant  at  the  breast  upon  the  maternal  instincts  aids  in 
promoting  the  secretion. 

Another  mode  of  increasing  the  functional  activity  of  the  mammary  glands 
is  by  the  electrical  current.  The  fact  is  established  by  physiological  experi- 
ments that  glandular  organs  can  be  made  to  secrete  more  actively  by  the 
stimulus  of  electricity,  and,  accordingly,  this  agent  has  been  successfully 
employed  to  promote  the  secretion  of  milk.  In  Eouth's  Infant  Feeding 
several  cases  are  related  which  show  the  beneficial  eff'ects  of  this  agent 
(page  149  ef  seq.).  Among  them  are  six  reported  by  Dr.  Skinner  of  Liver- 
pool. In  all  these  one  or  two  applications  of  the  electrical  current  sufficed 
to  restore  the  secretion.  The  following  is  Dr.  Skinner's  mode  of  employing 
this  treatment : 

"  1.  Direct. — Both  poles  must  terminate  in  cylinders,  with  sponges  well 
moistened  in  tepid  water.  The  positive  pole  is  pressed  deep  into  the  axilla, 
while  the  negative  is  lightly  applied  to  the  nipple  and  the  areola,  the  current 


58  WEIGHT,    GROWTH,   LACTATION. 

being  no  stronger  than  is  agreeable  to  the  patient's  feelings.     The  poles  are 
kept  in  this  position  for  about  two  minutes. 

"  2.  Intramammary . — The  poles  are  to  be,  as  it  were,  imbedded  in  the 
mamma  and  moved  about,  raising  and  depressing  both  poles  at  once  in  and 
around  the  organ  for  the  space  of  another  two  minutes.  The  same  is  to  be 
done  to  both  breasts  daily  until  the  secretion  is  properly  established.  Hith- 
erto one  or  two  sittings  have  always  sufficed  in  my  hands"  (^Communication 
of  Dr.  Skinner  to  Dr.  Houfh). 

In  all  cases  of  scanty  secretion  of  milk  the  regimen  of  the  mother  is  a  mat- 
ter of  importance.  Personal  and  domiciliary  cleanliness  is  essential  for  success- 
ful wet-nursing.  A  certain  amount  of  exercise  in  the  open  air  is  conducive  to 
the  health  of  the  mother  and  to  the  secretion  of  abundant  and  healthy  milk. 
A  case  is  related  to  show  the  effect  of  fresh  air  and  out-door  exercise  on  the 
lacteal  'secretion.  A  lady  of  cleanly  habits,  living  in  London,  had  a  very 
scanty  supply  of  milk.  She  removed  to  the  pure  air  of  the  seashore,  and 
immediately  the  quantity  became  abundant  and  continued  so  for  months. 
Such  cases  are  not  infrequent.  A  mode  of  life  that  contributes  to  the  gene- 
ral health  of  the  mother  will  not  fail  to  augment  the  quantity  of  her  milk  if 
it  be  scanty,  and  to  improve  its  quality. 

Much  has  been  written  in  reference  to  the  diet  of  women  who  suckle.  It 
is  a  popular  belief  that  certain  articles  of  food  promote  the  secretion  of  milk 
much  more  than  other  articles,  though  equally  nutritious.  No  doubt  writers 
have  erred  in  recommending  exclusively  this  or  that  kind  of  food  as  most 
likely  to  produce  milk.  The  exact  kind  of  food  which  is  preferable  in  a 
certain  case  depends  partly  on  the  physique  of  the  individual  and  partly  on 
the  character  of  the  food  to  which  she  has  been  accustomed.  A  mixed  diet 
contributes  most  to  the  sustenance  of  the  mother  and  to  an  abundant  secretion 
of  milk.  Animal  substances  which  furnish  a  due  supply  of  nitrogenous  ali- 
ment should  be  given  with  the  farinaceous.  Mothers  pallid  and  inclining  to 
an  anaemic  condition  require  a  larger  proportion  of  animal  diet  than  those 
in  good  general  health.  On  the  other  hand,  plethoric  women,  such  as  Routh 
describes,  who  with  excellent  appetite  consume  large  quantities  of  food,  and 
who  become  more  and  more  full-blooded  and  corpulent  while  the  milk  dimin- 
ishes, require  a  more  restricted  animal  diet  in  connection  with  more  exercise, 
especially  in  the  open  air. 

There  are  certain  kinds  of  food  which  do  appear  to  have  a  galactagogue 
effect  with  most  wet-nurses.  Oatmeal  gruel  is  one  of  these.  Wet-nurses 
often  remark,  after  taking  a  bowl  of  this,  that  they  feel  the  flow  of  milk.  Cow's 
milk  with  some  has  a  similar  effect.  Porter  or  ale,  taken  once  or  twice  a  day, 
also  promotes  the  secretion  of  milk,  especially  in  those  who  have  poor  appe- 
tite and  whose  systems  are  somewhat  reduced. 

A  great  variety  of  medicines  have  been  used  for  their  supposed  galacta- 
gogue effect.  Medicines  which  improve  the  general  health  are  no  doubt 
sometimes  useful  for  this  purpose,  such  as  the  vegetable  and  ferruginous 
tonics  and,  perhaps,  cod-liver  oil.  But  there  are  other  medicines  which  it  is 
claimed  have  a  specific  effect  on  the  mammary  gland,  promoting  its  secretion. 
Lettuce,  wintergreen,  fennel,  the  broom  tops  (scoparius),  and  marshmallow 
have  been  used  for  this  purpose.  There  can  be  no  doubt  that  the  aromatic 
stimulants,  as  fennel,  anise,  and  earraway  seed,  given  in  soups,  sometimes 
stimulate  the  lacteal  secretion.  Another  medicine  which  has  been  recom- 
mended to  the  profession  as  a  galactagogue  is  castor  oil  and  the  plant  from 
which  it  is  derived. 


EXAMINATION  OF   WET-NURSE.  59 

CHAPTER    V. 

SELECTION  OF  A   WET-NURSE. 

In  the  cities  cases  are  frequent  in  which  mothers,  with  all  possible  care 
or  endeavor,  find  themselves  unable  to  suckle  their  infants.  Their  health  is 
too  poor  or  the  milk  possesses  the  properties  of  colostrum,  or  it  is  no  longer 
secreted  on  account  of  nervous  excitement  or  exhaustion  or  inflammation  of 
the  breasts.  The  number  of  such  cases  in  the  city  would  surprise  phy.sicians 
who  arc  familiar  only  with  the  healthy  and  robust  mothers  of  the  country. 
The  infant  thus  deprived  of  the  mother's  milk  should,  if  practicable,  be  fur- 
nished with  a  wet-nurse. 

The  selection  of  a  wet-nurse  often  devolves  upon  the  physician,  and  is  a 
duty  of  great  responsibility.  It  is  better  to  select  one  between  the  ages  of 
twenty  and  thirty  years,  and  one  who  has  suckled  an  infant  previously.  A 
wet-nui'se  between  the  ages  of  twenty  and  thirty  is  usually  more  active, 
cheerful,  and  conciliatory  than  one  of  a  more  advanced  age,  and  her  milk  is 
more  apt  to  be  abundant  and  nutritious.  Those  who  have  previously  suckled 
and  had  charge  of  infants  are  obviously  more  competent  to  serve  as  wet-nurse 
than  are  primipar;T3.  The  milk  of  a  wet-nurse  whose  infant  is  under  the  age 
of  six  months  will  ordinarily  agree  with  a  new-born  infant.  If  above  that 
age  it  sometimes  agrees,  but  often  does   not. 

The  most  difficult  and  responsible  task  imposed  on  the  physician  in  the 
selection  of  a  nurse  is  to  ascertain  the  exact  condition  of  her  health  and  the 
quantity  and  quality  of  her  milk.  Constitutional  syphilis  is  common  in  the 
class  of  women  who  present  themselves  for  wet-nursing ;  it  is  often  latent  or 
its  symptoms  are  easily  concealed,  and  it  is  communicable  by  lactation.  The 
virus  may  be  received  by  the  infant  from  fissures  or  excoriations  of  the  nip- 
ple. The  nursling  tainted  by  syphilis  may,  on  the  other  hand,  communicate 
the  disease  to  the  nurse  through  the  same  source.  It  is  not  fully  ascertained 
whether  the  syphilitic  virus  may  be  conveyed  to  the  infant  by  the  milk.  But 
the  cases  which  have  accumulated  in  the  records  of  medicine  are  numerous  in 
which  infants  born  of  healthy  parents  have  contracted  syphilis  from  the 
breasts  of  diseased  nurses  (see  article  Syphilis).  These  infants  have  some- 
times led  a  short  and  miserable  existence,  and  have  occasionally  increased  the 
misery  of  the  household  by  imparting  the  disease  to  others.  The  duty  is 
therefore  imperative  on  the  part  of  the  physician  to  examine  carefully  the 
wet-nurse  in  reference  to  any  evidences  of  the  syphilitic  taint.  Acquainted 
with  the  symptoms  of  syphilis,  he  may  usually,  by  shrewd  questioning  and 
by  careful  examination  of  the  present  appearance  and  condition  of  the 
woman,  ascertain  with  considerable  certainty  whether  her  system  has  ever 
been  infected.  References  should  also  be  obtained  and  consulted,  and, 
if  practicable,  the  phy.sician  who  has  attended  her  be  communicated  with. 

It  is  safer  to  employ  a  wet-nurse  two  months  after  her  confinement  than 
previously,  for  if  she  have  the  syphilitic  taint  it  will  by  this  time  show  itself 
in  the  innutrition,  coryza,  and  anal  sores  of  her  infant. 

There  are  also,  among  the  women  who  present  themselves  for  wet-nursing 
in  the  cities,  many  of  a  scrofulous  habit  and  many  who  possess  an  hereditary 
tendency  to  tuberculosis,  if  indeed  they  do  not  already  have  the  incipient 
disease.  Such  applicants  should  be  rejected  on  account  of  the  poverty  of 
their  milk  and  the  probability  that  they  will  not  be  able  to  endure  the  debil- 
itating eflfeet  of  wet-nursing. 

The  milk  should  be  examined  in  order  to  ascertain  its  richness  and  quan- 
tity and  whether  it  contain  colostrum.     If  there  be  colostrum  after  the  eighth 


60  SELECTION  OF  A    WET-NURSE. 

day,  it  is  probable  that  there  is  some  fault  in  the  health  or  digestion  of  the 
wet-nurse,  and  that  her  milk  may  disagree  with  the  infant.  It  is  not  neces- 
sary that  the  breast  should  be  large  in  order  to  furnish  a  sufficient  quantity 
of  milk,  since,  as  has  been  already  stated,  in  some  the  secretory  function  is 
active  during  the  time  of  each  nursing,  so  that,  although  the  breasts  are  of 
moderate  size,  a  sufficient  amount  of  milk  is  furnished.  The  nipples  should 
be  well  formed  and  prominent,  and  preference  should  be  given  to  those  wet- 
nurses  in  whom  blood-vessels  are  seen  ramifying  over  the  breasts. 

By  examination  of  the  milk  its  degree  of  richness  can  be  readily  ascer- 
tained. A  quantity  of  it  should  be  placed  in  a  test-tube,  and  the  cream 
which  rises  to  the  top  indicates,  approximately,  the  character  of  the  milk. 
Good  milk  furnishes  3  per  cent,  of  cream,  and  the  casein  and  sugar  usually 
correspond  in  quantity  with  the  cream.  An  instrument  has  been  invented, 
called  the  lactometer,  by  which  the  exact  amount  of  the  cream  can  be  ascer- 
tained. It  is  simply  a  tube  graded  into  one  hundred  divisions.  It  is  placed 
upright  and  filled  with  milk,  and  the  number  of  divisions  occupied  by  the 
cream  indicates  its  proportion  in  one  hundred  parts.  The  lactoscope  is 
another  instrument  employed  for  the  purpose  of  ascertaining  the  richness 
of  the  milk.  It  consists  of  two  concentric  tubes  which  move  upon  each 
other.  Milk  which  we  wish  to  examine  is  poured  within  the  tubes  sufficient 
to  obscure  a  light  viewed  through  it  three  feet  distant.  The  column  of  milk 
is  then  diminished  till  the  light  begins  to  be  visible.  The  size  of  the  col- 
umn indicates  the  degree  of  opacity  and  the  richness.  The  lactoscope  was 
invented  by  M.  Donne,  and  is  described  by  him. 

Dr.  Minchin  recommends  a  simple  mode  of  determining  the  richness  of 
cow's  milk,  and  it  would  equally  answer  for  the  breast-milk.  A  vessel  hold- 
ing about  one  ounce,  and  containing  a  graduated  enamel  slab  passing  diago- 
nally from  above  downward,  is  filled  with  milk.  It  is  then  covered  with  a 
glass  slide  carried  over  it  in  such  a  way  as  to  exclude  bubbles.  The  number 
of  degrees  which  can  be  read  indicates  the  character  of  the  milk  as  regards 
its  richness. 

Examination  of  the  milk  by  the  microscope  not  only  enables  us  to  deter- 
mine whether  there  are  abnormal  corpuscles  or  granular  elements,  but  also 
its  richness.  It  should  be  examined  before  the  cream  has  separated.  Oil- 
globules  of  small  size  and  few  indicate  poverty  of  the  milk ;  very  large  oil- 
globules  are  said  to  indicate  milk  which  is  apt  to  be  indigestible,  especially 
in  feeble  infants.  Such  are  the  free  globules  of  the  colostrum.  Numer- 
ous oil-globules  of  medium  size  indicate  nutritious  milk.  In  examining  the 
milk  by  the  microscope  or  otherwise  in  order  to  determine  its  richness,  the 
important  fact  should  be  borne  in  mind  that  milk  removed  from  the  breast 
at  short  intervals  is  richer  or  more  concentrated  than  that  removed  at  long 
intervals,  as  we  have  stated  elsewhere.  A  larger  percentage  of  water  is 
present  if  the  interval  be  four  hours  than  if  it  be  two  hours.  Another  im- 
portant fact  which  should  be  borne  in  mind  in  testing  the  milk  is  that  that 
first  drawn  from  the  breast  is  more  watery,  or  not  so  rich,  as  that  last 
removed  or  the  stripping,  as  is  seen  by  the  following  analysis,  made  by 
Harrington  and  published  by  Rotch  in  his  interesting  paper  on  infant 
feeding  in  the    Qjdopaedia  of  Diseases  of  Children  : 


Total 
.Solids, 


Fat.  ^Tl  Water.  Ash. 


Fore  milk 3.88  13.34  86.66  0.85 

Middle  milk  ....  6.74  15.40  84.60  0.81 

Strippings 8.12  17.13  82.87  0.82 

The  increase  in  the   solid  constituents  of  the  milk  near  the  close  of  a 

nursing  is  said  to  be  chiefly  of  fat,  but  partly  of  the  albuminoids.     It  is 


EXAMINATION  OF   WET-NURSE.  61 

evident,  therefore,  that  the  milk  obtained  from  a  breast  that  is  emptied  at 
short  intervals  is  richer  than  that  obtained  when  the  breast  is  drawn  at  long 
intervals. 

Rotch  publishes  the  following  analysis  made  by  Harrington,  in  which 
this  fact  is  clearly  shown  : 

Milk  drawn  at  two  Milk  drawn  at  twelve 

hours'  interval.  hours'  interval. 

Total  solids  ....  15.32  10.14 

Water 84.68  89.86 

100.00  100.00 

Vogel  in  1850  made  the  discovery  of  vibriones  in  human  milk.  The 
fact  is  established  that  these  animalcules  may  be  generated  in  the  milk  within 
the  breast,  though  such  cases  are  not  frequent.  Dr.  Gibb  describes  a  case 
which  he  met  {Rankimfs  Abstract,  vol.  xxxiv.)  :  An  infant  seven  weeks  old, 
wet-nursed  by  its  mother,  who  had  the  appearance  of  perfect  health,  was, 
nevertheless,  ill-nourished  and  emaciated.  It  had  no  diarrhoea  or  other  appa- 
rent disease,  and  the  milk  was  therefore  examined.  Vibriones  were  dis- 
covered in  the  milk  immediately  after  it  was  obtained  from  the  breast.  The 
milk  had  the  usual  amount  of  cream,  and  seemed  to  the  naked  eye  of  good 
quality.  According  to  Dr.  Gibb,  two  genera  of  microscopic  organisms  occur 
in  the  milk — namely,  vibriones  and  monads.  It  is  believed  that  the  monads 
occur  in  consequence  of  fermentation  of  the  sugar  and  the  production  of 
lactic  acid.  Vogel  also  attributed  the  production  of  the  vibriones  to  fermen- 
tation occurring  in  consequence  of  heat  and  congestion  of  the  breast  connected 
with  sexual  excitement.  This  explanation  is  probably  not  correct,  because 
vibriones  sometimes  occur  when  there  is  no  unusual  heat  of  breast  and  no 
evidence  of  fermentation.  The  fact  that  such  organisms  may  be  found  in 
milk  which  seems  of  good  quality  to  the  naked  eye  affords  additional  proof 
of  the  usefulness  of  the  microscope  in  selection  of  a  wet-nurse. 

Many  wet-nurses  have  a  return  of  the  menses  as  early  as  the  fourth  or 
fifth  month  after  delivery.  The  re-establishment  of  this  function  in  some 
women  impairs  the  quality  of  the  milk,  so  as  to  render  it  less  nutritious,  and 
perhaps  less  digestible,  during  the  time  of  the  catamenial  flow,  as  we  have 
stated  in  a  preceding  paragraph.  In  the  selection  of  a  wet-nurse,  then,  pref- 
erence should  be  given  to  one  who  does  not  have  the  periodical  sickness ; 
but  if  she  be  already  employed  and  give  satisfaction,  the  reappearance  of 
the  catamenia  does  not  indicate  the  need  of  the  change  of  nurse,  unless  the 
digestion  of  the  infant  be  disordered  or  its  nutrition  be  impaired. 

In  the  selection  of  a  wet-nurse  attention  should  also  be  given  to  her 
mental  and  moral  traits.  Cheerfulness,  affection,  veracity,  and  a  proper 
appreciation  of  the  responsibility  of  her  situation  enhance  greatly  the  value 
of  a  wet-nurse.  Not  less  important  are  habits  of  temperance  and  cleanli- 
ness. I  could  cite  cases  of  the  most  melancholy  results  from  the  absence 
of  these  traits.  In  one  case  idiocy  resulted  from  an  infant  falling  upon  the 
pavement  from  the  arms  of  a  reckless  or  intemperate  wet-nurse. 

In  most  cases  the  mode  of  examination  indicated  above  suffices  to  show 
the  character  of  a  wet-nurse,  so  far  as  her  health  and  milk  are  concerned. 
It  should  be  borne  in  mind,  however,  that  the  microscope  does  not  always 
reveal  deleterious  properties  in  the  milk.  Elements  which  are  in  a  state  of 
solution,  and  are  invisible,  may  occur  in  excess,  so  as  to  impair  the  quality 
of  the  milk  and  render  it  indigestible.  The  following  case,  in  which  the 
saline  ingredients  seem  to  have  been  in  excess,  is  related  by  Dr.  Hartnian 
(^British  and  Foreign  Medical  Review,  vol.  xii.)  :  '"An  infant  whose  mother 
was  in  good  health  and  had  borne  several  children  exhibited  a  healthy  appear- 


62  COURSE  OF  WET-NURSING— WEANING. 

ance  for  the  first  five  weeks  after  birth.  The  alvine  evacuations  then  became 
copious,  fluid,  and  discolored,  and  the  child  lost  flesh  and  strength.  After 
the  usual  remedies  had  been  vainly  administered  for  a  fortnight,  the  mother 
remarked  that  the  child  did  not  take  the  right  breast  willingly,  and  so  much 
did  the  unwillingness  increase  that  at  length  the  mere  application  of  the  nip- 
ple to  the  child's  lips  occasioned  loud  crying.  On  examination  it  was  found 
that  the  milk  of  the  right  breast  had  a  distinctly  saline  taste,  whereas  the 
milk  of  the  opposite  breast  was  of  the  ordinary  sweetness ;  no  difierence  of 
consistence  or  color  was  discoverable.  From  that  time  the  child  was  only 
allowed  to  nurse  the  left  breast,  and  in  a  few  days  all  diarrhoea  and  sickliness 
of  appearance  vanished."  In  this  case  there  was  no  appreciable  disease  of 
the  breast,  although  its  secretion  was  perverted.  The  deleterious  character 
of  the  milk  was  discovered,  not  by  any  change  in  its  appearance,  but  by 
the  taste. 

It  is  obviously  very  necessary,  before  recommending  a  wet-nurse,  to  ascer- 
tain whether  she  will  probably  furnish  sufficient  milk  ;  for,  however  excellent 
she  may  otherwise  be,  if  she  do  not  satisfy  the  wants  of  the  infant  she  obvi- 
ously should  not  be  employed.  If  the  infant  of  the  nurse  be  well  nourished, 
and  if  it  seem  satisfied  after  nursing  ten  or  fifteen  minutes,  she  probably  has 
sufiicient  milk.  The  more  exact  method  of  weighing  the  infant  before  and 
after  it  nurses,  and  observing  whether  the  difi'erence  corresponds  with  that 
given  in  Chapter  VII.,  enables  us  to  determine  more  accurately  the  capabil- 
ities of  the  wet-nurse. 


CHAPTER  VI. 

COURSE  OF  WET-NURSING— WEANING. 

After  the  birth  of  the  infant  the  mother  needs  rest  a  few  hours — four 
or  five  or  a  little  longer  in  tedious  and  exhaustive  cases — and  then  it  should 
be  applied  to  the  breast.  There  is  frequently  a  little  milk  at  this  time,  and 
the  act  of  nursing  promotes  the  secretion  and  increases  the  quantity.  The 
full  secretion  is  not,  however,  established  before  the  third  day,  and,  though 
the  infant  be  applied  to  the  breast  often,  it  obtains  but  little  milk.  Infants 
are  so  constituted  that  they  require  but  little  food  until  it  is  naturally  pro- 
vided for  them,  and  the  common  practice  of  feeding  them  to  repletion  with 
various  sweetened  mixtures  almost  as  soon  as  life  begins,  because  they  obtain 
little  breast-milk,  is  to  be  deprecated.  Filling  their  stomachs  in  this  way  has 
a  tendency  to  prevent  their  drawing  upon  the  nipples  with  the  avidity  which 
is  required  to  stimulate  a  free  flow  of  milk.  Besides,  as  I  have  many  times 
observed,  indigestion,  diarrhoea,  and  sprue  are  common  results  of  this  inju- 
dicious feeding.  If,  therefore,  the  infant  be  applied  to  the  breast  every 
second  hour  when  the  mother  is  awake  till  the  third  day,  and  be  fed  nothing 
besides,  there  need  be  no  anxiety  as  regards  its  nutrition.  If  on  the  third 
day  the  breasts  do  not  begin  to  fill  and  the  secretion  be  delayed,  a  little  fresh 
cow's  milk,  diluted  with  double  its  quantity  of  warm  water,  and  slightly 
sweetened,  should  be  given  every  fourth  hour,  but  should  be  withheld  as. 
soon  as  the  flow  of  milk  occurs. 

Infants  under  the  age  of  one  month  should  nurse  about  every  hour  and 
a  half  by  day  and  at  longer  intervals  by  night,  or  about  twelve  times  in 
twenty-four  hours,  for  the  stomach  of  the  new-born  holds  but  little,  and 


AILMENTS  OF  NURSING  INFANTS.  63 

therefore  receives  but  little  at  each  nursing,  and  its  digestion  is  active. 
The  interval  should  be  longer  at  night  than  in  the  day-time,  so  as  to  allow 
the  mother  more  sleep.  In  the  second  month  the  interval  should  be  about 
two  hours,  and  it  should  be  gradually  lengthened  as  the  age  increases,  so  that 
after  the  fourth  month  nursing  should  be  about  every  third  hoar,  and  after 
the  sixth  month,  when  the  use  of  some  artificial  food  is  proper,  every  fourth 
hour. 

The  infant  should  be  habituated  to  nursing  at  regular  intervals,  and  when 
it  is  it  will  ordinarily  awaken  at  about  the  proper  time.  The  practice  on  the 
part  of  the  mother  of  applying  the  babe  to  the  breast  whenever  it  frets  and 
as  a  means  of  quieting  it,  although  it  have  but  just  nursed,  is  pernicious 
and  should  be  forbidden,  (xiving  the  stomach  no  time  to  rest  or  filling  it  to 
repletion  tends  to  produce  indigestion  and  diarrhoea  and  to  increase  its  fret- 
fulness.  The  cause  of  the  fretfulness  should  be  sought  for,  that  the  proper 
measures  may  be  applied.  In  ignorance  of  the  cause  it  is  better  to  quiet 
restlessness  by  carrying  the  child,  or  even  by  rocking  it,  than  to  increase  the 
task  of  the  digestive  function.  Fretfulness  of  infants  is  often  due  to  colic  or 
griping  produced  by  irritating  products  of  imperfect  digestion  in  the  intes- 
tines, and  the  addition  of  more  food  has  a  tendency  to  increase  rather  than 
to  diminish  it. 

While  regularity  in  nursing  is  required,  still,  as  M.  Donne  has  said, 
mathematical  exactness  in  this  matter  would  be  ridiculous.  Quiet  natural 
sleep  of  a  well-nourished  infant  should  not  be  interrupted  in  order  to  give  it 
the  breast,  unless  the  sleep  be  unusually  protracted.  It  will  usually  awaken 
when  the  system  requires  more  nutriment.  Ill-nourished  infants  often  sleep 
but  little,  making  known  their  want  by  crying  and  fretfulness,  until  they 
become  wasted  and  prostrated,  when  they  are  drowsy  in  consequence  of  pas- 
sive congestion  of  the  brain.  This  drowsiness  is  evidently  a  pathological 
symptom.  It  shows  the  need  of  increased  nutrition.  It  is  due  to  scantiness 
of  milk  or  milk  of  poor  quality,  and  the  infant  should  be  aroused  frequently 
for  the  purpose  of  giving  it  nutriment  or  even  stimulants.  The  breast-milk 
is  sufficient  for  its  nutrition  till  the  age  of  six  or  eight  months,  provided  that 
it  is  abundant  and  of  good  quality.  Therefore,  if  the  mother  be  strong  and 
experience  no  exhaustion,  no  other  nutriment  need  be  given  till  that  age. 

Many  mothers,  however,  by  the  third  or  fourth  month  of  wet-nursing  find 
that  they  have  not  sufficient  milk  to  meet  the  wants  of  the  infant.  The  con- 
stant drain  upon  their  systems  sensibly  impairs  their  health.  In  such  cases 
it  is  proper  to  commence  with  a  little  feeding  from  the  spoon  or  bottle,  and 
increase  the  quantity  given  as  the  infant  grows  older.  Great  care  is,  how- 
ever, requisite  in  the  preparation  of  food  for  so  young  an  infant,  whose 
digestive  organs  are  still  feeble  and  easily  deranged.  In  the  country,  where 
diarrhoeal  affections  and  the  so-called  gastric  derangements  are  not  frequent, 
the  danger  from  artificial  feeding  is  less  than  in  the  city,  and  in  the  cool 
months  in  the  city  the  danger  is  less  than  in  the  summer  season.  Infants  of 
the  city  between  the  months  of  May  and  October  have  a  strong  predisposition 
to  diarrhoeal  attacks,  the  result  of  antihygienic  influences  which  surround 
them.  Errors  of  diet  in  their  case  readily  provoke  disease  or  derangement 
of  the  digestive  organs,  often  of  a  severe  and  dangerous  form.  Moreover, 
experience  has  shown  that  artificial  feeding  during  the  period  when  nature 
designed  that  they  should  be  nourished  at  the  breast  very  commonly  produces 
in  the  hot  months  more  or  less  vomiting  and  diarrhoea,  followed  by  emacia- 
tion and  other  evidences  of  malnutrition.  Therefore  an  exception  must  be 
made  in  case  of  the  city  infant  as  regards  the  commencement  of  artificial 
feeding.  If  it  be  under  the  age  of  one  year,  it  should  be  nourished  exclu- 
sively, or  almost  exclusively,  at  the  breast  during  the  hot  months  when  prac- 


64  QUANTITY  OF  FOOD  REQUIRED. 

ticable,  even  if  the  mother  suffer  somewhat  in  her  health  from  the  constant 
drain  upon  her  system.  It  should,  however,  receive  the  amount  of  nutriment 
which  it  requires,  and,  if  there  be  not  sufficient  breast-milk,  it  will  be  neces- 
sary to  supply  the  deficiency  by  artificial  feeding.  The  reader  is  referred  to 
Chapter  VIII.  for  facts  relating  to  the  subject  of  artificial  feeding. 

Weaning  ought  to  take  place,  as  a  rule,  between  the  ages  of  ten  and 
twelve  months.  It  is  well,  if  the  mother's  health  be  good  and  her  milk 
sufficient,  to  defer  weaning  till  the  canine  teeth  appear.  The  infant,  then 
possessing  sixteen  teeth,  is  able  to  masticate  the  softer  kinds  of  solid  food. 
Weaning  should  be  gradual.  Mothers  often  speak  of  weaning  on  a  certain 
day.  Tney  have  given  but  little  artificial  food  and  have  suckled  at  regular 
intervals,  till  at  a  fixed  time  they  have  denied  the  breast  altogether.  This 
abrupt  change  of  diet  should  be  discouraged.  It  should  only  be  recom- 
mended under  peculiar  circumstances.  It  is  apt  to  derange  the  digestive 
organs,  and  it  causes  fretfulness  and  sleeplessness  on  the  part  of  the  infant 
for  a  week  or  more.  Weaning  should  commence  by  feeding  with  a  spoon  a 
little  oftener  through  the  day,  and  nursing  less,  and  by  discontinuing  the 
practice  of  suckling  at  night.  The  infant  tolerates  this  gradual  change  of 
diet,  while  it  rebels  against  sudden  weaning,  and  by  its  fretfulness  increases 
greatly  the  care  and  trouble  of  the  mother.  Nurslings  in  the  city  should 
not  be  weaned  in  warm  weather  nor  within  a  month  immediately  preceding 
it.  If  the  mother's  health  fail  or  her  milk  become  deficient  in  the  summer 
months,  so  that  she  cannot  continue  suckling,  a  wet-nurse  should  be  employed, 
or  the  infant  should  be  sent  to  some  rural  locality  and  weaned  there.  Wean- 
ing in  the  city  in  hot  weather  should,  if  practicable,  be  avoided  on  account 
of  the  liability  to  the  summer  diarrhoea  produced  by  change  of  diet,  although 
I  believe  there  is  less  danger  from  this  than  formerly^  since  we  now  under- 
stand better  how  to  feed  infants. 


CHAPTER    YII. 

QUANTITY  OF  FOOD  EEQUIRED  IN  INFANCY  AND  CHILDHOOD. 
Infantile  Feeding. 

Over-feeding. — Nearly  half  a  century  has  elapsed  since  the  most  distin- 
guished New  England  physician  of  his  day.  Dr.  James  Jackson  of  Boston, 
wrote  in  his  Letters  to  a  Young  Physician  that  a  certain  ailment  of  the  diges- 
tive system  of  infants  had  often  puzzled  him  when  a  young  practitioner.  It 
was  characterized  by  the  occurrence  of  green  and  unhealthy  stools,  showing 
imperfect  digestion.  The  stools  contained  an  unusual  amount  of  mucus,  and 
were  passed  more  frequently  than  the  normal  stools  of  a  healthy  infant. 
After  observing  many  infants  thus  affected,  and  ascertaining  the  manner  and 
frequency  of  their  feeding,  the  truth  gradually  dawned  upon  him  that  their 
unhealthy  evacuations  were  due  to  over-feeding.  By  diminishing  the  amount 
of  nutriment  given  and  lengthening  the  intervals  between  the  feedings,  these 
infants  were  soon  cured. 

Suction  by  the  lips  of  the  infant  seems  to  be  to  a  great  extent  automatic, 
so  that  if  its  mother  or  wet-nurse  have  a  copious  supply  of  milk,  it  is  liable 
to  over-nurse,  or,  if  it  be  bottle-fed,  is  liable  to  take  more  from  the  bottle 
than  it  requires  for  its  nutrition.     Some  infants  if  over-fed  regurgitate  the 


INSUFFICIENT  NOURISHMENT.  66 

surplus  food,  but  others  do  not,  and  tlie  portion  which  is  not  digested  under- 
goes fermentation  and  acts  as  an  irritant  to  the  stomach  and  intestines. 
Acids,  as  the  butyric  and  hictic,  and  gases  which  distend  the  stomach  and 
intestines  and  cause  colicky  pains,  form  from  the  fermentation.  An  infant 
thus  suffering  from  overtaxed  digestion,  and  from  the  presence  of  irritating 
acids  and  gases  in  the  stomach  and  intestines,  is  usually  fretful  and  its  sleep 
is  disturbed  and  broken.  The  cause  of  its  restlessness  is  often  misunder- 
stood by  the  mother,  who  thinks  it  may  be  due  to  insufficient  nutriment,  and 
accordingly  it  is  applied  more  frequently  to  the  breast,  or,  if  it  be  bottle-fed, 
it  is  given  the  bottle  more  frequently.  I  have  seen  not  a  few  over-fed  infants 
who  on  account  of  their  fretfulness  were  applied  to  the  breast  at  intervals  of 
a  few  minutes,  so  that  the  health  of  their  mothers  was  impaired  by  the  lack 
of  sleep  and  the  drain  upon  their  systems  ;  and  the  infants,  on  account  of 
too  frequent  nursing,  suffered  indigestion,  and  occasionally  from  gastro-intes- 
tinal  catarrh.  Moreover,  milk  drawn  too  frequently  from  the  breast  usually 
contains  an  excess  of  the  solids,  so  that  it  is  digested  with  more  difficulty 
than  when  it  is  drawn  at  the  proper  intervals,  as  I  have  elsewhere  stated. 
For  this  reason  also  too  frequent  application  of  infants  to  the  breast  is  likely 
to  cause  indigestion  and  gastro-intestinal  derangements. 

Cases  might  be  related  to  substantiate  these  statements.  Thus  in  Decem- 
ber last  I  attended  an  infant  of  four  months  that  had  been  very  fretful  and 
with  insufficient  sleep  for  weeks.  The  wet-nurse  who  had  charge  of  it  had 
apparently  the  proper  requisites,  such  as  health,  youth,  robustness,  and  well- 
developed  breasts,  which  seemed  to  furnish  sufficient  milk  and  of  good  qual- 
ity. But  the  infant,  though  fairly  nourished,  had  so  little  sleep  and  was  so 
fretful,  crying  so  much  during  the  night  as  well  as  day,  that  the  whole  house- 
hold was  deprived  of  the  needed  rest.  The  nature  of  the  baby's  ailment 
was  soon  detected,  for  its  stools  presented  appearances  indicative  of  indiges- 
tion and  intestinal  catarrh.  They  contained  numerous  rounded,  whitish 
masses,  apparently  of  casein  mixed  with  mucus  and  thin  fecal  matter. 
Pepsin  preparations  with  bismuth  were  at  first  employed,  without  any 
marked  result,  but  improvement  began  at  once  when  the  infant,  instead  of 
being  frequently  applied  to  the  breast,  as  had  been  the  practice,  was  allowed 
to  take  it  only  every  third  hour,  and  was  fed  nothing  in  the  interval.  It  had 
been  over-fed,  and  the  remedy  more  effectual  than  the  medicines  employed 
was  the  simple  one  of  its  less  frequent  application  to  the  breast.  Over-feed- 
ing is,  I  think,  more  common  with  bottle-fed  infants  than  with  those  nour- 
ished at  the  breast. 

Insufficient  Nutriment. — On  the  other  hand,  infants,  both  wet-nursed 
and  bottle-fed,  frequently  do  not  obtain  sufficient  nutriment.  In  families  of 
the  city  poor  nursing  mothers  often  have  scanty  diet  and  are  overworked,  and 
the  milk  which  they  furnish  to  their  nurslings  under  such  circumstances  is 
liable  to  be  watery  and  insufficient.  Sometimes  infants,  when  they  have 
reached  an  age  at  which  the  breast-milk  is  inadequate  and  additional  food 
is  urgently  needed,  are  nevertheless  denied  this  by  their  mothers.  Even 
mothers  who  are  apparently  robust  and  give  the  breast  at  proper  intervals, 
often  have  insufficient  milk,  so  that  their  infants  do  not  thrive,  and  they  are 
ignorant  of  the  cause.  MM.  Vernois  and  Becquerel,  on  careful  examination 
of  89  infants  wet-nursed  by  women  apparently  in  good  health,  ascertained 
that  15  were  insufficiently  nourished.  An  infant  that  obtains  sufficient  breast- 
milk  draws  the  breast  quietly  and  continuously  twelve  or  fifteen  minutes, 
when  it  releases  its  hold  of  the  nipple  and  probably  falls  into  a  quiet  sleep, 
having  a  satisfied  aspect.  If  the  breast-milk  is  scanty  and  insufficient,  the 
baby  is  fretful  when  it  nurses,  frequently  lets  go  of  the  nipple,  and  does  not 
have  the  quiet  sleep  of  the  satisfied  infant.     If  its  mouth  be  inspected  when 


66  QUANTITY  OF  FOOD  REQUIRED. 

it  is  nursing,  it  will  be  found  to  contain  but  little  milk.  But  if  the  supply 
of  breast-milk  be  abundant,  it  will  appear  in  quantity  between  the  lips  and 
in  the  mouth  of  the  infant  during  the  nursing. 

Again,  many  bottle-fed  infants  are  allowed  sufficient  food,  but  it  is  not 
adapted  to  their  age,  and  is  digested  with  difficulty,  so  that  the  nutriment 
which  they  derive  from  it  is  insufficient.  Much  has  been  said  and  written 
upon  the  practice  common  in  tenement-houses  of  giving  farinaceous  food  to 
infants  under  the  age  of  three  months,  when  the  saliva,  which  is  the  chief 
agent  that  digests  starch,  is  scanty  and  insufficient  for  its  digestion.  In  the 
feeding  of  older  children  in  families  of  the  laboring  class  we  know  how  fre- 
quently food  is  employed  that  is  unsuitable  to  the  age — that  acts  as  an  irri- 
tant to  the  stomach  and  intestines,  producing  attacks  of  vomiting  and  diar- 
rhoea. The  portion  of  such  food  that  is  digested  and  which  serves  for 
nutrition  is  insufficient,  while  the  undigested  part  acts  as  an  irritant.  Infants 
that  receive  such  unsuitable  diet  really  suffer  from  lack  of  food,  although  its 
bulk  may  be  sufficient.  They  are  hungry  from  the  lack  of  proper  nutri- 
ment, and  are  consequently  fretful.  They  digest  and  assimilate  so  small  a 
part  of  this  unsuitable  diet  that  they  lose  flesh  and  have  the  usual  symptoms 
of  innutrition. 

It  is  evident  from  this  survey  of  what  actually  occurs  in  the  feeding  of 
infants  that  while  it  is  of  the  utmost  importance  that  food  should  be  of  the 
proper  kind  according  to  the  age  and  properly  prepared,  it  is  also  equally 
necessary  for  their  successful  alimentation  that  they  be  fed  at  proper  inter- 
vals and  with  the  proper  amount  of  food.  Certain  physicians,  appreciating 
the  importance  of  a  correct  knowledge  of  the  amount  of  food  required  by 
infants,  have  made  careful  observations  in  order  to  ascertain  it.  M.  Parrot 
(^L'Athropsie,  Paris,  1877)  weighed  infants  before  and  after  each  feeding 
with  cow's  milk.  The  number  of  feedings  was  six  in  twenty-four  hours. 
His  observations  were  scarcely  sufficient  in  number  for  accurate  deductions, 
but  he  concluded  from  them  that  the  quantity  of  cow's  milk  required  in 
twenty-four  hours  is  as  follows  :  9  J  ounces  for  the  first  month,  19  ounces  for 
the  second,  third,  fourth,  and  fifth  months,  and  25  ounces  for  the  sixth  month. 
This  estimate  is  for  pure  cow's  milk,  used  without  dilution.  The  use  of 
milk  in  its  pure  state  and  undiluted  he  considers  preferable  to  that  of  diluted 
milk.  After  the  sixth  month  he  thinks  that  4^-  to  65  ounces  for  each  month 
should  be  added  to  the  quantity  previously  employed.  Meigs  and  Pepper 
mention  the  case  of  an  infant  of  four  months  that  took  36  ounces  of 
breast-milk  daily,  and  another  of  five  to  six  weeks  that  took  18  to  23 
ounces.  The  same  authors  cite  the  observations  of  M.  Bouchard,  who 
concludes,  from  weighing  infants,  that  while  the  newly-born  require  much 
less  breast-milk  than  those  who  are  older,  20  ounces  daily  are  needed 
between  the  ages  of  one  and  three  months,  23  ounces  after  the  third 
month,  27  ounces  after  the  fourth  month,  and  30  ounces  between  the  ages 
of  six  and  nine  months. 

Dr.  Ssnitkin  of  St.  Petersburg  some  time  since  prepared  a  formula  for 
determining  the  quantity  of  food  required  by  young  infants  which  he  believes 
is  a  safe  and  reliable  guide.  In  his  opinion  the  greater  the  weight  of  the 
infant  the  greater  is  the  capacity  of  its  stomach  and  the  greater  is  the  amount 
of  food  required.  If  this  rule  be  invariably  true,  or  true  in  a  large  majority 
of  instances,  the  difficult  problem  of  determining  how  much  to  feed  infants 
each  time  or  each  day  would  have  a  comparatively  easy  solution,  for  by 
weighing  the  infant  we  could  readily  determine  how  much  food  it  requires. 
Since  the  formula  devised  for  infant-feeding  by  Dr.  Seibert,  and  presented  to 
the  consideration  of  the  profession  in  this  country,  is  also  based  upon  differ- 


INSUFFICIENT  NOURISHMENT.  67 

ences  in  the  weight  of  infiints,  and  not  upon  differences  in  their  ages,  I  will 
briefly  relate  facts  which  in  my  opinion  show  the  impropriety  and  incorrect- 
ness of  this  method.  Is  it  a  fact  that  the  heaviest  animals  of  a  species  uni- 
formly require  the  most  food?  Is  not  the  amount  of  food  required  deter- 
mined to  a  considerable  extent  by  the  activity  of  the  animal  and  the  amount 
of  molecular  disintegration  consequent  on  exercise  ?  Take  two  infants  of 
the  same  age.  One  may  lead  a  sluggish  life,  being  most  of  the  time  asleep. 
It  has  a  superabundance  of  fat  and  weighs  heavily.  The  other  is  more  hours 
awake  and  its  limbs  are  more  active.  It  probably  weighs  one  or  two  pounds 
less  than  the  other  infant,  as  it  has  less  fat  and  more  frequent  evacuations. 
Does  not  the  latter  infant  require  as  much  food  as  the  former?  A  rachitic 
child  with  big  head  and  joints  and  pendulous  abdomen  may  weigh  a  pound 
more  than  a  healthy  child  of  the  same  age.  Does  he  in  consequence  require 
more  food?  A  large  proportion  of  the  infants  remaining  in  the  city  during 
the  summer  months  either  lose  or  do  not  gain  in  weight.  They  weigh  no  more, 
and  often  less,  at  the  close  of  September  than  at  the  beginning  of  June. 
Shall  we  give  them  the  same  amount  of  food,  or  even  less,  at  the  end  of 
September,  when  their  appetite  begins  to  return,  than  they  were  allowed  on 
the  first  of  June,  because  they  weigh  the  same  or  less  ?  Infants  that  have 
had  any  sickness  except  the  mildest  lose  in  weight :  must  we  diminish  the 
quantity  of  their  food  so  that  it  will  correspond  with  the  loss  of  weight  ? 
In  the  New  York  tenement-houses  a  large  proportion  of  the  infants,  even 
those  without  any  marked  ailment,  weigh  less  than  they  should  on  account 
of  their  improper  feeding.  Must  we  under  such  circumstances  give  them  at 
each  feeding  an  amount  of  food  corresponding  with  their  weight  ?  Let  me 
illustrate  by  a  case.  A  physician  in  large  practice  requested  me  to  examine 
an  infant  that  was  puny  and  delicate  and  had  ceased  growing.  It  probably 
did  not  have  more  than  three-fourths  of  the  ordinary  weight  of  infants  of 
the  same  age.  When  the  question  was  asked  how  the  infant  was  fed,  the 
physician  replied  before  the  family,  with  an  air  of  assurance,  that  he  had 
given  explicit  directions  that  the  baby  should  be  fed  with  one  teaspoonful  of 
condensed  milk  to  a  gobletful  of  water ;  and  this  had  been  the  diet  for  a 
considerable  time.  It  had  abundant  urination  with  uniformly  constipated 
bowels.  I  am  sure  that  neither  Dr.  Ssnitkin  nor  Dr.  Seibert,  had  he  been  in 
my  place,  would  have  put  this  diminutive  and  ill-used  infant  in  the  scales 
in  order  to  determine  how  much  food  to  give  it.  I  cite  these  instances  not 
to  throw  discredit  on  the  praiseworthy  investigations  of  Drs.  Ssnitkin  and 
Seibert,  but  in  order  that  I  may  ask  them  if  in  formulating  rules  for  the 
feeding  of  infants  it  is  not  necessary  to  regard  other  circumstances  besides 
the  weight,  especially  the  age.  We  know  that  improvements  in  the  care  and 
treatment  of  children,  especially  such  improvements  as  require  mechanical 
appliances,  are  seldom  perfected  at  once,  but  after  many  changes  which 
experience  suggests.  Witness,  for  example,  intubation.  Many  observations 
by  different  observers  and  under  different  circumstances  are  required,  in  my 
opinion,  in  order  to  obtain  the  data  for  formulating  rules  for  the  feeding  of 
infants  which  will  require  no  change. 

A  few  years  since  Drs.  Chadbourne,  Parker,  and  myself  made  observa- 
tions in  the  New  York  Infant  Asylum  and  New  York  Foundling  Asylum  in 
order  to  determine  how  much  food  children  require  at  different  ages.  Those 
selected  for  observation  were  well  nourished,  and  they  were  accurately  weighed 
before  and  after  each  nursing  or  feeding.  Eleven  infants  under  the  age  of 
three  weeks,  who  took  the  breast,  with  three  exceptions,  twelve  times  in  the 
twenty-four  hours,  were  found  to  take  in  the  average  12.55  ounces  of  the 
breast-milk  in  the  day  and  night,  as  is  seen  by  the  following  table : 


68 


QUANTITY   OF  FOOD  REQUIRED. 


Table  I. 

-Newli/-horn  Infants  {those  m 

der  the  Age  of  Three 

Weeks). 

Milk  nursed 

in  24  hours. 

No. 

Name. 

Age. 

Number  of 
nursings. 

Quantity  in 
weight. 

Quantity  in 
fluidounces. 

oz.      dr. 

1 

J.  F 

17  days. 

11 

10       J 

9.75 

2 

H.  C. 

16 

9 

13     5 

13.24 

3 

H.J. 

19 

9 

10     3 

10.07 

4 

R.  .    . 

5 

12 

22,  7 

22.22 

5 

H.  B. 

6 

12 

15     5i 

15.25 

6 

W.  F. 

5 

12 

10     1^ 

9.88 

7 

N.  H. 

14 

12 

17     3 

16.85 

8 

C,  F. 

5 

12 

5    4 

5.37 

9 

F.  D. 

7 

I 

12 

14    4 

14.8 

10 

E.S.  . 

6    " 

12 

8     1 

7.74 

11 

E.  B. 

3  weeks. 

12 

14     1 

13.68 

According  to  these  statistics,  infants  under  the  age  of  three  weeks  nour- 
ished at  the  breast  and  suckled  twelve  times  in  the  twenty-four  hours  require 
only  one  ounce,  or  not  more  than  one  ounce  and  a  drachm,  at  each  nursing; 
and  the  very  small  size  of  the  stomach  at  this  age  shows,  I  think,  that  it 
cannot  receive  much  more  than  this  without  distension.  After  the  third 
week  the  amount  required  for  healthy  nutrition  gradually  increases. 

Table  II. — Ages  from  One  Month  to  Ten  Months. 


Milk  nursed 

in  24  hours. 

No. 

Name. 

Age. 

Number  of 
nursiugs. 

Quantity  in 
weight. 

Quiintity  in 
fluidounces. 

oz.     dr. 

1 

A.  S 

6  months. 

8 

26     IJ 

25.3 

2 

J.  B 

4 

9 

38       J 

36.8 

3 

W.  G 

3*      " 

8 

24     2 

23.5 

4 

L.  B 

7       " 

10 

27     U 

26.6 

5 

W.  L 

5^      " 

11 

28    7 

28 

6 

J.C 

5 

31      " 

2''m.  10  d. 

10 

8 
7 

29    7 
19     2 
24    4 

29 

7 

AW 

18.6 

8 

F.  Van  B 

23.7 

9 

E.  W 

6  months. 

10 

12     4J 

12.2 

10 

F.  S 

3*      " 

8 

26    7 

26.1 

11 

s.  w 

4 

8 

23     5 

22.9 

12 

J.  G 

9 

8 

24     1^- 

23.4 

13 

B.J 

7        " 

8 

27     4 

26.6 

14 

T.  C 

6 

6       " 

10 
10 

26     U 
21     6 

26 

15 

A.  K 

21.1 

16 

C.  H 

1  m.  5  d. 

8 

11     1^ 

10.84 

The  observations  in  the  second  table  relate  to  infants  between  the  ages 
of  one  month  and  ten  months,  and,  with  one  exception,  between  the  ages  of 
two  months  and  ten  months.  It  was  found  that  they  received  in  the  average 
23.79  fluidounces  of  breast-milk  in  twenty-four  hours.  The  number  of 
nursings  in  the  day  and  night  varied  from  seven  to  ten.  Therefore  those 
infants  between  the  ages  of  one — or,  more  accurately,  two — months  and  ten 
irionths,  if  they  took  the  breast  eight  times  in  the  twenty-four  hours,  required 
three  ounces  at  each  nursing ;  if  twelve  times,  they  required  two  ounces 
each  time. 

The  following  observations  were  made  by  me  in  private  practice.  All 
the   infants  were  well   nourished,  having  the   symptoms  of   normal,  hearty 


NUMBER   OF  DATLY  FEEDINGS. 


69 


digu.stion.  An  infant  at  the  age  of  six  weeks  took  six  times  in  twenty-four 
hours  one  and  a  half  ounces  of  milk,  the  same  quantity  of  water,  and  one 
teaspoonful  of  barley  flour  with  the  starch  converted  into  maltose  by  the 
action  of  malt  (Liebig's  method);  an  infant  of  eight  weeks,  of  large  size, 
took  eight  times  daily  two  (xuices  of  milk,  two  of  water,  and  two  scant  tea- 
spoonfuls  of  Liebig's  flour  ;  an  infant  of  two  months  took  eight  times  daily 
one  teaspoonful  of  Liebig's  flour,  with  three  and  a  half  of  milk  and  three 
and  a  half  of  water ;  an  infant  of  six  months  took  at  each  feeding,  and  nine 
times  in  twenty-four  hours,  five  tablespoonfuls  of  milk  peptonized  by  Fair- 
child's  process,  with  four  of  water. 

According  to  my  observations,  infants  in  good  health  and  well  nourished 
do  not  all  require  or  take  the  same  amount  of  food.  Some  infants,  like 
adults,  need  more  food  than  others,  but  the  following  table  indicates,  1  think, 
nearly  the  quantity  required  during  the  first  twelve  months  of  infancy,  either 
of  breast-milk  or  of  food  prepared  so  as  to  resemble  as  closely  as  possible 
breast-milk  in  consistence  and  nutritive  properties.  It  will  be  observed  that 
this  table  resembles  closely  that  prepared  by  Professor  Rotch  of  Harvard 
University,  and  published  in  his  comprehensive  and  in.'^tructive  paper  on 
infant  feeding  in  the    C^clojisedia  of  the  Diseases  of  Children : 

Table  III. —  Quantity  of  Food  required  in  the  First  Year  of  Infancy. 


At  each  feeding. 

Number  of 
daily  feedings. 

Total 
daily  quantity. 

Durino"  the  first  week  1  oz 

10 

1 0  nz 

At  the  third  week  IJ  oz     .    .        

10                      15    " 

At  the  sixth  week  2  oz 

8                  16    " 

At  the  third  month  3  oz 

8                  24    " 

At  the  fourth  month  4  oz 

7                   28    " 

At  the  sixth  month  6  oz 

6                  36    " 

At  the  tenth  to  twelfth  months  8  oz 

5                 40    " 

Table  IV. —  Observations  relating  to  the  Diet  during  Twenty-four  Hours  of 
Twenty-eight  Healthy  Children  between  the  Ages  of  Two  and  Three  Years, 
with  an  Average  Age  of  Two  Years  and  Eight  Months. 


Total  amount. 

Average 

for  each. 

Bread  .    .    . 

Butter     .    . 

Breakfast. 

6  lbs.    4  oz.  1  dr. 

13  oz.  5  dr.i 
22  lbs.  14  oz.  2  dr. 

8  lbs.    0  oz.  5  dr. 

6  lbs.  13  oz.  7  dr. 
17  lbs.    9oz.  7dr. 

19  lbs.  12  oz.  1  dr. 

7  lbs.    1  oz.  2  dr. 

14  oz.  7  dr. 

3.5 
0.45 

12.7 

4.6 
3.9 
9.4 

10.5 
4.0 
0.53 

OZ. 
oz. 

Milk 

fi.  OZ. 

Meat   .    .    . 
Potatoes  .    . 
Milk    .    .    . 

Milk    .    .    . 
Bread  .    .    . 
Butter     .    . 

Dinner. 

Supper. 

OZ. 
OZ. 

fl.  oz. 

fl.  oz. 

oz. 

oz. 

DAILY   AVERAGE   FOR  EACH   CHILD. 

Bread 7.5  oz.  avoir. 

Butter 0.98  oz.      " 

Meat  (beef) 4.6  oz.      " 

Potatoes 3.9  oz.      " 

Milk 32.6  fl.  oz. 

^  354.6  fluidounces. 


70 


QUANTITY  OF  FOOD  REQUIRED. 


Table  V. —  Observations  wpon  Twelve  Children  between  the  Ages  of  Three  and 
Six  Years :  Average  Age,  Four  Years  and  Ten  Months. 


Bread  . 
Butter 
Milk   . 

Beef  . 
Bread  . 
Eice  . 
Milk  . 
Butter 

Bread  . 
Butter 
Milk   . 


Breakfast. 


Dinner. 


Supper. 


Total  amount. 

Average  for  each. 

4  lbs.    6  oz.  3|  dr. 
5  oz.  2    dr. 

280  fl.  oz. 

5.86    OZ. 

0.427  oz. 

23.3  fl.  oz. 

9  lbs.    1  oz.  3    dr. 
1  lb.      0  oz.  1    dr. 
9  lbs.  12  oz.  7    dr. 
112  fl.  oz. 

2  oz.  2J  dr. 

12.1  oz. 

1.6  oz. 
13.0  oz. 

9.3  fl.  oz. 

2  lbs.    4  oz.  H  dr. 
5  oz.  5^^  dr. 
192  fl.  oz. 

3.0  oz. 
16.0  fl.  oz. 

DAILY   AVERAGE   FOR   EACH   CHILD. 

Milk 48.6    fl.  oz. 

Beef 12.1    oz.  avoir. 

Eice 13.0    oz.      " 

Bread 10.3    oz.      " 

Butter 1.08  oz.      " 


Table  VI. —  Observations  relating  to  the  Diet  of  Twenty-four  Children —  Twelve 
Boys,  Twelve  Girls — between  the  Ages  of  Four  Years  and  Ten  Years : 
Average,  Six  Years  and  Ten  Months. 


Bread  . 
Butter 
Milk    . 


Eoast  beef 
Potatoes  . 
Bread  .    . 
Milk    .    . 
Butter     . 


Bread  . 
Milk  . 
Butter 


Breakfast. 


Dinner. 


Supper. 


Total  amount. 

Average 

for  each. 

7  lbs.  13  oz.  3    dr. 

5.21 

OZ. 

12oz.  3^  dr. 

0.51 

OZ. 

348  fl.  oz. 

14.5 

fl.  OZ. 

18  lbs.  11  oz.  0    dr. 

12.46 

oz. 

15  lbs.    8  oz.  3    dr. 

10.30 

oz. 

1  lb.      6  oz.    i  dr. 

0.92 

oz. 

192  fl.  oz. 

8.0 

fl.  oz. 

^dv. 

0.012 

oz. 

6  lbs.    2  oz.  3J  dr. 

4.1 

oz. 

384  fl.  oz. 

16.0 

fl.  oz. 

11  oz.  5 J  dr. 

0.16 

oz. 

DAILY   AVERAGE   FOR   EACH    CHILD. 

Eoast  beef 12.46  oz. 

Bread 10.23  oz. 

Potatoes 10.3    oz. 

Butter 0.99  oz. 

Milk 38.5    fl.  oz. 

Compare   the  above  observations  with   those  of   Professor   Dalton,  who 
estimates  that  a  healthy  adult  taking  active  exercise  requires  each  day — 


TIME  REQUIRED  FOR  DIGESTION.  71 

Meat 16    oz. 

Bread 19    oz. 

Butter 3J  oz. 

Water 52    oz., 

while  one  leading  a  sedentary  life  needs  considerably  less. 

It  will  be  seen  by  the  above  tables  that  even  more  food  appears  to  be 
needed  during  the  period  of  childhood  than  in  adult  life.  We  would  suppose 
this  to  be  so  without  statistical  evidence,  for  the  active  exercise  and  rapid  and 
progressive  growth  of  this  period  necessarily  require  a  large  amount  of  nutri- 
ment. Moreover,  while  adults  do  well  with  solid  food  and  water,  statistics 
show  that  the  best  diet  for  children  who  have  passed  beyond  infancy  is  one 
of  milk,  with  solid  food  for  at  least  breakfast  and  supper. 

Although  we  are  able,  by  observations,  to  determine  the  average  amount 
of  food  required  in  twenty-four  hours  by  children  of  various  ages,  we  repeat 
that  it  would  be  wrong  to  prescribe  a  fixed  amount  for  all  children  of  a  given 
age,  for  some  need  more  than  others.  A  child  should  never  go  hungry  after 
a  meal.  In  some  of  the  best-conducted  institutions  of  New  York  the  chil- 
dren eat  of  plain  food  all  that  they  desire  at  each  meal,  while  in  other  insti- 
tutions the  food  at  supper  is  limited,  but  is  abundant  at  the  other  meals.  As 
children  go  to  bed  so  soon  after  supper,  it  is  proper  to  have  this  meal  light 
and  of  such  food  as  is  easily  digested. 

The  time  required  in  the  digestion  of  different  foods  has  been  investigated 
by  Beaumont  and  Bichat,  but  their  investigations  relate  to  adults.  The  time 
occupied  in  the  gastric  digestion  of  various  foods  has  been  determined  in 
adult  cases  by  inspecting  the  interior  of  the  stomach  through  a  gastric  fistula. 
No  such  opportunity  has  ever  occurred,  so  far  as  I  am  aware,  of  inspecting 
the  process  of  digestion  in  the  interior  of  the  stomach  either  in  infancy  or 
childhood.  But  recently  experiments  have  been  made  for  the  purpose  of 
determining  the  time  occupied  in  gastric  digestion  in  infancy.  The  import- 
ance of  such  experiments  is  apparent,  for  if  we  know  how  soon  after  feeding 
gastric  digestion  is  completed  and  the  stomach  emptied,  we  will  know  how  fre- 
quent the  feeding  should  be.  According  to  H.  Leo,  in  an  infant  a  few  weeks 
old  one  hour  suffices  for  the  stomach  digestion  of  the  milk  which  it  receives, 
so  that  this  organ  is  already  empty  one  hour  after  the  nursing,  and  in  a  con- 
dition to  receive  more  milk.  In  older  infants,  who  receive  more  milk,  the 
milk  is  retained  longer  in  this  organ,  one  and  a  half  hours  being  required  for 
the  stomach  digestion  of  human  milk,  and  two  hours  for  the  digestion  of 
cow's  milk  (Berlin.  JcUn.  Wochenschr.,  No.  49,  1888).  Recently  (1889),  Dr. 
Max  Einhorn  of  New  York  has  investigated  the  stomach  digestion  of  infants, 
using  a  Nelaton  catheter  No.  14  A,  with  which  he  withdrew  the  contents  or 
determined  the  emptiness  of  the  stomach.  He  ascertained  that  in  the.  infant 
receiving  human  milk  the  stomach  was  empty  two  hours  after  the  nursing, 
and  probably  in  one  and  a  half  hours.  After  feeding  with  equal  parts  of 
cow's  milk  and  barley-water,  the  stomach  was  practically  empty  at  a  little 
before  the  close  of  the  second  hour.  After  feeding  with  milk  and  water, 
equal  parts,  the  stomach  was  empty  in  about  one  and  a  half  hours.  The 
digestibility  of  several  of  the  proprietary  foods  which  are  most  in  use  was 
also  ascertained  in  a  similar  manner.  A  considerable  amount  of  these  foods 
was  still  in  the  stomach  undergoing  digestion  two  hours  after  they  were 
administered.  These  interesting  and  instructive  observations  of  Dr.  Einhorn 
indicate  the  intervals  required  in  feeding  with  milk  and  with  other  foods. 

It  is  seen  that  there  is  a  general  agreement  in  the  result  obtained  by  dif- 
ferent observers  in  regard  to  the  amount  of  food  required  at  each  feeding, 
and  the  proper  intervals  between  the  feedings,  during  infancy  as  well  as 
childhood. 


72 


ARTIFICIAL  FEEDING. 


CHAPTER    VIII. 

ARTIFICIAL  FEEDING. 

Occasionally  the  mother  is  unable  to  suckle  her  infant,  and  a  hired  wet- 
nurse  cannot  be  or  is  not  obtained.  Artificial  feeding  is  then  necessary.  In 
the  large  cities  this  mode  of  alimentation  for  young  infants  should  always  be 
discouraged,  for  it  frequently  ends  in  death,  preceded  by  evidences  of  faulty 
nutrition.  A  considerable  proportion  of  those  nourished  in  this  manner  thrive 
during  the  cold  months,  but  on  the  approach  of  the  warm  season  they  are  the 
first  to  be  affected  with  diarrhoea  and  other  symptoms  indicating  derangement 
of  the  digestive  function.  In  New  York  City  a  large  proportion  of  the  arti- 
ficially-fed infants  who  enter  the  summer  months  die  before  the  return  of  cool 
weather,  unless  saved  by  removal  to  the  country,  but  the  mortality  of  these 
infants  has  been  in  a  measure  reduced  of  late  years  by  improvement  in  the 
mode  of  feeding,  and  in  the  sanitary  condition  of  the  city.  In  the  country 
and  in  small  inland  cities  the  i-esults  of  artificial  feeding  are  much  more  favor- 
able. In  elevated  farming  sections,  on  account  of  the  salubrity  of  the  air 
and  the  facility  with  which  milk,  fresh  and  of  the  best  quality,  is  obtained, 
artificial  feeding  is  attended  by  much  less  risk  than  in  the  cities. 

Young  infants,  fed  by  the  hand,  obviously  require  food  prepared  so  as  to 
resemble  as  closely  as  possible  human  milk  in  its  composition.  Woman's 
milk  in  health  is  always  alkaline.  It  has  a  specific  gravity  of  1031.7  ;  cow's 
milk  has  a  specific  gravity  of  1029.  That  of  cows  stabled  and  fed  upon  other 
fodder  than  hay  or  grass  is  decidedly  acid.  That  from  cows  in  the  country 
with  good  pasturage  is  also  slightly  acid.  In  two  dairies  in  Central  New 
York  a  hundred  miles  apart,  in  midsummer,  with  an  abundant  pasturage,  two 
competent  persons  whom  I  requested  to  make  the  examinations  found  the 
milk  moderately  acid  immediately  after  the  milking  in  all  the  cows. 

How  to  feed  infants  deprived  of  breast-milk  is  a  very  important  problem. 
The  following  results  of  a  large  number  of  analyses  of  woman's  and  cow's 
milk,  made  by  Konig  and  quoted  by  Leeds,  and  of  several  of  the  best-known 
and  most  used  preparations  designed  by  their  inventors  to  be  substitutes  for 
human  milk,  show  how  far  these  substitutes  resemble  the  natural  aliment  in 
their  chemical  characters : 


Woman's  milk. 


Mean. 


Minimum. 


Mean. 


Minimum. 


Maximum. 


Water  .  . 
Total  solids 
Fat  ... 
Milk-sugar 
Casein  .  . 
Albumen  . 
Albuminoids 
Ash   ...    . 


87.09 
12.91 
3.90 
6.04 
0.63 
1.31 
1.94 
0.49 


83.6 
9.10 
1.71 
4.11 
0.18 
0.39 
0.57 
0.14 


90.90 
16.31 

7.60 
7.80 
1.90 
2.35 
4.25 


87.41 
12.59 
3.66 
4.92 
3.01 
0.75 
3.76 
0.70 


80.32 
8.50 
1.15 
3.20 
1.17 
0.21 
1.38 
0.50 


91.50 
19.68 
7.09 
5.67 
7.40 
5.04 
12.44 
0.87 


The  following  analyses  of  the  foods  for  infants  found  in  the  shops,  and 
which  are  in  common  use,  were  made  by  Leeds  of  the  Stevens  Institute  : 


ARTIFICIAL   FOODS. 


73 


Farinaceous  Foods. 


Water 

Fat 

Grape-sugar 

Cane-sugar        ,    .    .    . 

Starch 

Soluble  carbohydrates 
Albuminoids     .    .    .    . 
Gum,  cellulose,  etc. 
Ash 


Blair's 

wheat 
food. 


9.85 
1.56 
1.75 
1.71 
64.80 
13.69 
7.16 
2.94 
1.06 


2_ 

■i. 

iiubb(iir» 

Iniperial 

wheat  food. 

gniuum. 

7.78 

5.49 

0.41 

1.01 

7.56 

Trace. 

4.87 

Trace. 

67.60 

78.93 

14.29 

3.56 

10.13 

10.51 

Undeteini'd 

0.50 

1.00 

1.16 

Ridge's 
food. 


"A  BC" 
Cereal  milk. 


9.23 
0.63 
2.40 
2.20 
77.96 
5.19 
9.24 

0.60 


9.33 

1.01 

4.60 

15.40 

58.42 

20.00 

11.08 

1.16 


10.10 
0.97 
3.08 
0.90 

77.76 
4.11 
5.13 
1.93 
1.93 


Liehig's  Foods. 


Water 

Fat 

Grape-sugar 

Cane-sugar 

Starch 

Soluble  carbohydrates . 

Albuminoids 

Gum,  cellulose,  etc. .    . 
Ash 


5.00 

0.15 
44.69 

3.51 
None. 
85.44 

5.95 


1.89 


Hawley's. 


6.60 

0.61 
40.57 

3.44 
10.97 
76.54 

5.38 


1.50 


3.39 
0.08 
34.99 
12.45 
None. 
87.20 
6.71 


1.28 


Keasbey 

and 
Matti- 
son's. 


27.95 
None. 
36.75 

7.58 
None. 
71.50 
None. 


0.93 


Savory 

and 
Moore's. 


8.34 

0.40 

20.41 

9.08 

36.36 

44.83 

9.63 

0.44 

0.89 


Baby  sup 
No.  1. 


5.54 

1.28 

2.20 
11.70 
61.99 
14.35 

9.75 

7.09 

Undeterm'd 


Baby 

SU]! 

No.  J. 


11.48 
0.62 
2.44 
2.48 
51.95 
22.79 
7.92 
5.24 
1.59 


Milk  Foods. 


Water 

Fat 

Grape-sugar  and  milk-sugar 

Cane-sugar 

Starch 

Soluble  carbohydrates  .    .    . 

Albuminoids 

Ash 


Nestle's. 


4.72 

1.91 

6.92 

32.93 

40.10 

44.88 

8.23 

1.59 


Anglo-Swiss. 


6.54 
2.72 
23.29 
21.40 
34.55 
46.43 
10.26 
1.20 


6.78 

2.21 

6.06 

30.50 

38.48 

44.76 

9.56 

1.21 


American-Swiss. 


6.81 
5.78 
36.43 
30.85 
45.35 
10.54 
1.21 


It  is  seen  by  examination  of  the  analyses  of  the  above  foods  that  all, 
except  such  as  consist  largely  or  wholly  of  cow's  milk,  differ  widely  from 
human  milk  in  their  composition,  and  although  some  of  them — as  the  Liebig 
preparations,  in  which  starch  is  converted  into  grape-sugar  by  the  action  of  the 
diastase  of  malt — may  aid  in  the  nutrition  and  be  useful  as  adjuncts  to  milk, 
physicians  of  experience  and  close  observation  agree  that  when  breast-milk 
fails  or  is  insufficient  our  main  reliance  for  the  successful  nutrition  of  the 
infant  must  be  on  animal  milk. 

Cow's  milk,  being  readily  obtained,  is  commonly  used  as  a  substitute  for 
human  milk,  compared  with  which  it  contains  less  sugar,  but  more  casein  and 
salts.  Its  composition,  however,  varies  considerably,  according  to  the  food 
of  the  cow.  The  variations  in  the  milk  of  the  cow  according  to  the  nature 
of  its  food  and  other  circumstances  have  been  considered  in  a  preceding 
chapter. 


74  .  ARTIFICIAL  FEEDING. 

It  is  obvious  from  the  above  facts  that  the  analyses  of  different  specimens 
of  cow's  milk  must  differ  greatly,  and  the  same  is  true  of  the  milk  of  the  goat 
and  ass,  and  probably  of  the  ewe.  In  fact,  different  samples  of  the  milk  of 
the  same  animal  may  differ  more  from  each  other  in  their  chemical  character 
than  the  average  milk  of  one  animal  from  that  of  another. 

The  milk  of  the  goat  and  that  of  the  ass  have  been  recommended  as  food 
for  infants  in  preference  to  cow's  milk,  on  the  ground  that  they  more  nearly 
resemble  human  milk.  But  neither  the  milk  of  the  ass  nor  goat,  so  far  as  its 
chemical  character  is  concerned,  would  seem  to  possess  any  marked  advantage 
■over  cow's  milk.  The  ass's  milk  is  procured  with  difficulty,  and  is  seldom 
used.  An  objection  to  goat's  milk  is  the  unpleasant  odor  which  it  often  pos- 
sesses, due  to  the  presence  of  hircic  acid.  It  is  stated,  however,  by  Parmen- 
tier,  that  this  odor  is  only  noticed  in  the  milk  of  goats  that  have  horns.  An 
important  advantage  in  the  city  in  the  use  of  goat's  milk  is  that  the  animal 
■can  be  kept  at  little  expense,  so  that  even  poor  families  who  are  not  able  to 
purchase  and  feed  a  cow  can  generally  possess  a  goat  from  which  fresh  milk 
can  be  obtained  at  any  time.  Preference  is  to  be  given  to  goat's  milk  when 
fresh  over  cow's  milk  brought  from  the  country,  perhaps  watered  on  the  way, 
several  hours  old  when  received,  and  in  commencing  fermentation.  But 
■cow's  milk  of  good  quality  and  free  from  fermentative  changes  is  probably 
not  inferior  to  goat's  milk  as  a  food  for  infants,  and  from  its  abundance  it 
must  continue  to  be  in  common  use  for  this  purpose. 

In  order  to  solve  the  problem  of  the  feeding  of  infants  deprived  of  the 
Tjreast  milk,  it  will  be  well  to  recall  to  mind  the  part  performed  in  the  diges- 
tive function  by  the  different  secretions  which  digest  food. 

1st.  The  saliva  is  alkaline  in  health.  It  converts  starch  into  grape-sugar. 
It  has  no  effect  upon  fat  or  the  protein  group.  It  is  the  secretion  of  the 
parotid,  submaxillary,  and  sublingual  glands,  which  in  infants  under  the  age 
■of  three  months  are  very  small,  almost  rudimentary.  The  power  to  convert 
starch  into  sugar  possessed  by  saliva  is  due  to  a  ferment  which  it  contains 
■called  ptyalin. 

2d.  The  gastric  juice  is  a  thin,  nearly  transparent,  and  colorless  fluid,  acid 
from  the  presence  of  a  little  hydrochloric  acid.  It  produces  no  change  in 
starch,  grape-sugar,  or  the  fats,  except  that  it  dissolves  the  covering  of  the 
fat-cells.  Its  function  is  to  convert  the  proteids  into  peptone,  which  is 
■effected  by  its  active  principle,  termed  pepsin. 

3d.  The  bile  is  alkaline,  and  it  neutralizes  the  acid  product  of  gastric 
•digestion.  It  has  no  effect  on  the  proteids.  It  forms  soaps  with  the  fatty 
acids,  and  has  a  slight  emulsifying  action  on  fat.  The  soaps  are  said  to  pro- 
mote the  emulsion  of  fat.  Their  emulsifying  power  is  believed  to  be  increased 
by  admixture  with  the  pancreatic  secretion.  Moreover,  the  absorption  of  oil 
is  facilitated  by  the  presence  of  bile  upon  the  surface  through  which  it  passes. 

4th.  The  pancreatic  juice  appears  to  have  the  function  of  digesting  what- 
ever alimentary  substance  has  escaped  digestion  by  the  saliva,  gastric  juice, 
and  bile.  It  is  a  clear,  viscid  liquid  of  alkaline  reaction.  It  rapidly  changes 
starch  into  grape-sugar.  It  converts  proteids  into  peptones  and  emulsifies  fats. 
While  the  gastric  juice  requires  an  acid  medium  for  the  performance  of  its 
digestive  function,  the  pancreatic  juice  requires  one  that  is  alkaline.  These 
important  facts  should  be  borne  in  mind,  that  such  a  mistake  as  prescribing 
pepsin  with  chalk  mixture  or  the  extractum  pancreatis  with  dilute  muriatic 
acid  may  be  avoided. 

5th.  The  intestinal  secretions  are  mainly  from  the  crypts  of  Lieberkiihn, 
and  their  action  in  the  digestive  process  is  probably  comparatively  unimport- 
ant, but  in  some  animals  they  have  been  found  to  digest  starch.  It  will  be 
observed  that  of  all  these  secretions  that  which  digests  the  largest  number 


PEPTONIZED  MILK.  75 

of  nutritive  principles  is  the  pancreatic.  It  digests  all  those  which  are 
essential  to  the  maintenance  of  life  except  fat,  and  it  aids  the  bile  in  emul- 
sifying fat. 

It  is  seen  from  this  brief  review  of  the  action  of  the  digestive  ferments 
that  starch  is  digested  in  only  a  very  small  quantity  by  infants  under  the 
age  of  three  months,  and  therefore  that  those  foods  which  consist  largely  of 
starch  afford  but  little  nutriment  at  this  age.  The  impropriety  also  of  admin- 
istering for  days  large  quantities  of  an  alkali,  as  is  frequently  done,  is  apparent 
from  the  above  statement  in  regard  to  the  action  of  pepsin,  since  it  may  retard 
or  prevent  gastric  digestion. 

In  1882  a  conference  was  held  in  Salzburg,  Germany,  of  physicians  from 
various  parts  of  the  Grerman  Empire  known  throughout  the  world  as  special- 
ists in  the  diseases  of  children.  The  purpose  of  the  convention  was  to  dis- 
cuss the  diet  of  infancy  and  childhood.  They  agreed  that  animal  milk  is 
the  best  substitute  for  human  milk  in  the  feeding  of  infants,  either  as  the 
main  food  or  as  the  basis  of  the  food  employed.  Useful  as  some  of  the  prep- 
arations of  the  shops  are  as  adjuvants,  nevertheless  experience  shows  the 
soundness  of  the  opinion  expressed  by  the  conference ;  and  yet  feeding  with 
animal  milk  of  the  best  quality  must  be  carefully  managed,  or  it  will  be 
found  to  disagree  with  the  feeble  and  readily  disturbed  digestive  functions 
of  the  infimt. 

Milk  should  always  be  given  at  a  uniform  temperature  of  about  99°.  Em- 
ployed habitually  too  hot  or  too  cold,  it  frequently  produces  stomatitis  or  a 
more  serious  disease  of  the  digestive  organs. 

Infants  under  the  age  of  ten  months  should  nurse  from  the  nursing-bot- 
tle, and  this  as  soon  as  used  should,  with  the  India-rubber  tip  and  attach- 
ment, be  immersed  in  a  quart  or  two-quart  bowl  of  cold  water  to  which  a 
teaspoonful  of  sodium  bicarbonate  has  been  added,  and  water  should  be 
drawn  thi'ough  the  tube  and  nipple  by  suction   with   the  mouth. 

Cow's  milk,  though  possessing  nearly  the  same  composition  as  human 
milk,  nevertheless  behaves  differently  in  some  respects  in  digestion.  The 
casein  of  human  milk  coagulates  in  light  flocculi  in  the  stomach  of  the 
infant,  so  as  to  be  readily  acted  on  by  the  digestive  ferments,  while  that  of 
cow's  milk  forms  large  and  firm  coagula  which  are  with  difficulty  digested. 
The  irritating  products  of  a  slow  and  imperfect  digestion  frequently  cause 
colic  and  fever,  with  more  or  less  intestinal  catarrh.  Cow's  milk,  therefore, 
disagrees  with  many  infants,  who  suffer  from  indigestion  in  consequence  of  the 
feeding,  whose  stools  show  masses  of  partly-digested  casein,  with  abundant 
mucus,  who  fret  from  gastro-intestinal  uneasiness  and  vomit  often,  and  do  not 
thrive  like  infants  nourished  at  the  bi'east.  Therefore,  the  profession  has 
long  felt  the  need  of  some  modification  of  cow's  milk,  so  that  it  more  closely 
resembles  human  milk  in  its  digestion.  This  has  in  a  measure  been  accom- 
plished by  the  process  known  as  peptonizing,  by  which  the  casein  is  digested 
or  so  far  digested  that  it  coagulates  in  flakes.  Peptonized  milk,  or  milk  which 
is  partially  digested  by  artificial  means,  is  prepared  by  the  action  upon  it  of 
extractum  pancreatis  and  sodium  bicarbonate.  We  may  here  briefly  state 
the  method.  Extractum  pancreatis  gr.  v  and  sodium  bicarbonate  gr.  xv  are 
added  to  one  gill  of  tepid  water,  and  this  is  mixed  with  one  pint  of  tepid  milk 
as  fresh  as  possible.  The  mixture  is  allowed  to  stand  in  water  having  a  tem- 
perature of  about  100°  to  110°  for  half  an  hour,  or  even  one  hour  if  it  do 
not  become  bitter.  After  the  half  hour  the  milk  should  be  frequently  tasted, 
and  if  it  be  in  the  least  bitter  it  should  be  immediately  removed  from  the 
heat,  and  what  is  not  used  should  be  placed  upon  ice.  If  it  be  fully  digested. 
it  is  too  bitter  for  use.  If  it  be  slightly  digested,  the  bitterness  is  not  appre- 
ciable, or  is  so  slight  that  it  is  readily  taken  by  the  infant,  and  the  casein 


76  ARTIFICIAL  FEEDING. 

coagulates  in  flakes  instead  of  large  coagula.  Professor  Leeds  recommends 
the  following  method  as  an  improvement.  In  his  opinion  it  produces  milk 
so  closely  resembling  breast-milk  in  its  chemical  character  and  behavior  that 
he  designates  it  humanized  cow's  milk  : 

1  gill  of  cow's  milk. 

1  gill  of  water. 

2  tablespoonfuls  of  rich  cream. 
200  grains  of  milk-sugar. 

Ij  grains  of  extractum  pancreatis. 
4    grains  of  sodium  bicarbonate. 

"Put  this  in  a  nursing-bottle,  place  the  bottle  in  water  made  so  warm 
that  the  whole  hand  cannot  be  held  in  it  without  causing  pain  longer  than 
one  minute.  Keep  the  milk  at  this  temperature  for  exactly  twenty  minutes. 
The  milk  should  be  prepared  just  before  using."  Messrs.  Fairchild  have  pre- 
pared according  to  the  above  formula  what  they  designate  a  peptogenic  pow- 
der in  a  can  accompanied  by  a  measure  which  holds  sufficient  for  peptonizing 
two  ounces  of  milk  with  half  an  ounce  of  cream.  The  use  of  Fairchild's 
peptogenic  powder  simplifies  the  process  of  peptonizing.  The  measure  full 
of  the  powder,  one  tablespoonful  of  cream,  four  tablespoonfuls  of  milk,  and 
four  tablespoonfuls  of  water  are  mixed  in  a  convenient  vessel  and  maintained 
six  minutes,  with  constant  stirring,  at  a  temperature  so  hot  that  it  can  barely 
be  sipped.  The  casein  by  this  process,  though  but  partially  digested,  coag- 
ulates in  ilakes.  I  have,  I  think,  improved  this  food  for  a  large  proportion 
of  infants,  especially  for  those  over  the  age  of  three  months  and  in  the  sum- 
mer season,  by  substituting  barley-water  for  plain  water.  Barley  flour  is 
boiled  dry  seven  days  in  a  double  boiler,  so  that  a  considerable  portion  of  the 
starch  is  converted  into  dextrin,  and  the  gruel  is  made  by  adding  a  heaped 
teaspoonful  of  the  flour  to  eighteen  of  water.  The  dextrin  in  the  barley 
gruel  thus  prepared  is  assimilated  by  the  youngest  child,  and  any  starch- 
granules  which  may  not  be  converted  into  dextrin  separate  mechanically 
the  particles  of  casein,  and  aid  in  preventing  the  formation  of  curds  in  the 
stomach. 

Peptonized  milk  is  a  useful  addition  to  the  dietetic  preparations  for 
infants.  By  peptonizing  is  accomplished  what  physicians  have  long  felt 
the  need  of — to  wit,  a  mode  of  preparing  cow's  milk  so  that  its  casein  coag- 
ulates in  flakes  like  that  of  human  milk.  Milk  employed  for  this  purpose 
should  be  as  fresh  as  possible,  but  unfortunately  in  hot  weather,  when  there 
is  most  need  of  having  a  food  for  artificially-fed  infants  which  bears  the  clos- 
est possible  resemblance  to  human  milk,  in  order  to  prevent  the  summer 
diarrhoea,  much  of  the  cow's  milk  when  it  reaches  the  cities,  twenty-four 
hours  after  the  milking,  has  begun  to  undergo  fermentation,  and  is  therefore 
unsuitable  for  peptonizing,  though  employed  for  this  purpose.  This  is  prob- 
ably one  of  the  chief  causes  of  the  fact  that  peptonized  milk  not  unfrequently 
disappoints  our  expectations.  The  peptonizing  of  milk  rests  on  a  scientific 
basis,  and  as  clinical  experience  thus  far  has  demonstrated  the  usefulness  of 
milk  prepared  in  this  manner  in  the  feeding  of  infants  in  a  certain  proportion 
of  cases,  it  will  probably  continue  to  be  regarded  as  one  of  the  best  substi- 
tutes for  breast-milk.  It  has  also  been  found  useful  for  children  with  feeble 
digestion  who  have  passed  beyond  the  period  of  infancy.  But  recently  a 
great  improvement  has  been  made  in  the  preparation  of  cow's  milk  for  the 
nursery  by  sterilizing  it  by  the  prolonged  action  of  heat.  It  is  placed  in  a 
steamer  and  maintained  at  nearly  the  heat  of  boiling  water  one  and  a  half  or 
two  hours.  This  destroys  any  microbes  which  may  have  fallen  into  it.  and 
it  appears  that  the  prolonged  action  of  heat  increases  the  digestibility  of  the 


LIEBIG'S  FOOD.  77 

casein,  by  rendering  it  more  liable  to  coagulate  in  flakes.  Milk  thus  pre- 
pared, and  given  with  some  farinaceous  food  in  which  the  starch  is  converted 
into  dextrin  or  grape-sugar,  will  frequently  agree  with  young  infants  and  be 
fully  digested  without  the  aid  of  the  peptogenic  powder. 

It  is  known  that  infants  prior  to  the  third  month  can  digest  only  a  very 
small  amount  of  starch,  since  the  salivary  and  pancreatic  glands,  whose  secre- 
tions convert  starch  into  glucose — a  necessary  change  in  digestion — are  almost 
rudimentary  in  the  first  months  of  infancy.  In  a  monograph  relating  to 
Infant  Diet  written  by  Professor  A.  Jacobi,  and  revised,  enlarged,  and  adapted 
to  popular  reading  by  Dr.  Mary  Pu'^  -am  Jacobi,  it  is  stated  that  the  parotid 
glands,  which,  together,  weigh  80  gra  -s  at  fifteen  months  and  120  grains  at 
two  years,  weigh  but  34  grains  at  the  ag  of  one  month.  In  several  instances 
we  weighed  the  pancreas  taken  from  the  b,  Mes  of  infants  who  had  died  under 
the  age  of  six  months  in  the  New  York  Infant  Asylum.  Its  weight  was  very 
different  in  those  whose  ages  were  about  the  same  :  in  several  under  the  age  of 
four  months  it  was  less  than  one  drachm,  and  in  some  more  than  one  drachm, 
but  in  no  instance  did  it  reach  two  drachms.  The  submaxillary  and  sublin- 
gual glands,  which  also  secrete  saliva,  are  comparatively  insignificant  in  young 
infants,  so  that  the  combined  action  of  the  parotid,  submaxillary,  sublingual, 
and  pancreatic  secretions  must  be  inadequate  for  the  saccharification  of  the 
starch  which  ordinary  farinaceous  food  contains  during  the  first  three  or  four 
months  of  infancy. 

But  it  is  now  ascertained  that  the  salivary  and  pancreatic  secretions  are 
not  the  only  agents  by  which  starch  is  digested.  The  mucous  surface  fur- 
nishes an  "epithelial  ferment  which  assists  in  the  change,  so  that  the  secre- 
tions from  the  buccal  and  intestinal  surfaces  materially  aid  in  the  digestion  " 
(^Rf'vue  des  Sciences  med.,  1879,  by  Charles  Richert ;  also  remarks  by  Profes- 
fessor  Flint,  Jr.,  in  Physiol,  of  Man'). 

It  appears,  therefore,  that  young  infants  are  able  to  digest  a  certain 
amount  of  starch,  but  a  much  smaller  proportion  than  those  who  are  older ; 
and  in  the  preparation  of  farinaceous  food  this  fact  should  be  borne  in  mind. 
Young  infants  can  digest  the  two  derivatives  of  starch — to  wit,  dextrin  and 
grape-sugar — and  it  seems  judicious,  since  they  are  more  readily  assimilated, 
to  employ  them  in  place  of  starch  for  sick  children  and  for  all  children  under 
the  age  of  six  months. 

The  late  Baron  Liebig,  who  devoted  considerable  time  in  the  last  years 
of  his  life  to  the  study  of  the  food  of  infants,  was  the  first  who  recommended 
the  conversion  of  starch  into  grape-sugar  by  the  action  of  the  malt  diastase, 
and  this  constitutes  the  special  excellence  of  several  of  the  infant  foods  which 
under  other  names  have  been  largely  used,  and  often  with  good  results.  But 
of  all  the  farinaceous  foods  containing  derivatives  of  starch  which  ai'e  found 
in  the  shops,  and  which  have  been  used  and  recommended  for  infant  feeding, 
barley  flour  with  a  considerable  part  of  its  starch  converted  into  dextrin  by 
the  prolonged  action  of  heat  (seven  days  at  212°),  is  probably  one  of  the 
best,  if  not  the  best.  Containing  no  admixture,  it  can  be  preserved  with- 
out change  for  an  indefinite  time,  and  as  the  youngest  child  can  digest  dex- 
trin as  well  as  peptonized  milk,  the  combination  of  the  two  makes  a  useful 
food  for  infants  in  sickness  as  well  as  in  health. 

But  whatever  may  be  the  dietetic  preparation  designed  for  infant  feeding, 
we  have  stated  above  that  animal  milk  should  form  the  basis.  This  fact 
is  generally  recognized,  and  the  various  proprietary  foods  either  contain  a 
large  proportion  of  milk  or  milk  is  added  to  them  in  the  nursery.  Hence, 
during  the  last  few  years  much  attention  has  been  directed  to  the  milk-sup- 
ply of  the  cities,  and  in  some  of  the  cities  it  is  under  strict  surveillance.  It 
is  now  regarded  as  important  that  the  health  and  condition  of  the  cows  in  the 


78  ARTIFICIAL  FEEDING. 

distant  dairies  should  be  closely  inspected,  that  their  milk  should  not  be  sent 
to  market  until  several  days  after  calving,  and  that  the  pastures  in  which 
they  feed  should  not  only  have  abundant  grass  and  clover,  but  be  free  from 
foul  water  and  noxious  weeds.  One  at  least  of  the  companies  that  prepare 
food  for  the  nursery  insist  on  the  observance  of  the  above  conditions  in  obtain- 
ing their  milk  from  the  farmer.  Immediately  after  the  milking  the  milk  should 
be  placed  in  open  cans  and,  except  in  midwinter,  surrounded  by  ice  or  cold 
water,  so  as  to  reduce  its  temperature  as  soon  as  possible  to  60°  or  65°.  We 
have  stated  elsewhere  that  neglect  to  treat  milk  in  this  manner  in  a  hot  sum- 
mer day  led  to  the  development  of  tyrotoxicon  in  six  or  eight  hours  after  the 
milking,  and  the  poisoning  of  the  guests  of  two  hotels  at  Long  Branch.  In 
view  of  such  cases  the  sterilization  of  milk,  which  we  have  recommended 
above,  merits  more  than  a  passing  notice. 

Dr.  Soxhlet  of  Germany  was  among  the  first  to  recoqimend  the  steriliza- 
tion of  milk  by  heat  in  an  interesting  monograph  published  in  1886.  He 
alludes  to  the  fact  that  particles  of  manure  and  other  dirt  fall  into  the  milk 
in  milking,  and  are  liable  to  set  up  fermentation,  which  renders  it  unsuitable 
as  a  food.  Drs.  Jeifries,  Warner,  A.  Jacobi,  and  A.  Caille  have  also  written 
instructive  papers  commendatory  of  the  sterilization  of  milk  by  steam.  Dr. 
Warner  states  that  in  his  experiments  milk  thus  sterilized  has  remained  sweet 
five  weeks.  Soxhlet's  mode  of  sterilizing  milk  is  described  by  Dr.  Caille  as. 
follows : 

Ten  5-ounce  bottles  are  filled  with  milk  to  within  half  an  inch  of  the 
neck.  Into  each  bottle  a  perforated  rubber  stopper  is  pressed.  The  bottler 
are  placed  in  a  tray  which  is  set  in  a  pot  of  water.  After  the  water  has 
come  to  a  boil  and  expansion  has  taken  place,  the  glass  stoppers  are  pressed 
into  the  perforated  rubber  stopper,  thus  hermetically  closing  each  bottle. 
The  milk  remains  in  the  boiling  water  fifteen  to  twenty  minutes  longer,  and 
is  for  that  length  of  time  under  pressure  in  a  temperature  of  212°  F.,  which 
is  sufiicient  to  destroy  all  germs  and  impurities  liable  to  produce  fermenta- 
tion. Milk  so  prepared  will  keep  sweet  four  to  six  weeks,  according  ta 
Soxhlet. 

When  the  milk  is  to  be  used  the  bottle  is  put  into  hot  water  a  few  min- 
utes, until  the  contents  are  warm.  The  stopper  is  then  removed  and  an  ordi- 
nary nipple  attached.  A  long  feeding-tube  may  also  be  used  in  the  usual 
way  if  desirable.  Milk  remaining  in  the  bottle  after  the  child  has  been  fed 
is  thrown  away. 

The  Arnold  steam  sterilizer  (an  American  invention)  has  also  lately  been 
brought  to  the  notice  of  the  profession.  It  is  an  ingenious  apparatus  fulfill- 
ing all  the  requirements,  not  allowing  the  escape  of  steam  into  the  room,  and 
furnished  at  a  reasonable  price.  But,  as  Dr.  Warner  remarks,  the  simple 
kitchen  steamer  found  at  the  hardware  store  answers  the  purpose  if  supplied 
with  the  proper  bottles.  Milk  sterilized  by  steaming  in  this  manner,  and 
diluted  with  boiled  water  according  to  the  age  of  the  child,  may  agree  with 
the  youngest  infant. 

Meigs  and  Pepper  recommend  for  artificially-fed  infants  the  admixture  of 
prepared  gelatin  or  Russian  isinglass  with  the  milk,  and  they  state  that  in< 
their  practice,  extending  over  many  years,  infants  "  have  thriven  better  upon 
it  than  upon  anything  else."  A  piece  of  gelatin  two  inches  square  ''  is  soaked 
for  a  short  time  in  cold  water,  and  then  boiled  in  half  a  pint  of  water  until 
it  dissolves — about  ten  or  fifteen  minutes."  To  this  is  added,  with  constant 
stirring,  the  milk,  containing  some  farinaceous  food.  Others  who  have  used 
food  prepared  in  this  manner  speak  well  of  it.  Although  gelatin  contains 
little  nutriment,  its  presence  may  aid  digestion,  and  a  food  recommended  by 
physicians  of  such  experience  as  Meigs  and  Pepper  is  worthy  of  trial  in. 


FOOD   AFTER   THE  FIRST   YEAR.  79 

cases  of  habitual  indigestion  or  of  intestinal  catarrh  in  which  the  ordinary 
food  disagrees. 

Milk  should  be  the  chief  article  of  food  during  infancy,  hut  the  older  the 
infant  becomes  the  larger  should  be  the  proportion  of  solid  food  given  with 
it.  After  tiie  first  year  the  food  may  be  made  of  such  consistence  as  to  be 
given  with  the  spoon.  In  the  second  year  and  subsequently  a  pap  may  be 
made  of  stale  bread  boiled  in  water  sufficient  to  cover  it,  and  mixed  with  fresh 
milk,  care  being  taken  that  all  lumps  are  reduced  to  a  pulp.  Beef  tea  is  a 
laxative,  on  account  of  the  salts  which  it  contains,  as  is  also  chicken  tea  ;  but 
a  small  or  moderate  amount  of  it  may  be  given  once  a  day.  Stale  wheat 
bread  or  soda  cracker  should  be  crumbled  in  it,  and  soaked  so  as  to  be  soft. 
If  there  be  diarrhoea  the  ordinary  beef  tea  should  not  be  allowed,  on  account 
of  its  laxative  effect,  but  the  expressed  juice  may  be  given  instead.  Few 
vegetables  are  proper  for  infants  under  the  the  age  of  one  year,  but  the 
potato,  baked  and  mashed  so  as  to  be  like  flour,  may  be  given  at  the  tenth  or 
twelfth  month.  It  contains  a  large  amount  of  starch,  but  appears  to  be 
readily  digested  by  infants  of  the  age  mentioned  if  given  once  a  day  in  mod- 
erate quantity,  with  a  little  butter  and  salt  added.  In  the  second  year  a 
greater  variety  of  food  may  be  allowed,  but  the  full  diet  of  the  table  must 
not  be  given  till  after  infancy,  or  at  the  age  of  three  years.  In  the  beginning 
of  the  second  year  the  infant  is  weaned.  He  has  twelve  teeth,  eight  inci- 
sors, and  four  molars,  which,  with  their  broad  surfaces,  are  designed  for  chew- 
ing. Let  him  have  now,  once  or  twice  each  day,  in  addition  to  the  food 
which  has  previously  been  employed,  a  small  piece  of  roast  beef,  rare  done 
and  cut  very  fine.  Other  meat,  as  mutton,  may  sometimes  be  given  instead. 
After  the  age  of  eighteen  months  light  puddings  of  farinaceous  substances, 
properly  prepared,  as  of  rice  and  corn  meal,  may  be  added  to  the  dietary. 

All  the  teeth  of  the  first  set  have  appeared  at  the  age  of  two  years  and 
five  months,  and  the  time  has  now  arrived  when  a  more  marked  transition 
may  be  made  from  liquid  to  solid  food.  Certain  fruits  may  be  allowed,  even 
before  this  period,  as  also  the  jellies  of  most  berries  and  of  fruits,  which 
being  deprived  of  seeds  and  parenchyma  are  for  the  most  part  readily 
digested,  while  they  give  a  relish  to  the  farinaceous  food  with  which  they 
are  eaten.  Pastries  as  ordinarily  made,  whatever  fruits  they  may  contain, 
are  too  rich  and  indigestible  for  young  children.  The  following  judicious 
rule  for  the  pi'eparation  of  fruits  for  children,  copied  in  popular  treatises  on 
hygiene  of  infancy  and  childhood,  is  from  Murrai/s  Modern  Cookery  Book : 
.  .  .  .  "Put  apples  sliced,  or  plums,  currants,  gooseberries,  etc.,  into  a 
stone  jar,  and  sprinkle  among  them  as  much  Lisbon  sugar  as  necessary :  set 
the  jar  in  an  oven  or  on  a  hearth,  with  a  teacupful  of  water  to  prevent  the 
fruit  from  burning,  or  put  the  jar  into  a  saucepan  of  water  till  its  contents 
be  perfectly  done.  Berries  and  fruits  thus  prepared  and  the  fruit  jellies  are 
best  eaten  spread  on  bread  and  butter  or  on  soda  crackers." 


80  BATHING,   CLOTHING,  SLEEP,  EXERCISE. 

CHAPTER   IX. 

BATHING,   CLOTHING,   SLEEP,   EXEECISE. 

Bathing  is  now  recognized  in  all  civilized  countries  as  one  of  the  chief 
promoters  of  bodily  comfort  and  health.  The  first  bathing  of  the  infant, 
which  is  immediately  after  birth,  should  be  in  water  at  a  temperature  a  little 
below  that  of  the  blood — namely,  at  about  96° — after  which  the  general 
bath  is  inadmissible  until  the  navel-string  is  detached.  In  the  infant  reaction 
of  the  surface  when  chilled  is  tardy  and  uncertain,  and  therefore  there  is 
great  danger  of  catching  cold  when  the  surface  is  cooled  by  water  and  does 
not  quickly  react.  It  is  a  matter  of  daily  observation  that  infants  become 
chilly  and  their  extremities  remain  cool  in  a  medium,  whether  air  or  water, 
in  which  older  children  and  adults  would  have  comfortable  warmth.  There- 
fore they  are  liable  to  contract  bronchitis,  sore  throat,  intestinal  catarrh,  or 
other  inflammation  from  very  slight  exposures.  This  fact  must  be  borne  in 
mind  in  considering  the  subject  of  bathing. 

During  the  first  year  after  the  detachment  of  the  navel-string  the  bath 
should  be  employed  daily,  but  not  longer  than  three  minutes,  during  which 
time  thorough  ablution  can  be  performed.  Different  authorities  disagree  in 
regard  to  the  proper  temperature  of  the  bath  during  the  first  months  of 
infancy.  Steiner  of  Prague,  a  high  authority  in  children's  diseases,  says : 
^'  During  the  first  nine  months  the  infant  should  have  a  daily  bath  a  little 
above  blood  heat,"  but  most  authors  recommend  a  temperature  a  little  below 
blood  heat.  In  my  opinion  it  should  be  at  92°,  which  is  considerably  below 
blood  heat,  but  which  communicates  a  moderately  warm  sensation  to  the  hand. 
After  the  age  of  ten  months,  or  even  of  eight  months  for  vigorous  children, 
the  temperature  of  the  bath  may  be  reduced  to  90°,  and  it  should  not  be 
lower  than  this  during  the  remainder  of  infancy,  or  if  it  be  used  a  little 
lower  care  should  be  taken  to  produce  reaction  by  brisk  rubbing  and  exercise 
after  a  short  bath.  At  the  close  of  infancy,  or  at  two  and  a  half  years,  the 
temperature  may  be  still  further  reduced,  but  it  should  not,  even  for  the  most 
robust  children  of  eight  or  ten  years,  be  below  78°,  which  is  recorded  on  our 
thermometers  as  the  temperature  of  summer  heat,  and  is  about  that  of  our 
northern  lakes  during  midsummer. 

The  rules  given  in  the  books,  not  to  bathe  or  direct  a  child  to  be  bathed 
immediately  after  eating  or  after  much  exercise,  when  the  pores  of  the  skin 
are  perspiring,  should  be  heeded.  The  head  should  first  be  wet  with  the 
water,  and  castile  soap  should  be  applied  over  the  surface  to  ensure  cleanli- 
ness. The  strongly-scented  toilet  soaps  sometimes  contain  rancid  fats  or 
other  deleterious  substances,  and  should  be  regarded  with  suspicion.  In  hot 
weather  a  daily  bath  is  advisable,  but  in  the  cooler  months  it  is  sufficient  if 
the  child  bathe  twice  or  three  times  in  the  week.  If,  from  lack  of  conveni- 
ences or  for  other  reasons,  general  bathing  be  dispensed  with  and  the  surface 
be  washed  from  a  basin  or  bowl,  cooler  water  may  be  used  than  would  be 
proper  for  the  general  bath,  and  a  longer  time  to  complete  bathing  would 
evidently  be  required.  The  bath-room  should  be  comfortably  warm,  and 
after  the  bath  the  surface  should  be  briskly  rubbed  with  flannel  or,  in  case 
of  older  children,  with  a  suitable  coarse  towel,  and  exercise  afterward  encour- 
aged to  ensure  full  reaction.  In  New  York,  in  one  of  the  largest  and  best 
managed  asylums,  both  boys  and  girls  are  allowed  to  bathe  in  bath-houses  in 
the  Hudson  when  the  water  and  weather  are  not  too  cool. 


CLOTHING.  81 

It  may  be  well  to  add  to  these  general  remarks  on  bathing  the  recent 
remarkable  statement  of  a  high  authority  on  thermoraetric  observations  and 
temperature,  that  during  hot  days  a  bath  in  hot  water,  employed  in  the  hours 
of  greatest  atmospheric  heat,  tends  to  reduce  the  heat  of  body  and  to  pre- 
serve its  normal  temperature  during  the  remainder  of  the  day.  Wunderlich 
says :  "  In  tropical  countries  and  in  very  hot  seasons  no  means  of  cooling  is 
so  lasting  as  a  bathe  or  douche  of  very  warm  water." 

Clothing. 

One  of  the  most  important  duties  of  the  mother  or  nurse  is  the  selection 
of  clothing  for  children  which  will  be  suitable  for  their  age  and  the  season. 
In  the  matter  of  dress,  as  in  that  of  diet,  many  errors  are  unconsciously 
committed.  In  a  room  of  proper  temperature,  which  during  the  cool  months 
should  be  70°  for  infants  and  68°  for  children  old  enough  to  run  about,  the 
head  should  never  be  covered  unless  in  case  of  young  infants ;  but  the  sides 
of  the  head,  as  well  as  the  neck  and  shoulders,  may  be  lightly  covered  in 
sleep.  It  is  the  common  practice  to  leave  off  the  "  bellyband  "  which  is 
applied  after  birth  when  the  infant  has  reached  the  age  of  three  or  four 
months ;  but  from  the  fact  that  infants  so  often  take  cold,  especially  at  night 
by  throwing  off  bedclothes,  both  in  cool  weather,  when  the  temperature  of 
the  apartment  may  fall  below  70°,  and  in  summer,  when  there  are  currents 
of  air  through  open  windows,  I  advise  the  continuance  of  the  band  during 
the  first  year  or  eighteen  months.  In  the  summer  it  should  be  made  of  light 
merino  and  in  the  winter  of  flannel.  It  should  never  be  so  thick  and  heavy 
as  to  be  uncomfortable,  or  so  snug  as  to  interfere  in  the  least  with  the  free 
movements  of  the  chest  and  abdomen  in  respiration.  It  should  extend  to 
and  not  over  the  ribs,  and  should  be  secured  either  with  safety-pins  or  a  few 
stitches.  If  excoriations  or  prickly  heat  appear  on  the  skin  under  the  band 
in  hot  weather — a  very  common  eruption  in  infancy — the  surface  should  be 
dusted  with  subnitrate  of  bismuth  or  a  mixture  in  equal  parts  of  lycopodium 
and  oxide  of  zinc,  and  a  single  layer  of  linen  should  be  applied  over  it  and 
under  the  band.  If  the  eruption  be  severe,  it  might  be  best  to  substitute  a 
linen  or  soft  muslin  band  for  a  time  in  place  of  the  merino. 

A  cardinal  principle  in  the  clothing  of  children  is  that  the  garments  should 
always  be  so  loose  as  not  to  interfere  in  the  least  with  the  functional  activity 
of  organs.  The  fitting  and  putting  on  of  the  dress  is  left  too  much  to  the 
discretion  of  the  nurse,  who  is  usually  ignorant  of  the  important  facts  in 
physiology,  and  unwittingly  and  with  the  best  intentions  injures  her  charge, 
I  have  often  interposed  to  loosen  the  dress  of  young  infants,  which  was  so 
tight  as  sensibly  to  embarrass  respiration  ;  and  the  case  of  a  new-born  infant 
has  been  reported  to  me  in  which  it  seemed  probable  that  death  resulted  from 
this  cause.  Infants  especially,  who  are  so  liable  to  pulmonary  collapse  and 
intestinal  hernia,  should  have  loose  covering  of  both  chest  and  abdomen. 
Pressure  over  the  stomach  always  feels  uncomfortable,  and  this  organ,  almost 
as  much  as  the  lungs,  needs  full  expansion  and  free  movement  in  order  to 
perform  its  function  of  digestion  properly.  The  same  is  true  also  of  the 
intestines,  but  they  tolerate  compression  better,  and  their  movements  are  less 
impeded  than  those  of  the  stomach  by  too  tight  dressing.  Another  part 
where  too  snug  an  application  of  the  dress  does  very  great  harm  is  the  neck, 
since  moderate  pressure  in  this  region  may  retard  the  circulation  of  blood 
through  very  important  vessels — to  wit,  those  which  supply  the  brain  or  return 
blood  from  this  organ.  The  dress  about  the  neck  should  always  be  so  loose 
that  the  four  fingers  of  the  nurse  can  be  readily  introduced  underneath  it. 
Skirts  upon  girls   are  sometimes  supported   by  being  tied  tightly  around  the 


82  BATHING,   CLOTHING,  SLEEP,  EXERCISE. 

waist  and  over  the  stomach.  This  should  never  be  allowed,  but  they  should 
always  be  supported  by  shoulder-straps  and  be  loose  around  the  waist. 

Clothing  protects  the  body  according  to  its  thickness  and  the  feebleness 
of  its  conducting  power  of  heat.  Woollen,  fur,  and  feather  garments  have 
very  low  conducting  power,  and  wool,  from  its  plentiful  supply  and  cheap- 
ness, must  always  be  the  material  which  is  chiefly  worn  in  the  winter  season  ; 
while  cotton,  and  in  still  greater  degree  linen,  are  active  conductors  of  heat, 
allowing  its  quick  escape  from  any  part  of  the  body  which  it  covers,  and 
they  are  therefore  the  proper  material  for  summer  clothing. 

The  color  of  the  garment  matters  little  as  regards  the  escape  of  heat  from 
the  body,  for  whatever  its  color  its  surface  next  the  body  is  necessarily  dark 
from  the  exclusion  of  light ;  but  the  color  is  iinportant  as  regards  the 
absorption  of  heat  from  the  atmosphere  and  the  solar  rays.  Black  has  the 
highest  absorptive  power,  while  white  has  the  least,  and  the  mixed  colors 
have  absorptive  powers  which  are  intermediate.  In  experiments  made  with 
shirtings  of  different  colors,  while  white  received  100°  F.,  black  received 
208°  F.  A  light  color  is  therefore  the  best  to  dress  children  in  during  the 
hottest  weather. 

The  covering  which  is  proper  for  the  head  of  a  child  when  outdoors  must 
evidently  vary  considerably  in  different  seasons  and  in  different  states  of 
weather.  Many  a  young  child  with  scanty  growth  of  hair  has  contracted 
that  painful  disease,  inflammation  of  the  ear,  followed  perhaps  by  a  protracted 
discharge  and  more  or  less  impairment  of  hearing,  in  consequence  of  taking 
cold  from  insufl&cient  covering  of  head  and  ears  in  inclement  and  changeable 
weather  ;  even  leaving  off  accidentally  a  band  or  tie  which  a  child  is  accus- 
tomed to  will  sometimes  give  it  a  cold. 

In  this  connection  I  wish  to  call  attention  to  the  common  and  dangerous 
practice  among  the  poor  of  allowing  children  to  go  bareheaded  in  the  sun 
during  the  season  when  the  atmospheric  heat  is  highest.  Not  a  summer 
passes  in  which  I  do  not  meet  cases  of  inflammation  of  the  brain  whiph  I, 
believe  to  be  largely  due  to  exposure  to  the  sun's  rays.  There  is  no  better 
and  safer  covering  for  the  head  of  a  child  who  is  allowed  to  go  in  the  open 
air  during  the  hot  weather  than  the  light,  cool,  and  inexpensive  straw 
hat. 

The  feet  should  always  be  warm  and  dry,  the  shoes  worn  in  wet  weather 
being  waterproof;  and  special  care  should  be  taken  in  the  selection  of  shoes 
that  they  be  pliable  and  loose,  so  as  to  allow  freedom  of  growth  without  com- 
pression of  any  part.  If  during  the  period  of  growth  proper  precautions  are 
taken  in  this  respect,  the  chiropodist  would  have  little  to  do  in  subsequent 
years.  Corns,  bunions,  and  ingrowing  toe-nails  originate  from  shoes  hard  and 
unyielding  or  too  tightly  fitting. 

Sleep. 

The  newly-born  infant  until  about  the  age  of  six  or  eight  weeks  requires 
not  less  than  twenty-one  hours'  sleep  each  day.  It  sleeps,  therefore,  most  of 
the  time  when  not  awake  for  the  purpose  of  nursing,  bathing,  and  change  of 
clothing.  If  it  do  not  have  this  amount  of  sleep  and  be  wakeful,  it  is  prob- 
ably not  well.  After  the  eighth  week  it  requires  less  and  less  sleep  with 
advancing  age,  and  at  the  end  of  the  first  year  fourteen  hours  of  sleep  each 
day  suffices.  At  the  age  of  eighteen  months  about  twelve  hours  of  sleep  are 
needed,  a  part  of  which  should  be  in  the  middle  of  the  day.  At  the  age  of 
two  and  a  half  or  three  years,  and  subsequently  during  childhood,  about  ten 
hours  are  required  at  night,  and  if  the  child  be  tired  or  sleepy  in  the  day- 
time it  should  be  allowed  to  sleep.     Sufficient  sleep  is  essential  for  the  nor- 


EXERCISE.  83 

mal  development  of  the  body  and  the  normal  functional  activity  of  the 
organs  in  infancy  and  childhood. 

During  sound  sleep  the  senses  no  longer  receive  and  communicate  impres- 
sions. They  enter  into  the  state  of  sleep  in  the  following  order :  Sight  is 
first  lost,  and  then  touch,  taste,  smell,  and  lastly  hearing.  In  sound  sleep 
also  the  frequency  of  the  respiration  and  pulse  is  slightly  diminished.  Exci- 
tation of  any  of  the  senses  has  a  tendency  to  prevent  sleep.  A  bright  light, 
rough  handling,  and  loud  noises  render  young  children  wakeful,  and,  if  there- 
by deprived  of  the  needed  sleep,  fretful.  Slight  excitation  of  certain  of  the 
senses,  as  by  a  low  humming  voice  or  gentle  rocking,  on  the  other  hand,  tend 
to  procure  sleep.  The  time  of  soundest  sleep  is  about  one  hour  after  its 
commencement,  after  which  it  becomes  gradually  less  profound  until  the 
child  awakens.  The  child  should  be  habituated  to  taking  its  sleep  at  a  cer- 
tain hour,  and  if  it  be  well  and  not  subjected  to  any  unusual  excitement,  it 
will  be  drowsy  and  will  sleep  readily  when  that  hour  arrives.  In  the  asylums 
of  New  York,  where  from  long  and  abundant  experience  the  management  of 
children  is  systematized,  infants  and  the  younger  children  are  usually  put  to 
bed  between  six  and  seven,  and  the  older  children  between  seven  and  eight, 
o'clock,  the  last  meal  being  light  and  readily  digested. 

Various  causes  produce  wakefulness  in  children.  We  have  already  alluded 
to  strong  impressions  upon  the  senses.  A  swollen  and  tender  gum,  indiges- 
tion with  flatulence  and  colic,  eczema  with  tenderness  and  itching,  as  well  as  the 
more  serious  forms  of  sickness,  produce  wakefulness.  Unpleasant  and  excit- 
ing sensations  of  whatever  kind,  reaching  the  brain,  keep  up  a  state  of 
excitement  and  prevent  its  repose.  The  fretful  and  sleepless  baby  in  the  hot 
and  stifling  air  of  the  tenement-house  in  the  heat  of  summer  soon  falls  asleep 
when  taken  to  cooler  air  outside. 

It  is  scarcely  necessary  to  call  attention  to  some  accepted  and  important 
facts  regarding  the  dormitory  of  children.  Free  ventilation  is  required  either 
through  ventilators  or  through  the  windows,  slightly  raised  in  winter,  and 
more  widely  open  in  summer.  A  small  room  should  not  contain  more  than 
two  children,  and  the  temperature  of  the  sleeping  apartment  should  be  at 
about  68°.     A  temperature  too  cool  causes  wakefulness. 

The  amount  of  blood  circulating  in  the  brain  in  sleep  is  less  than  when  awake, 
and  too  active  a  circulation,  as  from  fever  or  much  excitement,  causes  wake- 
fulness. If  the  head  be  unduly  hot,  and  in  the  infant  the  anterior  fontanel 
pulsate  forcibly,  a  cloth  wrung  out  of  cold  water  should  be  applied  over  it, 
and  a  general  bath  or  hot  foot-bath  should  be  used  in  order  to  diminish  the 
cerebral  circulation.  On  the  other  hand,  if  the  brain  be  not  properly  nour- 
ished in  consequence  of  poverty  of  the  blood,  as  is  sometimes  the  case  with 
pallid  and  scrofulous  children,  the  diet  should  be  more  nutritious  and  iron 
may  be  needed. 

If  the  sleeplessness  continue  when  all  causes  so  far  as  possible  have  been 
removed,  medicinal  treatment  will  be  necessary.  Frequently  in  families 
before  the  physician  is  summoned,  the  so-called  soothing  syrups  have  been  used, 
which  contain  an  opiate,  and  the  use  of  which  should  be  forbidden.  The  safest 
remedy  is  one  of  the  bromides,  which  may  be  given  dissolved  in  water  in 
three-grain  doses  to  an  infant  between  the  ages  of  six  and  twelve  months, 
and  one  grain  additional  should  be  added  for  each  year,  or  the  aniseed  cordial 
of  the  National  Formulary.  The  dose  if  required  may  be  repeated  after  two 
hours. 

Exercise. 

Exercise  is  an  important  hygienic  requirement.  Harm  often  results  from 
modes  of  exercise  which  are  not  adapted  to   the   age.     Occasionally  I  meet 


84  BATHING,   CLOTHING,  SLEEP,   EXERCISE. 

cases  of  permanent  bow-leg  which  have  manifestly  resulted  from  attempts  to 
make  infants  stand  at  the  age  of  four  or  five  months.  They  should  never  be 
encouraged  to  walk  or  stand  till  about  the  age  of  one  year,  and  if  they  do  at 
the  age  of  nine  or  ten  months  let  it  be  voluntary,  and  not  taught  by  stand- 
ing them  upon  their  feet.  In  case  of  infants  with  rachitis — which  disease  is 
common  in  cities,  and  is  characterized  by  a  lack  of  lime-salts  in  the  bones, 
and  can  be  detected  by  great  backwardness  in  teething — attempts  to  stand 
or  walk  for  any  length  of  time  should  be  discouraged  till  by  the  use  of  lime- 
salts  and  cod-liver  oil  and  improvement  of  the  general  health  the  rachitis  is 
cured.  Much  of  the  permanent  deformity  which  mars  the  beauty  and  sym- 
metry of  adult  life  originates  in  rachitis  and  might  have  been  prevented. 

The  infant  before  he  is  old  enough  to  stand  takes  sufficient  exercise  in  a 
way  that  is  natural  and  harmless.  Let  him  lie  upon  his  back  in  the  crib  or 
on  the  floor,  with  a  blanket  under  his  body  and  pillow  under  his  head,  with 
all  his  clothes  loose,  so  as  not  to  restrain  the  free  movement  of  his  limbs.  A 
healthy  infant  seems  to  enjoy  this  attitude,  moving  all  his  limbs  sufficiently 
to  give  them  the  required  exercise,  and  evincing  his  delight  and  exuberance 
of  life  by  utterances  which  are  as  expressive  as  words. 

In  the  cool  months  of  our  latitude  infants  should  not  be  taken  outdoor 
until  the  age  of  three  months,  and  then  only  for  a  brief  time  in  the  warmest 
part  of  the  day ;  but  in  the  summer  they  should  begin  to  receive  outdoor  air 
and  exercise  at  the  age  of  one  month.  In  warm  weather  the  face  should 
never  be  covered  by  a  veil  or  otherwise,  and  air  and  light  should  have  free 
access  to  it.  The  rays  of  the  sun,  however,  from  a  clear  sky  should  be 
excluded,  either  by  a  parasol  or  the  shade  of  trees  or  houses  or  by  the  carriage 
in  which  the  infant  is  conveyed.  In  cold  weather  or  when  there  is  a  strong 
wind  the  protection  of  a  veil  is  needed.  Rude  tossing  of  infants,  which  is 
common  in  families,  should  always  be  forbidden.  Its  effect  on  the  cerebral 
circulation  is  likely  to  be  bad,  and  it  involves  risk  of  serious  accident.  In 
one  instance  to  my  knowledge  death  resulted  from  injury  received  in  this 
way. 

Walking,  as  it  is  the  natural,  so  it  is  the  best,  exercise  for  the  older  infants 
and  during  the  period  of  childhood.  It  promotes  digestion  when  not  carried 
to  the  extent  of  fatigue,  and  gives  gentle  exercise  to  all  the  muscles.  The 
baby-carriage  answers  a  useful  purpose  when  combined  with  walking.  With 
the  ordinary  hired  nurse  it  is  safer  for  the  infant  to  be  taken  out  in  this 
vehicle  than  in  the  arms,  for  if  the  nurse  in  careless  walking  should  trip  great 
harm  might  result.  In  one  instance  which  came  under  my  notice  convulsions 
and  idiocy  were  plainly  referable  to  the  fall  of  an  infant  from  its  nurse's 
arms  upon  its  head. 

The  ordinary  lawn  sports  of  childhood,  as  croquet  for  both  sexes,  play- 
,  ing  ball  or  quoits  for  boys,  which  are  rendered  more  exciting  by  the  spirit  of 
rivalry,  are  also  useful  for  muscular  exercise  and  development,  while  they 
involve  little  danger.  The  swing  affords  a  pleasant  exercise,  and  with  the 
propulsion  required  it  gives  gentle  but  efficient  activity  to  most  of  the 
muscles. 

Many  of  the  gymnastic  exercises  are  too  severe,  involve  too  much  risk 
of  ruptured  tendons,  sprained^  joints,  and  even  of  dislocated  or  broken 
limbs. 

Among  all  the  ingenious  inventions  to  provide  sports  and  pastimes  for 
children,  there  are  none  better  than  gardening  and  farming  where  facilities 
will  allow  them,  conjoined  with  the  ordinary  household  duties.  The  healthy 
and  robust  development  of  the  farming  population,  their  almost  complete 
immunity  from  rachitic  and  scrofulous  ailments,  is  attributable  to  their  out- 
door mode  of  life  and  the  many  kinds   of  healthful   work  which   farm-life 


FEATURES,  ETC.  IN  DISEASE.  85 

requires.  Such  work  is  always  in  the  highest  degree  beneficial  for  children 
old  enough  to  participate  in  it,  while  it  develops  the  habit  of  productive 
industry. 


CHAPTER    X. 
DIAGNOSIS  OF  INFANTILE  DISEASES. 

General  Observations. 

Diseases  in  early  life  differ  in  important  particulars  from  those  occurring 
in  maturity.  Some  which  are  common  in  the  former  age  are  unknown  or  are 
rare  in  the  latter,  and  those  which  occur  equally  at  all  ages  often  present 
peculiar  symptoms  and  a  peculiar  clinical  history  in  the  young.  Therefore 
physicians  who  are  skilful  in  treating  adults  may  be  unskilful  in  treating 
children.  Excellence  as  a  physician  of  children  can  only  be  achieved  by 
special  and  continued  study  of  their  ailments. 

Again,  as  regards  the  diseases  of  infancy,  in  which  period  there  are  a  great 
amount  of  sickness  and  a  large  mortality,  diagnosis  must  evidently  be  made 
from  the  objective  symptoms — from  examining  the  features,  attitude,  utter- 
ances, the  pulse,  respiration,  etc..  and  inspecting  the  surfaces,  so  far  as  they 
are  accessible  to  view,  and  the  eliminated  products.  We  lack  for  this  age  the 
important  inft)rmation  which  speech  affords.  Some  general  remarks,  there- 
fore, in  reference  to  the  appearances  and  functions  of  the  system  in  early  life, 
and  the  changes  which  they  undergo  in  various  pathological  states,  seem 
requisite  in  order  to  a  clearer  appreciation  of  the  symptoms  and  more  ready 
diagnosis  of  individual  diseases. 

Features,  External  Appearance  of  the  Head,  Trunk,  and 

Limbs  in  Disease. 

In  the  new-born,  as  soon  as  respiration  and  the  new  circulation  are  estab- 
lished, the  cutaneous  capillaries  become  distended  with  blood  and  the  skin 
presents  a  congested  appearance.  By  the  close  of  the  first  week  this  external 
hypersemia  begins  to  abate,  and  is  soon  replaced  by  the  normal  capillary 
circulation. 

Icterus  is  common  in  the  first  and  second  weeks.  Bouchut  attributes  it 
to  mild  hepatitis.  A  much  more  plausible  view  of  its  causation,  and  prob- 
ably the  correct  one,  is  that  of  Frerichs,  who  attributes  it  to  the  effect  on  the 
hepatic  circulation  of  ligation  of  the  umbilical  cord.  By  ligation  the  current 
of  blood  through  the  umbilical  vein  to  the  liver  ceases,  the  amount  of  blood 
in  the  hepatic  capillaries,  which  connect  with  the  branches  of  the  vein,  dimin- 
ishes, and  then,  according  to  Frerichs,  by  the  law  of  diffusion,  diversion 
occurs  of  a  part  of  the  bile  from  the  hepatic  cells  into  the  capillaries,  while 
the  rest  flows  in  the  normal  manner  into  the  bile-ducts.  The  degree  of  jaun- 
dice is  proportionate  to  the  amount  of  bile  which  enters  the  circulation. 
Icterus  neonatorum  is  ordinarily  not  a  disease  of  importance.  If  the  gen- 
eral health  remain  good,  it  subsides  without  medicine  in  the  course  of  one 
or  two  weeks,  when  the  circulation  through  the  liver  becomes  equalized  and 
regular. 

The  surface  or  portions  of  the  surface  of  the  new-born  often  present  for  a 
few  hours  a  livid  color,  due  to  the  mode  of  delivery.     Protracted  lividity 


86  DIAGNOSIS  OF  INFANTILE  DISEASES. 

occurs  from  atelectasis  or  malformation  of  the  heart  or  great  vessels  ;  lividity 
induced  by  exertion  or  excitement,  while  the  respiration  is  normal,  indicates 
malformation  of  the  heart  or  vessels ;  temporary  lividity  sometimes  occurs  in 
severe  acute  diseases,  especially  those  of  the  respiratory  organs ;  lividity, 
whether  temporary  or  permanent,  is  a  sign  of  imperfect  decarbonization  of 
the  blood. 

The  cheeks  of  children  are  congested  in  febrile  and  inflammatory  diseases, 
except  in  a  cachectic  or  prostrated  state  of  the  system.  Transient  circum- 
scribed congestion  of  the  face,  ears,  or  forehead  constitutes  a  reliable  sign  of 
cerebral  disease.  Strabismus  occurring  in  connection  with  febrile  reaction, 
oscillation  of  iris,  inequality  of  pupils,  and  drooping  of  upper  eyelids,  also 
denote  cerebral  disease.  The  pupils  are  contracted  during  sleep,  evenly 
dilated  in  death. 

Dilatation  of  the  alae  nasi  during  inspiration,  with  contraction  of  the  eye- 
brows and  a  countenance  indicative  of  suffering,  attends  severe  inflammation 
of  the  respiratory  organs.  Absence  of  tears  during  the  act  of  crying  shows 
a  severe  and  probably  fatal  form  of  disease  in  infants  over  the  age  of  four 
months. 

Rapid  wasting  of  the  features,  causing  deep  suborbital  depressions,  prom- 
inence and  pointedness  of  the  cheek-bones  and  chin,  and  hollowness  of  the 
cheeks,  are  signs  of  severe  diarrhoeal  malady ;  the  most  striking  examples  of 
this  sudden  collapse  of  features  are  afi"orded  by  patients  affected  with  cholera 
infantum.  In  severe  cases  of  this  disease  the  physiognomy,  from  a  state  of 
fulness  and  health,  presents  in  a  few  hours  such  a  wasted  and  senile  appear- 
ance that  the  friends  with  difiiculty  recognize  the  features  with  which  they 
are  familiar.  Muscular  tonicity  is  also  greatly  impaired  in  this  disease — that 
of  the  orbicular  muscles  of  the  lips  and  eyelids  to  such  an  extent  that  the 
mouth  is  open  and  the  eyeballs  exposed  during  sleep.  Great  emaciation 
occurring  gradually  is  a  symptom  of  subacute  or  chronic  disease  of  a  grave 
character,  often  of  tuberculosis  or  chronic  entero-colitis. 

Strabismus  sometimes  occurs  in  children  who  have  no  serious  disease.  It 
is  then  due  to  simple  paralysis  of  one  or  more  of  the  motor  muscles  of  the 
eye.  But  when  supervening  upon  other  symptoms  of  a  neuropathic  charac- 
ter it  is  a  grave  symptom,  indicating  organic  disease  of  the  encephalon,  as 
eff"usion,  meningitis,  etc.  A  permanently  downward  direction  of  the  axes  of 
the  eyes,  with  smallness  of  the  face  and  great  expansion  of  the  cranium,  is  a 
sign  of  chronic  hydrocephalus.  The  scalp  in  this  disease  is  tense,  bald,  or 
sparingly  covered  with  hair,  the  fontanels  and  sutures  open  and  enlarged, 
and  the  cranial  bones  yield  to  pressure.  Great  expansion  of  the  cranium 
above  the  ears,  while  the  frontal  portion  is  not  enlarged  or  but  slightly, 
denotes  hypertrophy  of  the  brain. 

The  appearance  of  the  general  cutaneous  surface  possesses  much  greater 
diagnostic  value  in  the  diseases  of  infancy  and  childhood  than  in  those  of 
adult  life.  The  eruptive  fevers,  so  common  in  the  young  and  comparatively 
rare  in  the  adult,  reveal  themselves  to  us  in  great  part  by  the  changes  which 
they  cause  in  the  appearance  of  the  integument.  The  peculiar  color  of  the 
skin  in  constitutional  syphilis,  hereafter  to  be  described,  and  which  is  more 
marked  in  infancy  and  early  childhood  than  at  any  other  age,  is  a  diagnostic 
sign  of  great  value  in  obscure  cases.  In  the  infant  the  cold  stage  of  inter- 
mittent fever  is  manifested,  not  by  muscular  tremors,  but  by  lividity,  pallor, 
and  the  goose-skin  appearance  of  the  surface. 

Bulbous  enlargement  of  the  fingers  and  incurvation  of  the  nails  are  signs 
of  cyanosis,  and  therefore  of  malformation  at  the  centre  of  the  circulatory 
apparatus,  or  of  tuberculosis  or  chronic  pulmonary  disease  attended  by  mal- 
nutrition.    Enlargement   of  the    spongy   portions   of   bones,   causing    prom- 


ATTITUDE— MOVEMENTS— THE   VOICE.  87 

inences,  softness,  and  bending  of  the  bones,  and  consequent  deformity  of 
the  limbs,  patency  of  the  fontanels,  a  large  and  square  shape  of  the  head 
from  calcareous  deposit  external  to  the  cranium,  and  delayed  dentition,  are 
among  the  signs  of  rachitis. 

In  early  infancy  the  gUuids  of  the  skin  and  mucous  surfaces,  or  which 
connect  by  their  orifices  with  these  surfaces,  are  slightly  developed.  There- 
fore, sensible  perspiration  and  lachrymation  are  rare  under  the  age  of  three 
months.  A  thick  Meibomian  secretion  of  a  puriform  appearance  collecting 
between  the  eyelids  is  an  unfavorable  prognostic  sign  ;  it  indicates  a  state  of 
great  depression  ;  it  is  observed  most  frequently  in  cerebral  and  intestinal 
maladies  shortly  before  death.  Passive  congestion  of  the  vessels  of  the  con- 
junctiva sometimes  occurs  under  the  same  circumstances,  due  to  feebleness 
of  the  heart's  action  and  imperfect  capillary  circulation.  It  indicates  the 
near  approach  of  death. 

Attitude — Movements — the  Voice. 

A  sharp,  piercing  cry,  head  firmly  retracted,  flexure  of  the  limbs  with  a 
degree  of  rigidity,  abduction  of  the  great  toe,  clonic  or  tonic  spasm  of  the 
muscles,  irregular  movements  of  one  or  more  limbs,  with  consciousness 
impaired  or  with  mental  hallucinations,  are  symptoms  of  grave  disease  of 
the  cerebro-spinal  system.  Irregular  muscular  movements,  partly  controlled 
by  the  will  and  occurring  during  full  consciousness,  are  symptoms  of  chorea, 
a  disease  nearly  always  ending  favorably  in  children,  though  incurable  in  the 
adult.  Contraction  of  the  eyebrows,  turning  of  the  eyes  and  face  from  light, 
avoidance  of  noises  as  if  painful,  are  signs  of  headache.  Frequent  carrying 
of  the  hand  to  the  ear  and  pressing  with  the  ear  against  the  breast  of  the 
mother  or  nurse  are  symptoms  of  otalgia.  Frequent  carrying  of  the  fingers 
to  the  mouth  in  connection  wi£h  fretfulness  or  other  symptoms  of  sufiiering 
indicates  stomatitis,  gingivitis  whether  from  difficult  dentition  or  other  causes, 
painful  pharyngitis,  or  some  obstructive  disease  of  the  larynx.  Frequent 
rubbing  or  pressing  the  nose  may  be  due  to  intestinal  worms  or  intestinal 
irritation  from  other  causes.  It  may  be  due  to  coryza  or  headache.  Fre- 
quent forcible  rubbing  or  striking  the  nose  should  lead  to  a  careful  examina- 
tion and  perhaps  guarded  prognosis.  It  often  indicates  grave  cerebral  disease, 
and  may  be  a  precursor  of  convulsions. 

In  severe  obstructive  disease  of  the  larynx  the  child  is  restless,  moving 
from  side  to  side.  In  most  inflammations  of  the  respiratory  organs  a  semi- 
erect  position  gives  most  relief.  The  voice  in  severe  laryngitis  is  often  hoarse 
or  indistinct,  and  is  usually  so  in  the  pseudo-membranous  form  ;  in  pleuritis 
or  pneumonitis  it  is  restrained  and  abrupt,  since  the  movements  of  the  walls 
of  the  chest  give  pain. 

The  voice  in  severe  diseases  of  the  abdominal  organs  is  feeble  and  plain- 
tive. It  is  sometimes  short  and  restrained  in  acute  dyspepsia,  in  peritonitis, 
and  in  cases  of  great  abdominal  distension.  The  horizontal  position  gives 
most  relief  in  abdominal  diseases.  In  case  of  abdominal  pain  the  parient 
often  presses  his  hand  upon  the  abdomen  and  flexes  his  thigh  over  it.  Per- 
fect quietude,  with  features  sunken  and  unchanged  by  smile  or  crying,  is  a 
symptom  of  severe  and  exhausting  diarrhoeal  afi'ections. 

Respiratory  System. 

The  respiration  of  the  infant  under  the  age  of  six  months  is  very  irreg- 
ular, and  it  is  more  irregular  the  nearer  the  time  to  birth.  If  the  new-born 
infant  be  closely  observed,  it  will  be  seen  to  sigh  often  ;  it  breathes  pretty 


88  DIAGNOSIS  OF  INFANTILE  DISEASES. 

uniformly  and  regularly  for  a  moment,  and  then,  without  appreciable  cause, 
the  respiration  is  intermitted ;  it  holds  its  breath  when  it  smiles  or  moves 
its  head  or  even  its  limbs ;  it  is  very  subject  to  hiccup ;  this  is  more  common 
the  first  week  of  life  than  at  any  other  age.  So  much  is  the  breathing  of 
the  young  infant  disturbed  by  these  causes  that  the  number  of  respirations 
ordinarily  varies  in  consecutive  minutes.  In  order,  therefore,  to  determine 
with  accuracy  the  frequency  of  the  normal  respiration  for  this  time  of  life 
it  is  necessary  to  take  the  average  of  several  observations. 

At  birth,  while  the  function  of  the  heart  has  for  months  been  regularly 
performed,  the  lungs  are  still  quiescent.  The  one  organ  has  been  active  dur- 
ing the  greater  part  of  foetal  development,  the  other  is  yet  untried.  Here- 
after, in  the  new  order  of  things,  so  intimate  is  the  relation  between  the  heart 
and  lungs  that  the  proper  performance  of  the  function  of  the  one  is  essential 
to  that  of  the  other.  Therefore,  the  commencement  of  respiration  and  the 
return  of  circulation,  which  is  modified  and  temporarily  arrested  at  birth, 
are  nearly  simultaneous.  Respiration  begins  in  the  first  half  minute  of  inde- 
pendent existence  ;  often,  indeed,  attempts  to  inspire  occur  before  delivery  is 
completed.  The  exceptions  to  this  early  establishment  of  respiration  are 
after  tedious  or  unnatural  births.  The  establishment  of  the  new  circula- 
tion is  a  moment  later. 

Respiration  in  Health. — As  the  air-cells  at  birth  are  closed,  the  estab- 
lishment of  respiration  is  difiicult.  The  air  at  first  penetrates  a  few  pulmo- 
nary cells,  but  gradually  more  and  more  are  inflated  through  the  forcible 
inspirations  which  the  crying  of  the  infant  produces,  till  after  a  variable 
time  respiration  becomes  easy  and  complete.  If  the  cry  be  feeble,  and  espe- 
cially if  with  this  feebleness  there  be  considerable  congestion  of  the  brain, 
the  result  of  tedious  birth,  the  full  establishment  of  respiration  is  in  a  cor- 
responding degree  gradual  and  slow. 

The  frequency  of  the  respiration  in  health  should  be  ascertained  in  order 
to  determine  whether  in  a  given  case  it  be  abnormally  accelerated.  The  fol- 
lowing table  embodies  the  result  of  observations  which  I  have  made  in  order 
to  determine  the  normal  frequency  of  respiration  in  the  first  year  of  life : 


Normal  Infantile 

Respirations  (number 

per 

minute). 

Age. 

From  first 

From  close 

From  close 

Close  of 

Close  of 

half  hour  to 

of  first  week 

of  first 

third  to  close 

sixth  month 

close  of  first 

to  close  of 

month  to 

of  sixth 

to  close  of 

First 

week. 

first  month. 

close  of  third. 

month. 

first  year. 

half 
hour. 

A! 

a. 

M 

o. 

ffi 

o. 

o. 

^ 

o. 

'f 

"m 

^ 

■3 

^ 

^ 

'm 

^ 

<5 

< 

<5 

-< 

< 

<5 

< 

< 

< 

< 

Number  of  observations. 

29 

28 

14 

13 

13 

16 

10 

25 

7 

19 

6 

Extreme  number  of  res- 

pirations per  minute  .   25-104 

32-64 

40-64 

40-96 

28-60 

32-68 

28-52 

36-88 

24-40 

28-64 

24-36 

Mean  number  of  respira- 

tions per  minute  .   .   .     48..") 

52 

52 

59 

45 

51 

39 

54 

33 

41 

29 

As  the  child  advances  from  the  age  of  one  year,  the  number  of  respi- 
rations per  minute  gradually  diminishes,  but  through  the  whole  period  of 
childhood  it  remains  greater  than  in  the  adult.  At  the  age  of  five  years, 
when  the  child  is  quiet  but  awake,  it  is  about  27 ;  at  the  age  of  ten  years, 
about  22. 

Respiration  in  Disease. — In  cerebral  diseases  the  respiration  becomes 


RESPIRATORY  SYSTEM.  89 

slow,  and,  if  somnolence  occur,  intermittent  and  accompanied  by  sighing. 
In  young  infants,  in  the  drowsiness  which  supervenes  when  the  blood  is 
imperfectly  decarbonized,  during  severe  attacks  of  capillary  bronchitis  or 
broncho-pneumonia,  respiration  is  likely   to  be  intermittent. 

In  inflammatory  diseases  of  the  larynx  and  trachea  respiration  is  but 
slightly  accelerated,  and,  if  there  be  no  obstruction,  its  rhythm  is  normal ; 
if  there  be  obstructive  disease  its  rhythm  is  altered ;  the  inspiratory  act  is 
lengthened.  In  bronchitis  respiration  is  accelerated  in  proportion  to  the 
degree  of  extension  downward  of  the  inflammation.  It  is  in  no  disease  more 
accelerated  than  in  severe  capillary  bronchitis. 

In  pleuritis  and  pneumonitis  the  respiration  is  accelerated  in  proportion 
to  the  extent  and  acuteness  of  the  inflammation.  Inspiration  ending  abruptly 
and  succeeded  by  an  expiratory  moan  is  a  symptom  of  both  pleuritis  and 
pneumonitis  in  their  acute  stages.  In  certain  cases  of  irritative  or  inflam- 
matory disease  of  the  abdominal  organs  respiration  presents  a  similar  charac- 
ter ;  it  is  modified  in  this  manner  in  consequence  of  the  pain  experienced  in 
movements  of  the  diaphragm.  Ordinarily,  however,  in  abdominal  diseases, 
respiration  is  nearly  natural. 

The  cough  is  an  important  diagnostic  symptom.  It  is  loud  and  sonorous 
in  spasmodic  croup,  hoarse  or  harsh  in  true  croup,  clear  and  distinct  in  bron- 
chitis, suppressed  and  painful  in  the  early  stages  of  pneumonitis  and  pleuritis, 
convulsive  and  with  more  inspirations  than  expirations  in  pertussis.  A  cough 
due  to  coexisting  bronchitis  is  one  of  the  first  and  most  constant  symptoms  of 
measles.  Typhoid  and  remittent  fevers,  difl&cult  dentition,  intestinal  worms, 
irritating  ingesta,  and  severe  burns  sometimes  give  rise  to  a  cough  which  is 
nearly  dry  and  painless.  Occurring  in  such  diseases,  it  is  sometimes  depend- 
ent on  more  or  less  bronchitis,  to  which  the  primary  disease  has  given  rise. 

A  strongly-marked  nasal  or  palatal  cry  is  present  in  syphilitic  ozaena, 
hypertrophied  tonsils,  and  paralysis  of  the  soft  palate.  If  these  can  be 
excluded  it  indicates  retropharyngeal  abscess.  On  one  occasion  Pollitzer 
heard  this  cry  in  a  baby  that  the  mother  said  was  well ;  but  he  introduced 
his  finger  in  the  fauces,  felt  the  expected  swelling,  and  by  an  incision  evac- 
uated a  considerable  amount  of  pus. 

An  excessively  prolonged,  loud-toned  expiration,  with  normal  inspiration 
and  without  dyspnoea,  is,  according  to  Pollitzer,  an  early  symptom  of  chorea, 
sometimes  preceding  all  other  symptoms.  He  was  once  called  to  a  child, 
apparently  well  and  asleep,  in  whom  this  symptom  had  continued  two  hours, 
and  was  supposed  by  the  mother  to  indicate  croup.  Later  the  ordinary 
symptoms  of  chorea  appeared.  The  same  author  regards  a  high  thoracic, 
continued  sighing  inspiration  as  almost  pathognomonic  of  weak  heart  and 
of  certain  cases  of  acute  fatty  heart.  Unlike  the  condition  in  laryngeal 
stenosis,  while  the  diaphragm  is  nearly  inactive  the  accessory  muscles  of 
inspiration  act  strongly.  This  symptom  occurs  early,  antedating  the  lividity, 
pallor,  weak  pulse,  and  cold  extremities. 

A  distinct  pause  after  each  expiration,  ascertained  in  a  quiet  room  by 
placing  the  ear  close  to  the  mouth,  distinguishes  laryngeal  catarrh  from  croup 
(Pollitzer).  Stridulous  inspiration  usually  indicates  acute  laryngeal  catarrh, 
but  I  have,  in  a  considerable  number  of  instances,  been  asked  to  prescribe  for 
infants  with  stridulous  respiration  which  commenced  early,  perhaps  in  the 
first  or  second  month,  and  continued  night  and  day  till  about  the  close  of 
the  first  year,  when,  in  the  development  of  the  child,  it  ceased.  It  is 
attended  by  no  dyspnoea  or  suffering,  does  not  interfere  with  the  nutrition 
or  growth,  is  not  benefited  by  any  known  treatment,  and  it  seems  that  it 
may  exi.st  within  physiological  limits. 

A  shrill,  loud  cry,  night  after  night,  in  sleep,  while  the  child  is  well  in  the 


90 


DIAGNOSIS  OF  INFANTILE  DISEASES. 


day-time,  is  probably  due  to  dreams,  and  it  may  be  treated  by  a  large  dose 
of  quinine  at  bed-time,  but  a  full  dose  of  the  bromide  of  potassium  or  sodium 
is  perhaps  more  likely  to  give  relief.  A  cry  lasting  five  or  ten  minutes  and 
occurring  several  times  in  the  day  indicates  spasm  of  the  bladder,  especially 
if  dysuria  be  present.  It  is  best  treated  by  belladonna,  provided  that  there 
be  no  calculus.  A  cry  during  defecation  indicates  fissure  of  the  anus,  and 
is  to  be  treated  by  an  ointment  of  zinc  and  belladonna.  A  violent  and  pro- 
tracted cry,  with  restlessness,  pressing  the  head  on  the  pillows  or  breast  of 
the  nurse,  and  frequent  carrying  of  the  finger  to  the  ear,  indicate  otalgia. 


Circulatory  System. 

In  all  ages  and  countries  the  pulse  has  been  considered  an  important 
symptom,  both  in  diagnosis  and  prognosis.  'It  aids  the  practitioner  in  deter- 
mining, approximately,  not  only  the  character,  but  the  gravity,  of  diseases.  It 
is  somewhat  remarkable,  from  the  importance  which  is  attached  to  the  pulse 
in  medical  practice,  that  its  natural  frequency  and  its  character  in  infancy  are 
not  more  accurately  known.  It  is  true  that  eminent  observers,  as  Trousseau 
and  Valleix,  have  published  statistics  relating  to  the  infantile  pulse  in  health, 
but  these  statistics  disagree,  and  therefore  do  not  aiFord  a  reliable  standard 
with  which  to  compare  the  pulse  in  disease.  Moreover,  some  published 
statistics  of  the  pulse  possess  but  little  value  from  the  small  number  of 
observations ;  some  from  the  fact  that  records  of  the  infantile  pulse  are 
grouped  with  those  of  older  children  ;  and  others  because  the  state  of  the 
infant  as  regards  its  activity  or  emotions  is  not  mentioned. 

Pulse  in  Health. — It  is  not  easy  to  collect  statistics  of  the  pulse 
during  the  period  of  infancy  which  are  entirely  free  from  error,  since  slight 
derangements  of  the  system  in  the  infant  frequently  occur  which  are  not 
manifested  by  any  marked  symptoms,  but  which  produce  acceleration  of 
pulse.  In  collecting  the  following  statistics  sources  of  error,  so  far  as  pos- 
sible, were  avoided. 

The  movements  of  the  heart  commonly  begin  about  one-eighth  of  a  min- 
ute after  birth.  They  are  at  first  slow,  the  ventricular  contractions  not 
numbering  more  than  eight  or  ten  by  the  close  of  the  first  quarter  minute. 
In  the  second  quarter  the  cries  are  vigorous,  and  the  pulse  now  is  rapidly 
-accelerated,  rising  commonly  above  120,  and  sometimes  above  160  beats,  per 
minute.  In  fifty-seven  observations  of  the  pulse  in  healthy  infants  during 
the  first  half  hour  of  life,  after  the  first  quarter  of  a  minute  I  found  that  the 
extremes,  with  one  exception,  were  104  and  164 — average,  139. 


Tahl 

e  of  Infantile  Pulse 

in  Health. 

Age. 

From  close  of 

From  close  of 

From  close  of 

iFrom  close  of 

first  week  to 

first  month  to 

third  month  to 

1  sixth  month 

close  of  first 

close  of 

close  of 

1    to  close  of 

month. 

third. 

sixth. 

first  year. 

Awake. 

Awake 

Awake. 

Awake. 

Awake.- 

Quiet ; 

S" 

Quiet ; 

c. 

Quiet; 

p, 

Quiet ; 

p. 

Quiet ; 

&. 

movmg 

moving 

— 

moving 

s 

moving 

I  moving 

<» 

slightly; 

< 

slightly; 

< 

slightly; 

< 

slightly; 

< 

i  slightly; 

< 

nursing. 

nursing. 

nursing. 

nursing. 

nursing. 

Number  of  ob- 

servations .  . 

22 

16 

10 

10 

15 

17 

25 

6 

20 

a 

Extremes  .  .   . 

104-152 

108-140 

124-160 

104-144 

112-148 

104-1.32 

112-146 

104-116 

112-144 

Mean 

126 

122 

1.39 

118 

132 

118 

129 

108 

127 

109 

CIRCULATORY  SYSTEM. 


91 


'*  M.  Ledeberder,"  says  Bouchut,  "could  only  count  the  pulse  in  the  first 
minute  of  life  in  six  children,  and  he  has  observed  from  72  to  94  pulsations." 
Valleix  estimates  the  pulse  between  the  ages  of  two  and  twenty-one  days  at 
87.  Trousseau  states  that  the  pulse  in  the  first  week  of  life  varies  from  78 
to  150  ;  and  Dr.  Gorham's  observations  are  in  the  main  similar  to  Trousseau's. 
My  observations,  as  seen  from  the  above  table,  do  not  correspond  with  the 
assertions  of  Ledeberder  and  Valleix.  Indeed,  if  there  were  no  conflicting 
testimony  there  would  still  be  a  strong  presumption  that  these  authors  are  in 
error,  for  we  would  not  suppose  that  the  pulse  of  the  infant,  in  whom  there 
is  greater  functional  activity  both  muscular  and  visceral,  would  fall  so  much 
below  that  of  the  fa3tus.  It  is  probable  from  the  expression,  "  could  only 
count  the  pulse  ....  in  six  children,"  that  Ledeberder,  and  perhaps  Val- 
leix, counted  the  pulse  in  the  wrist,  which,  with  exceptional  cases,  is  very 
ditficult  and  often  impossible  in  the  first  week  of  life,  and  that  they  missed 
some  of  the  beats,  or,  not  unlikely,  sometimes  counted  their  own  pulse. 
Immediately  after  birth  there  is  so  little  force  of  the  ventricular  systole,  and 
the  extreme  arteries,  therefore,  of  the  system  pulsate  so  feebly,  that  neither 
in  the  limbs  nor  at  the  anterior  fontanel  can  the  frequency  of  the  pulse  be 
readily  ascertained.  It  can  be  readily  and  accurately  ascertained  only  by 
auscultation  or  by  placing  the  hand  on  the  precordial  region,  or  directly  after 
birth  by  the  pulsations  in  the  umbilical  cord. 

The  average  pulse  of  the  healthy  infant  in  the  first  and  second  months  is, 
according  to  Trousseau,  137  per  minute,  128  from  the  third  to  the  sixth 
month,  and  120  from  the  sixth  to  the  twelfth  month.  It  is  seen  that  his 
observations  agree  closely  with  mine  as  regards  infants  who  are  quiet,  but 
awake.  One  point  of  interest  established  by  the  above  statistics  is  the  great 
diminution  in  the  frequency  of  the  pulse  in  sleep. 

Pulse  during  or  after  Active  llovements  or  Great  Mental  Excitemient. 


Age. 

Close  of  first 

Close  of  first 

Close  of  third 

Close  of  sixth 

First  week. 

week  to  close  of 

to  close  of  third 

to  close  of  sixth 

month  to  close 

first  month. 

month. 

month. 

of  firet  year. 

140 

162 

176 

132 

132 

160 

156 

152 

148 

144 

140 

140 

158 

148 

152 

152 

152 

144 

144 

182 

152 

156 

198 

180 

156 

160 

Extremes  .    . 

140-160 

146-162 

144-180 

132-156 

132-198 

Mean .    .    .  • 

148 

152 

160 

147 

156 

It  is  seen  by  the  above  table  that  by  active  exercise  or  great  mental  excite- 
ment the  pulse  may  become  as  rapid  as  in  grave  diseases.  There  is  greater 
acceleration  of  pulse  from  the  emotions  and  from  exercise  in  feeble  than  in 
robust  children.  Obviously,  in  order  to  determine  to  what  extent  the  pulse 
is  accelerated  in  disease  it  is  necessary  that  it  should  be  counted  during  a 
state  of  quietude.  As  the  age  increases  it  is  less  and  less  influenced  by  the 
emotions  and  physical  exertion  ;  still,  during  the  whole  period  of  childhood 
such  influences  do  have  more  or  less  eff"ect  on  its  frequency. 

Pulse  in  Disease. — Febrile  and  inflammatory  diseases  produce  greater 
acceleration  of  pulse  in  early  life  than  in  maturity.  Diseases  or  derangements 


92  DIAGNOSIS  OF  INFANTILE  DISEASES. 

of  system,  particularly  those  of  tlie  digestive  organs,  which  do  not  materially 
affect  the  pulse  in  the  adult,  often  cause  acceleration  of  it  in  children.  The 
febrile  pulse  of  early  life  usually  has  exacerbations  in  its  frequency.  These 
commonly  oc3ur  in  the  latter  part  of  the  day.  Distinct  and  more  or  less  reg- 
ular febrile  exacerbations  and  remissions  are  common  in  several  diseases  of 
early  life,  some  of  which  are  serious,  while  others  involve  little  danger. 
Among  these  diseases  may  be  mentioned  difficult  dentition,  intestinal  worms, 
incipient  meningitis,  and  constipation.  An  intermittent  and  irregular  pulse 
is  common  in  fully-developed  meningitis  and  certain  other  severe  organic 
diseases  of  the  encephalon.  It  may  be  due  also  to  disease  of  the  heart,  and 
it  also  occurs  in  some  children  from  temporary  disturbance  of  the  digestive 
function.  The  pulse  is  slow  in  compression  of  the  brain  and  in  sclerema  of 
the  new-born. 

Animal  Heat. 

The  internal  temperature  of  the  body  in  health  is  uniform.  In  33  infants 
under  the  age  of  seven  days  M.  Roger  found  the  average  temperature  98.6° 
Fahr.,  while  in  25  from  four  months  to  fourteen  years  old  it  was  99°.  The 
external  temperature  alone  varies  in  health  according  to  the  temperature  of 
the  atmosphere. 

Elevation  of  temperature  above  the  normal  standard  is  a  sign  of  inflam- 
matory and  febrile  diseases.  The  increase  of  heat  varies  according  to  the 
nature  of  the  disease  and  its  type.  In  favorable  cases  of  inflammation  and 
in  simple  fevers  it  is  not  ordinarily  more  than  two  or  three  degrees.  The 
greater  the  severity  and  malignancy  of  inflammatory  and  febrile  diseases  the 
greater  the  elevation.  An  elevation  of  more  than  six  degrees  indicates  a 
malady  which  is  likely  to  prove  fatal.  It  is  rare  that  the  temperature,  even 
in  fatal  cases,  rises  above  107°.  In  measles,  in  the  eruptive  stage,  it  is  from 
101°  to  103°;  in  scarlatina  from  102°  to  104°  if  no  complication  exist.  In 
diphtheria  the  temperature  is  elevated  at  first,  but  it  frequently  falls  to  nearly 
the  normal  during  the  stage  of  profound  toxaemia. 

Reduction  of  the  internal  temperature  is  an  unfavorable  prognostic  sign  ; 
it  is  observed  a  few  hours  before  death  in  infants  who  are  greatly  reduced  by 
certain  chronic  diseases,  as  entero-colitis.  In  these  cases  the  tongue,  and  even 
sometimes  the  breath,  communicate  co  the  finger  or  hand  a  sensation  of  cold- 
ness. 

The  importance  of  thermometric  observations  as  an  aid  to  the  diagnosis 
of  children's  diseases  is  within  a  few  years  more  fully  recognized  by  the  pro- 
fession. Two  diseases  which  in  their  commencement  present  very  similar 
symptoms  often  vary  as  regards  the  temperature.  Thus,  meningitis,  present- 
ing in  its  first  stages  symptoms  very  similar  to  those  of  typhoid  fever,  has  a 
lower  temperature  till  an  advanced  stage,  when  the  amount  of  heat  increases. 

Digestive  System. 

Inspection  of  the  buccal  and  faucial  surfaces  discloses  some  of  the  most 
frequent  local  diseases  of  infancy,  as  the  various  forms  of  stomatitis,  and 
others  which,  though  not  frequent,  involve  great  danger,  as  gangrene  of  the 
mouth,  diphtheria,  and  retro-pharyngeal  abscess.  Inspection  of  the  tongue 
aids  in  determining  in  many  cases  whether  the  disease  be  pursuing  a  favor- 
able course  or  has  become  asthenic  and  is  exhausting  the  vital  powers. 

Febrile  movements,  even  when  slight,  give  rise  to  coating  of  the  tongue 
and  intumescence  and  distinctness  of  its  follicles.  The  eruptive  fevers  are 
attended  by  changes  upon  the  buccal  and  faucial  surfaces  which  possess 
diagnostic  and  prognostic  value.     Hypersemia  of  these  surfaces  appears  early 


DIGESTIVE  SYSTEM. 


93 


in  rubeola  and  scarlatina  prior  to  those  phenomena  which  are  justly  regarded 
as  pathognomonic.  It  is  therefore  often  an  important  sign  in  the  initial  period 
of  these  diseases  when  the  diagnosis  is  obscure.  The  appearance  of  the 
fauces  in  diphtheria  and  croup,  indicating  not  only  the  nature  of  the  disease, 
but  its  gravity,  need  only  be  referred  to  in  this  connection. 

Inspection  of  the  buccal  and  faucial  surfaces  sometimes  enables  us  to 
form  a  probable  opinion  in  reference  to  the  nature  of  diseases  which  are 
seated  in  other  parts.  In  the  infant  protracted  stomatitis  is  a  common 
accompaniment  of  chronic  diarrhoea,  and  it  indicates  its  inflammatory 
nature. 

Vomiting  is  more  frequent  in  infancy  than  in  childhood,  and  in  either 
period  than  in  adult  life.  It  is  common  in  cerebral  affections,  and  is  one  of 
the  first  symptoms  of  scarlet  fever,  and  is  not  uncommon,  though  less  fre- 
quent, in  the  commencement  of  other  essential  fevers  and  of  acute  inflam- 
mations. It  is  a  symptom  of  indigestion,  entero-colitis,  cholera  infantum, 
and  intussusception  ;  it  is  common  also  after  the  paroxysmal  cough  of  per- 
tussis, and  not  infrequent  in  the  bronchial  inflammations  of  young  infants. 
In  both  these  diseases  it  is  excited  by  the  muco-purulent  matter  upon  the 
faucial  surface. 

Intestinal  gas  is  in  part  secreted  or  exhaled  from  the  mucous  membrane, 
as  the  experiments  of  Hunter  and  others  have  shown,  and  is  in  part  the 
product  of  chemical  changes  in  the  food.  A  certain  amount  of  gas  in  the 
intestines  is  normal ;  it  subserves  a  useful  purpose.  An  abnormal  amount 
of  it  is  common  in  various  diseases,  as  indigestion,  chronic  entero-colitis,  peri- 
tonitis, typhoid  fever.  It  is  a  frequent  cause  of  gastralgia  and  enteralgia  in 
the  infant.  In  scrofulous  or  feeble  infants  with  impaired  muscular  tonicity 
and  faulty  digestion  the  abdomen  is  often  habitually  more  or  less  distended 
with  gas,  which  does  not,  under  such  circumstances,  give  rise  to  pain  or  other 
local  symptoms ;  it  has  significance  as  showing 
the  general  condition  of  the  child. 

In  the  rachitic,  whose  thorax  is  compressed 
and  liver  often  enlarged,  while  the  vertebral 
column  is  shortened,  the  abdomen  is  commonly 
protuberant.  In  feeble  children,  not  decidedly 
rachitic,  whose  lungs  are  seldom  fully  inflated, 
and  whose  chests  are  consequently  depressed, 
the  abdomen  is  also  prominent.  The  accom- 
panying woodcut  represents  one  of  these  cases 
presented  for  treatment  at  the  Out-door  Depart- 
ment at  Bellevue. 

In  feeble  children  who  have  suff"ered  from 
repeated  and  pi'otracted  attacks  of  bronchitis, 
and  whose  chest-walls  are  consequently  de- 
pressed, a  similar  abdominal  prominence  occurs. 

Retraction  of  the  abdominal  walls  is  common 
in  meningitis  and  in  many  exhausting  diseases. 
Tenesmus  is  a  symptom  of  intussusception  in 
the  infant    and  of  colitis  in   children. 

Much  light  is  thrown  on  the  character  of 
intestinal  diseases  by  the  appearance  of  the 
stools.  Muco-sanguineous  stools  accompanied 
by  fever  are  a  sign  of  colitis.  Stools  contain- 
ing unmixed  blood  and  not  accompanied  by  fever  may  result  from  a  rectal 
polypus  and  from  purpura  hsemorrhagica.  Scanty  evacuations  of  blood,  with 
obstinate  constipation,  are  a  symptom  of  intussusception  in  infants. 


Fig.  4. 


94  DIAGNOSIS  OF  INFANTILE  DISEASES. 

The  alvine  discharges  of  infants  often  present  a  green  color ;  sometimes 
they  have  the  normal  yellow  hue  when  passed  from  the  bowels,  but  become 
green  on  exposure  to  the  air  or  from  reaction  of  the  urine.  By  the  microscope 
the  green  coloring  matter  is  seen  to  occur  in  small,  irregular  masses.  This 
green  substance  has  been  supposed  to  be  bile.  I  am  convinced  that  as  it 
occurs  in  the  stools  of  the  infant  it  is  commonly  produced  by  the  action  of  the 
intestinal  secretions  on  the  contents  of  the  intestines  ;  for  I  have  often  noticed 
that  the  contents  in  and  above  the  jejunum  were  yellow,  while  in  and  below 
the  ileum  their  color  was  green.  Probably  the  green  color  is  due  to  the  for- 
mation of  biliverdin  from  the  bile  which  is  mixed  with  the  fecal  matter. 

The  green  hue  may  occur  from  very  different  causes.  It  may  be  due  to  over- 
feeding, to  the  action  of  cold,  to  irritating  ingesta,  to  inflammation,  etc. ;  it 
may  be  transient,  subsiding  within  a  day  or  two,  or  it  may  continue  several 
days.  All  infants  at  times  have  green  evacuations,  even  when  they  appear 
in  good  health. 

In  the  commencement  of  a  large  proportion  of  diarrhoeal  maladies  in 
infancy  the  stools  give  an  acid  reaction  to  litmus-paper.  This  acid,  if  in 
considerable  quantity,  is  irritating,  increasing  the  peristaltic  movements  of 
the  intestines  and  the  functional  activity  of  the  intestinal  follicles,  causing 
erythema  of  the  skin  around  the  anus,  and  reacting  upon  and  intensifying 
the  intestinal  disease.  Hence  the  indication  .for  the  use  of  antacids  in  the 
diarrhoeal  affections  of  infancy. 

The  presence  of  intestinal  worms  and  the  species  may  be  ascertained  by 
microscopic  examination  of  the  stools  of  a  child  which  is  affected  with  these 
entozoa.  The  stools  contain  ova,  which  differ  in  size  and  shape  according  to 
the  species  of  worm. 


Nervous  System. 

Pain. — This  symptom  affords  important  aid  to  the  physician  in  determin- 
ing the  seat  and  nature  of  the  diseases  of  children.  Pain  in  the  head  may 
occur  in  them  from  coryza  involving  the  frontal  sinuses,  or  from  febrile 
movement  in  the  commencement  of  an  essential  fever,  or  from  inflammation 
of  one  of  the  organs  of  the  trunk.  Produced  by  such  a  cause,  it  abates  in 
two  or  three  days.  If  it  be  protracted,  whether  constant  or  intermittent,  it 
is  in  many  cases  not  neuralgic,  as  it  so  often  is  in  the  adult,  but  is  due  tO' 
organic  disease  of  the  brain  or  meninges.  Complaint,  therefore,  of  head- 
ache in  a  child,  without  any  apparent  general  cause  or  local  cause  external 
to  the  cranium,  should  awaken  solicitude,  and  if  it  be  protracted  the  physi- 
cian should  examine  carefully  in  reference  to  the  presence  of  a  cerebral  or 
meningeal  disease.  Mild  frontal  headache  continuing  for  weeks  or  months  is. 
neuralgic  and  due  to  anaemia.  It  is  increased  by  pressure  over  the  occiput 
and  upper  cervical  vertebrae. 

Grave  thoracic  or  abdominal  inflammations  in  the  adult  are  almost  always 
attended  by  a  corresponding  amount  of  pain  and  tenderness,  but  in  children 
these  symptoms  are  often  absent,  or  when  present  are  frequently  not  commen- 
surate with  the  amount  of  disease.  Thus,  entero-colitis  of  nursing  infants  is, 
in  a  large  proportion  of  instances,  almost  free  from  these  symptoms. 

Pain  in  the  chest  or  abdomen,  occasional  or  constant,  continuing  for  weeks 
or  months,  with  fever,  and  unattended  by  thoracic  or  abdominal  disease,  indi- 
cates caries  of  the  vertebra3.  Its  most  common  seat  is  the  epigastric,  umbil- 
ical, or  hypochondriac  region.  It  is  a  neuralgia  due  to  irritation  of  the 
sensitive  root  of  one  or  more  of  the  spinal  nerves.  It  is  a  very  important 
symptom  to  the  diagnostician,  showing  the  nature  of  the  disease,  which  in  its- 


THERAPEUTICS.  95 

incipiency  is  so  obscure.     Pain  in  the  leg,  especially  the  inside  of  the  knee, 
is  of  a  similar  character,  indicating  disease  of  the  hip-joint. 

Children  with  certain  acute  febrile  and  inflammatory  diseases  sometimes 
have  hypenesthesia  of  portions  of  the  surface  ;  it  is  especially  marked  upon 
the  anterior  aspect  of  the  trunk.  The  physician  might  be  misled  into  the 
belief  that  the  tenderness  occurred  over  the  seat  of  the  disease  and  indicated 
an  inflammation  ;  but  the  pain  of  hyper;iesthesia  can  be  diagnosticated  from 
that  of  inflammation  by  the  fact  that  it  is  so  extensive,  is  less  on  firm  than 
light  pressure,  and  is  especially  observed  upon  the  inner  surface  of  the  thighs. 
The  symptoms  pertaining  to  the  nervous  system  occurring  in  the  various  dis- 
eases treated  of  in  this  book  will  be  fully  described  in  connection  with  those 
diseases,  and  therefore  need  not  detain  us  in  this  connection. 


CHAPTER    XI. 

THERAPEUTICS. 

The  young  practitioner  is  often  perplexed  in  deciding  exactly  what  dose 
of  the  stronger  and  more  dangerous  medicinal  agents  to  prescribe  for  a  child. 
A  practical  rule,  which  holds  good  for  many  medicines,  has  been  proposed  by 
Dr.  Cowling,  as  follows :  "  The  proportional  dose  for  any  age  under  adult  life 
is  represented  by  the  number  of  the  following  birthday  divided  by  twenty- 
four."  This  rule  is  inadmissible  for  infants  under  the  age  of  six  months,  but 
will  apply  for  those  that  are  older  for  the  use  of  a  large  number  of  medicines. 
Another  rule,  proposed  by  another  British  physician.  Professor  Clarke,  is  based 
on  diff"erences  in  weight  of  children  and  adults  :  The  adult  dose  is  represented 
by  150.  The  dose  of  a  child  is  determined  by  dividing  its  weight  in  pounds 
by  150.  But  it  is  an  interesting  fact,  and  one  of  practical  importance,  that 
children  bear  and  often  require,  in  order  to  obtain  the  desired  eff"ect,  a  much 
larger  proportionate  dose  of  certain  agents  than  adults.  This  is  partly  attrib- 
utable to  the  active  elimination  in  childhood.  Belladonna  is  notably  one  of 
the  agents  which  children  tolerate,  and  it  may  be  added  that  some  children 
can  take  a  much  larger  dose  of  it  than  others  without  producing  the  physio- 
logical efiects.  Thus,  recently  I  increased  gradually  the  tincture  of  bella- 
donna to  twelve  drops  for  a  child  of  four  years  without  producing  the  usual 
efflorescence ;  and  Farquharson  says  "  the  dose  ....  I  have  pushed  in  a 
child  of  ten  sufi"ering  from  incontinence  of  urine  to  f^ij  (British  Pharmacop.) 
with  good  eff"ect  and  the  development  of  mild  forms  of  physiological  disturb- 
ance." Arsenic  is  also  better  tolerated  by  children  than  adults.  An  infant 
of  six  months  can  take  two-drop  doses  of  Fowler's  solution  three  times  daily 
without  ill  eff"ect.  Prussic  acid,  strychnia,  iron,  ipecacuanha,  and  alcohol  are 
also  required  in  larger  proportionate  doses  in  childhood  than  is  indicated  by 
the  rule  either  of  Dr.  Cowling  or  Professor  Clarke. 

When  practicable,  medicines  should  be  given  in  the  liquid  form.  Those 
not  soluble  may  often  be  given  in  suspension  in  some  vehicle  which  in  great 
part  disguises  the  taste.  A  good  vehicle  for  the  bitter  vegetables,  as  the  salts 
of  quinia,  is  the  elixir  adjuvans  of  Caswell  and  Hazard. 

The  elixir  adjuvans  may  also  be  advantageously  employed  in  the  adminis- 
tration of  many  other  medicines  apart  from  those  which  are  repulsive  on 
account  of  their  bitterness.  It  holds  them  in  suspension,  so  that  if  they  have 
a  greater  specific  gravity  than  the  elixir,  it  is  necessary  to  shake  the  bottle 


96  THERAPEUTICS. 

thorouglily  before  using  it.  The  elixir  taraxaei  comp.  is  another  good  vehi- 
cle for  the  bitter  vegetables,  but  perhaps  their  bitterness,  especially  that  of 
quinine,  is  more  eiFectually  disguised  by  the  syr.  yerbae  santae  comp.  than 
by  any  other  vehicle.  I  am  sure,  from  many  observations,  that  unpleasant 
doses  are  liable  to  be  wasted  to  a  greater  or  less  extent,  and  the  repug- 
nance of  children  to  medicines  employed  has  induced  many  a  parent  to  seek 
other  and  less  disagreeable  modes  of  treatment.  Chemistry  has  greatly  aided 
the  therapeutics  of  childhood,  in  that  it  has  enabled  us  in  so  many  instances 
to  prescribe  the  active  principles  in  place  of  the  large,  nauseous  doses  formerly 
employed. 


PART   II. 


DISEASES   OF   THE   NEWLY-BORN. 


CHAPTER    I. 

MALFORMATIONS. 

Asphyxia,  or  apnoea  neonatorum,  is  the  first  in  time  in  the  long  cata- 
logue of  human  maladies.  It  requires  and  receives  the  immediate  attention 
of  the  accoucheur,  and  is  treated  of  fully  in  books  relating  to  midwifery. 
We  will  therefore  omit  the  consideration  of  it  from  our  remarks  on  diseases 
of  the  newly-born.  We  will  also  postpone  our  remarks  on  diphtheria  of  the 
newly-born  until  we  treat  of  diphtheria  in  full. 

The  malformations,  both  of  internal  and  external  organs,  are  numerous, 
and  they  require  attention  according  to  their  seat  and  gravity.  We  will 
describe  only   such  as  are  of  especial  interest  to  the  physician. 


Fig.  5. 


ACRANIA. 

In  this  malformation  the  bones  and  integuments  forming  the  cranial  arch 
are  absent.  In  extreme  cases  the  cranial  arch,  part  of  the  neck,  the  brain, 
and  the  medulla  oblongata  are  lacking.  A 
vascular  mass  lies  on  the  exposed  base  of 
the  skull,  often  resembling  the  placenta  in 
appearance.  It  consists  of  connective  tis- 
sue in  addition  to  the  vessels.  It  is  the 
representative  of  the  cerebral  meninges, 
and  is  continuous  below  with  the  spinal 
meninges.  Its  smooth  surface  is  the  ana- 
logue of  the  arachnoid.  The  sensation  which 
is  imparted  to  the  finger  of  the  accoucheur 
pressed  upon  it  is  very  similar  to  that  pro- 
duced by  a  placenta.  In  some  specimens 
small  portions  of  cerebral  matter  are  found 
among  the  vessels  of  this  tumor,  but  they 
are  so  disconnected  and  isolated  that  they 
do  not  perform  in  any  way  the  functions  of 
a  brain.  Occasionally  the  vascular  tumor  is  absent  and  the  medulla — or,  if 
this  be  absent,   the  upper  extremity  of  the  spine — is  exposed. 

The  absence  of  the  brain  and  cranial  arch  gives  a  remarkable  appearance. 
7  97 


98  MALFORMATIONS. 

The  frontal,  parietal,  and  occipital  bones  are  absent,  except  those  portions 
which  are  near  the  base  of  the  cranium.  These  portions  are  very  thick  and 
closely  united,  as  if  there  were  the  usual  amount  of  osseous  substance,  but 
instead  of  expanding  into  the  arch  it  had  collected  in  an  irregular  mass  at 
the  base  of  the  cranium.  The  eyes  are  prominent,  the  neck  thick  and  short, 
while  the  body  and  limbs  are  ordinarily  well  developed.  The  physiognomy 
has  a  frog-like  appearance.  Those  portions  of  the  cranial  nerves  which  lie 
without  the  cranium  are  well  developed,  although  the  intracranial  portions 
are  absent.  In  this  anomaly  of  acrania  and  anencephalus  a  twin  is  often 
present  which  in  some  manner  has  interfered  with  the  normal  development 
of  the  foetus. 

Symptoms. — If  the  medulla  be  absent,  of  course  viability  is  impossible. 
If  it  be  present,  respiration  may  occur  for  a  time,  but  is  irregular.  The 
monster  may  be  made  to  cry,  but  the  cry  is  a  reflex  phenomenon  resembling 
a  sob  or  hiccough.  It  may  nurse,  its  digestive  function  is  well  performed, 
and  regular  urinary  and  fecal  evacuations  occur.  There  is  a  tendency  in  such 
monsters  to  convulsions.  Blowing  upon  them  and  pressure  upon  the  project- 
ing medulla,  if  this  be  present,  frequently  produce  this  result. 

Prognosis. — Fortunately,  non-viability  or  speedy  death  is  the  result.  If 
the  medulla  be  present  and  respiration  and  circulation  be  established,  never- 
theless death  usually  results  within  two  or  three  days,  and  with  scarcely  an 
exception  within  ten  days.  Convulsions  sooner  or  later  supervene,  ending  in 
fatal  coma. 

Incomplete  Brain.  ' 

Deficiencies  occur  in  the  formation  of  the  brain,  so  that  there  are  various 
grades  of  incompleteness  between  the  normal  and  absent  brain.  Portions  of 
the  brain  may  be  absent  or  rudimentary,  while  the  remainder  of  the  organ 
has  its  normal  development.  The  deficiencies  are  usually  in  the  cerebral 
hemispheres,  while  the  base  of  the  brain,  which  is  important  for  the  main- 
tenance of  life,  is  perfect.  Both  hemispheres  may  be  absent,'  or  one  absent 
while  the  other  is  complete  or  small  and  rudimentary.  Incompleteness  of  the 
brain  may  be  manifested  by  the  small  size  of  the  cranium  and  the  retreating 
forehead,  but  occasionally  the  cranium  has  its  normal  shape  and  size,  on 
account  of  an  increase  in  the  cerebro-spinal  fluid  proportionate  to  the  defi- 
ciency in  the  cerebi'al  development.  Such  a  case  was  under  observation  in 
the  Nursery  and  Child's  Hospital  in  1862.  She  took  the  breast  and  received 
food  when  placed  in  her  mouth,  but  without  apparent  relish.  She  was  sup- 
posed for  a  time  to  be  blind,  as  she  was  apparently  unconscious  of  objects 
around  her.  There  was  a  total  absence  of  intellectual  manifestations.  The 
size  and  shape  of  the  head  did  not  diff"er  materially  from  the  normal,  but  the 
frontal  bone  lay  a  little  lower  than  the  parietal.  She  died  of  entero-colitis  at 
the  age  of  ten  months,  and  at  the  autopsy  a  sac  containing  about  three-fourths 
of  a  pint  of  nearly  transparent  cerebro-spinal  liquid  occupied  the  site  of  the 
cerebral  hemispheres.  Rudimentary  hemispheres  were  found  constituting  a 
part  of  the  walls  of  the  sac.  The  weight  of  the  brain  after  being  a  few  days 
in  dilute  alcohol  was  6t  ounces.  In  this  case  the  fluid  was  nearly  sufiicient 
to  compensate  for  the  lack  of  brain-substance. 

Symptoms. — Since  in  cases  of  imperfect  brain  in  which  life  is  preserved 
the  arrest  of  development  is  usually  in  the  cerebral  hemispheres,  the  symp- 
toms which  indicate  the  deficiency  relate  chiefly  to  the  degree  of  mental 
endowment.  If  the  hemispheres  are  partially  developed,  there  is  a  degree 
of  intelligence  proportionate  to  the  amount  of  the  cerebral  substance  present. 
If  the  arrest  of  development  be  on  one  side,  there  may  be  no  appreciable  lack 


MENINGOCELE,  ENCEPHALOCELE,  HYDRENCEPHALOGELE.      99 

of  intelligence  or  mental  activity,  since  one  hemisphere  may  perform  the  func- 
tions of  both. 

Prognosis. — This  as  rej^ards  life  depends  on  the  seat  of  the  arrested 
development.  If  the  cerebral  hemispheres  be  deficient,  the  child  may  live 
and  thrive,  though  idiotic ;'  but  if  the  arrest  of  development  be  at  the  base 
of  the  brain,  which  controls  the  functions  of  animal  life  and  gives  origin  to 
nerves  which  are  essential  to  the  physical  well-being,  life  is  uncertain  and 
probably  will  be  short.  It  is  evident  that  therapeutic  measures  cannot 
remedy  a  congenital  deficiency  in  the  brain,  but  the  patient,  philanthropic 
teacher  can  impart  some  instruction  to  the  idiotic,  and  occasionally  improve 
in  a  measure  their  lamentable  condition. 

Meningocele,  Encephalocele,  Hydrencephalocele. 

This  is  the  analogue  of  spina  bifida.  An  opening  exists  at  some  point  in 
the  skull,  through  which  the  meninges,  or  meninges  with  brain-substance, 
protrude.  The  deficiency  is  congenital,  and  the  tumor  exists  at  birth  or  is 
noticed  soon  after.  It  is  termed  a  meningocele  if  only  meninges  protrude ; 
an  encephalocele  if  it  contain  brain-substance  in  addition  to  the  meninges  ; 
and  a  hydrencephalocele  if,  in  addition  to  the  brain-substance,  the  mass  con- 
tain liquid  in  its  interior. 

The  most  frequent  site  of  these  tumors  is  the  occiput,  where  the  protru- 
sion occurs  from  an  opening  in  or  at  the  edge  of  the  occipital  bone.  The 
next  most  frequent  location  is  the  naso-frontal  region.  Rarely  they  occur 
upon  the  temporal,  parietal,  and  basilar  portions  of  the  skull.  Ordinarily, 
the  opening  in  the  occipital  bone  through  which  the  protrusion  takes  place  is 
at  the  median  line,  or  near  it,  anterior  or  posterior  to  the  occipital  pi'otuber- 
ance.  The  opening,  if  in  the  anterior  part  of  the  occipital  bone,  may  extend 
to  the  fontanel ;  if  in  the  posterior  part,  it  may  extend  to  the  foramen  mag- 
num. It  may  connect  posteriorly  through  the  foramen  magnum  with  the 
cleft  of  a  spina  bifida.     If  the  opening  in  the  occipital  bone  be  large,  the 

Fig.  6. 


tumor  is  also  usually  large.  Prescott  Hewitt  cites  a  case  in  which  it  extended 
to  the  loins ;  but  so  large  a  mass  consists  mostly  of  liquid  and  is  rare.  An 
occipital  encephalocele  contains  brain-substance  from  the  cerebellum  or  pos- 
terior cerebral  lobes  or  from  both.  If  the  tumor  upon  the  occiput  be  a 
hydrencephalocele,  the   liquid   is   from   the   posterior   cornu   of  a   distended 


100  MALFORMATIONS. 

lateral  ventricle  or  from  a  distended  and  dropsical  fourth  ventricle,  and  it 
occupies  the  interior  of  the  tumor,  the  brain-substance  surrounding  it. 

If  the  tumor  be  in  the  frontal  region,  the  protrusion  usually  occurs 
between  the  cribriform  plate  of  the  ethmoid  bone  and  the  frontal  bone,  and 
it  appears  externally  between  the  nasal  and  the  frontal  bones.  Exception- 
ally, the  point  of  protrusion  is  between  the  lateral  halves  of  the  frontal  bone. 
The  anterior  lobe  or  lobes  of  the  cerebrum  protrude  in  an  eneephalocele  in 
this  location  ;  if  the  tumor  be  a  hydrencephalocele,  the  liquid  is  derived  from 
the  anterior  cornua  of  the  lateral  ventricles.  As  a  rule  the  frontal  are  smaller 
than  the  occipital  tumors,  and  the  skin  covering  them  is  more  frequently  red 
and  vascular,  so  as  to  present  the  appearance  of  vascular  tumors. 

Exceptionally,  the  protrusion  occurs  from  a  fontanel  or  from  the  line 
of  one  of  the  sutures,  so  that  it  is  seated  upon  the  side  of  the  skull.  Cases 
are  also  on  record  in  which  the  opening  existed  between  the  ethmoid  and 
sphenoid  bones,  through  the  sphenoid,  or  between  the  sphenoid  and  its  greater 
wing.  Tumors  in  this  location  appear  in  the  pharynx  or  mouth,  or  enter  an 
orbit,  displacing  the  eye,  or  protrude  through  the  spheno-maxillary  fissure. 
The  tumor  having  this  site  is  usually  an  eneephalocele  or  hydrencephalocele, 
the  meningocele  being  rare.  Its  walls  consist  of  skin,  dura  mater,  and 
arachnoid,  with  intervening  connective  tissue.  If  the  protrusion  be  at  the 
base  of  the  brain,  of  course  the  external  covering  of  skin  is  lacking.  In 
other  locations  the  skin  constitutes  the  external  coat,  and  it  may  be  tense  and 
scantily  covered  with  hair,  or  red  and  vascular.  The  interior  of  the  sac  is 
lined  by  the  arachnoid  and  dura  mater.  These  tumors,  whatever  the  exact 
character  of  their  interior,  can  be  more  or  less  reduced  by  compression,  with 
a  return  of  a  part  of  their  contents  into  the  cranial  cavity ;  but  such  com- 
pression usually  produces  cerebral  symptoms,  as  stupor  or  fretfulness,  vomit- 
ing, and  strabismus.  The  following  characteristics  of  the  three  forms  of  these 
tumors  aid  in  their  diflPerential  diagnosis : 

Meningocele. — Small  at  first,  and  remaining  either  small  or  of  moderate 
size,  fluctuation  distinct,  pedunculated,  translucent,  no  pulsation,  tense  on 
forced  expiration,  reducible. 

Eneephalocele. — Small,  base  wide,  no  fluctuation,  opaque,  or  some- 
times translucent  at  the  apex,  distinct  pulsation,  enlargement  by  forced  expi- 
ration, partly  reducible,  cerebral  symptoms  occurring  from  compression. 

Hydrencephalocele. — Tumor  usually  large,  often  pendulous,  and  its 
surface  lobulated,  pedunculated,  fluctuating ;  portions  translucent ;  pulsation 
absent  or  rare.  It  is  seldom  affected  by  pressure,  and  the  patient  is  likely  to 
be  microcephalic  from  the  escape  of  brain-substance  external  to  the  cranium. 

These  protrusions  have  been  mistaken  for  various  cysts,  as  cephalaema- 
toma,  serous  and  sebaceous  cysts,  abscesses,  vascular  growths,  and  polypi. 
The  fact  that  such  errors  in  diagnosis  have  been  made  by  various  surgeons 
shows  the  importance  of  a  thorough  and  careful  examination  before  operative 
measures  are  employed. 

Most  patients  with  this  deformity  die  in  a  few  weeks  or  months.  The 
prognosis  depends  on  the  size  of  the  aperture  and  the  amount  of  protrusion. 
It  is  most  unfavorable  in  hydrencephalocele,  which  is  usually  attended  by 
deficiency  of  brain  within  the  cranium,  sometimes  to  such  an  extent  that  the 
patient  is  microcephalic  and  early  death  unavoidable.  The  hydrencephalic 
tumor  is  very  liable  to  grow,  and,  after  a  time,  rupture,  causing  immediate 
death  in  convulsions  or  collapse.  In  meningocele,  if  the  aperture  be  small, 
the.  tumor  may  remain  small,  become  isolated  from  the  cranial  cavity,  and 
the  patient  may  live  for  years.  But  of  the  three  forms  of  the  tumor,  eneeph- 
alocele is  regarded  as  the  most  favorable,  since  it  is  usually  small,  and 
patients  with  it  not  infrequently  live  many  years.     The  prognosis  in  these 


SPINA    BIFIDA. 


101 


tumors  is  very  similar  to  that  in   spina  bifida,   which  varies  according  to  size 
of  the  aperture  and  the  amount  and  character  of  the  protrusion. 

Trkatment. — Those  who  have  had  experience  with  these  tumors  concur 
for  the  most  part  in  the  opinion  that  surgical  interference  should  not  be 
resorted  to  unless  rupture  be  imminent.  The  mass  should  be  protected  from 
abrasion,  and  that  degree  of  pressure  should  be  employed  which  can  be  toler- 
ated without  producing  cerebral  symptoms.  It  is  proper  to  draw  off  the 
liquid  of  a  meningocele  if  it  be  distended  and  likely  to  rupture,  and  the  tap- 
ping may  be  repeated,  with,  exceptionally,  the  result  of  a  cure  or  of  render- 
ing the  tumor  stationai-y.  Mr.  Holmes  has  injected  the  tumor  with  two 
drachms  of  a  mixture  consisting  of  one  part  of  tincture  of  iodine  and  two 
of  water,  allowing  it  to  remain  :  and  Mr.  Annandale  has  ligatured  the  mass 
in  one  instance,  and  effected  a  cure.  In  encephalocele  and  hydrencephalocele 
support  and  moderate  pressure  should  be  employed,  and  in  the  latter  some 
of  the  liquid  should  be  removed  by  a  small  trocar  if  rupture  be  threatening. 


Spina  Bifida. 

This  is  one  of  the  most  common  of  the  malformations.  In  its  severe 
form  it  is  from  its  nature  incurable,  admitting  only  of  palliative  treatment, 
while  in  its  milder  forms  it  may  be  cured  or  so  relieved  that  it  does  not 
endanger  life.  The  term  spina  bifida  is  applied  to  a  hernia  of  the  spinal 
meninges,  which  produces  a  rounded  tumor,  situated  posteriorly  over  the 
spine  in  the  median  line.  It  is  due  to  the  congenital  absence  or  incomplete- 
ness of  one  or  more  of  the  arches  of  the  vertebrae.  In  exceptional  instances 
the  arch  is  said  to  be  complete  at  birth  ;  but  the  lateral  portions  separate  and 
are  pressed  outward  during  the  first  weeks  of  life.  The  tumor  contains  cere- 
bro-spinal  fluid,  and  unless  it  be  small  and  its  walls  unusually  thick  fluc- 
tuation may  be  detected  in  it.  When  the  child  cries  the  tumor  enlarges,  and 
it  is  reduced  by  compression,  the  fluid  re-entering  the  spinal  canal.  If  the 
tumor  be  large,  its  complete  subsi- 
dence by  pressure  often  produces  Fig.  7. 
dangerous  cerebral  symptoms.  Spina 
bifida  is  the  analogue  of  hydro- 
cephalus, and  the  two  often  coexist. 
If  we  compress  the  hydrocephalic 
head  the  spinal  tumor  enlarges,  and 
vice  versa.  Club-foot  is  another  not 
infrequent  complication.  In  the 
case  which  is  represented  in  the 
accompanying  wood-cut  (Fig.  7), 
hydrocephalus,  spina  bifida,  and 
club-foot  coexisted.  The  child  was 
brought  to  the  children's  class  in 
the  Out-door  Department  at  Belle- 
vue,  and  after  a  few  visits  I  lost 
sight  of  it.  It  probably  died  soon 
after,  since  the  tumor,  over  which 
the  cuticle  was  wanting,  presented 
a  deep  red  appearance  as  if  inflamed,  so  that  ulceration  and  escape  of  the 
fluid  seemed  near  at  hand.  There  is  ordinarily  but  one  spina  bifida,  the  com- 
mon seat  of  which  is  the  lumbar  region,  but  occasionally  two  or  more  are 
present.  If  the  aperture  through  which  the  tumor  protrudes  be  small,  it  is 
usually  pedunculated,  but  if  large  it  is  sessile.  In  some  patients  it  is  cov- 
ered with  skin,  which  may  be   normal  or  somewhat  indurated ;  in  others  the 


102  MALFORMATIONS. 

skin  is  absent  over  the  entire  tumor  or  its  most  prominent  part,  and  the  dura 
mater  or  the  connective  tissue  lying  directly  over  the  dura  mater  is  exposed, 
and  is  liable  to  inflammation  from  friction.  If  the  walls  of  the  tumor  be 
thin,  the  liquid  may  transude  in  drops,  and  they  are  liable  to  give  way  by 
ulceration  or  rupture.  Sudden  escape  of  the  liquid  and  collapse  of  the  spina 
bifida  involve  great  danger,  for  convulsions,  coma,  and  death  are  the  common 
result. 

The  relation  of  the  spinal  cord  or  nerves,  or  of  the  cauda  equina,  to  the 
tumor  is  a  matter  of  great  importance.  In  many  patients  the  adjacent  por- 
tion of  the  cord  or  cauda  equina  is  deflected  through  the  aperture,  and  lies 
against  the  anterior  of  the  sac.  Spinal  nerves  also  not  infrequently  lie  within 
the  sac,  some  returning  into  the  spinal  canal,  and  others  passing  through  the 
walls  of  the  sac  to  their  points  of  distribution.  Those  which  are  deflected 
into  the  tumor  and  return  into  the  canal  obviously  lie  lowest.  In  the  most 
favorable  cases — to  wit,  those  with  a  small  aperture  or  small  tumor  or  a  nar- 
row and  long  peduncle — neither  the  cord,  cauda  equina,  nor  nerves  lie  within 
the  sac.  It  is  important  to  the  practitioner  to  bear  in  mind  that  in  all  prob- 
ability, unless  under  the  favorable  anatomical  circumstances  stated  above,  the 
sac  contains  nervous  elements.  In  rare  instances  the  liquid,  instead  of  lying 
externally  to  the  cord,  lies  within  its  central  canal.  The  substance  of  the 
cord  then  becomes  distended,  and  it  encloses  the  liquid  like  a  delicate  sac, 
just  as  the  hemispheres  of  the  brain  are  unfolded  and  expanded  in  the  com- 
mon form  of  congenital  hydrocephalus.  As  might  be  expected  from  the 
anatomical  characters  of  the  more  serious  forms  of  spina  bifida,  paralysis, 
more  or  less  complete,  of  the  vesical  and  rectal  muscular  fibres  and  par- 
aplegia sometimes  occur,  in  which  event  the  fatal  issue  is  probably  not  far 
distant. 

Diagnosis. — This  is  easy  in  ordinary  cases.  The  congenital  nature  of 
the  tumor  and  the  bony  edge  of  the  aperture,  appreciable  to  the  touch,  suflSce 
in  ordinary  cases  to  establish  the  diagnosis.  The  diminution  of  the  tumor 
by  pressure,  and  its  enlargement  when  the  child  cries,  are  important  diag- 
nostic signs.  There  are  various  lumbo-sacral  tumors  located  in  the  median 
line  from  which  it  is  important  that  spina  bifida  should  be  diagnosticated. 
Sometimes  a  cyst  occurs  in  this  situation  which  was  originally  a  spina  bifida, 
but  obliteration  of  the  canal  in  the  pedicle  occurred,  just  as  the  canal  con- 
necting a  hydrocele  with  the  abdominal  cavity  closes.  Solid  congenital 
tumors  sometimes  also  grow  in  the  same  situation,  among  which,  as  most 
common,  may  be  mentioned  fatty  tumors  and  tumors  containing  foetal  remains. 
The  most  common  seat  of  tumors  which  enclose  foetal  remains  is  at  the  point 
where  spina  bifida  ordinarily  occurs.  Physicians  have  erred  in  mistaking 
these  tumors,  as  well  as  those  which  consist  of  fat,  for  spina  bifida  ;  but  a 
mistake  in  diagnosis  can  only  occur  through  haste  or  carelessness  of  exami- 
nation. 

Prognosis. — This  is  in  most  instances  unfavorable.  Ordinarily  the  tumor 
increases  slowly,  and  finally  the  sac  gives  way  by  ulceration  or  rupture ;  the 
liquid  escapes,  and  death  occurs  in  convulsions  and  coma ;  or,  if  the  escape 
of  the  liquid  be  prevented  by  pressure  and  the  aperture  closes,  a  second  rup- 
ture is  probable,  with  a  fatal  result.  In  other  cases  the  tumor  may  not  rup- 
ture, but  the  cord  is  softened  or  it  is  injured  by  being  bent,  so  that  paraplegia 
results,  and  death  after  a  time  occurs  in  a  state  of  emaciation.  Rarely  the 
tumor  may  shrivel  by  absorption  of  the  liquid,  and  the  disease  is  cured,  or 
so  nearly  cured  that  it  gives  no  inconvenience  and  the  patient  lives  for  years. 
In  other  rare  instances  the  tumor  may  remain  without  any  material  change 
and  without  giving  rise  to  symptoms.  The  spina  bifida  being  small  and  cov- 
ered with  skin,  and  the  aperture  leading  from  it  into  the  spinal  canal  being 


SPINA   BIFIDA.  103 

also  small,  the  patient  lives  through  the  natural  period  of  life  with  little 
inconvenience. 

Treatment. — ^It  is  evident,  from  what  has  been  stated,  that  no  fixed 
rule  can  be  laid  down  for  the  treatment  of  spina  bifida.  In  the  most  favor- 
able cases,  in  which  no  symptoms  occur  and  there  is  no  indication  that 
the  tumor  will  undergo  any  unfavorable  change,  surgical  treatment  is  not 
required,  except  the  application  of  a  soft  pad  to  support  the  tumor,  so  as  to 
prevent  its  injury  by  friction.  Indications  which  justify  active  surgical  inter- 
ference are  growth  of  tumor,  absence  of  skin  from  it,  with  tension  of  the 
parietes,  so  that  an  early  rupture  is  inevitable,  and  the  occurrence  of  dan- 
gerous nervous  symptoms,  as  convulsions  or  paraplegia. 

From  the  nature  of  spina  bifida  it  is  evident  that  operations  upon  it  must 
be  conducted  with  caution.  The  usual  presence  of  the  spinal  cord  in  the 
pedicle  and  in  the  sac  forbids  ligation  and  excision,  and  renders  hazardous 
attempts  to  obliterate  the  sac  by  producing  inflammation  within  it.  A  safe 
mode  of  treatment,  but  not  the  most  efficient,  is  to  puncture  the  sac  and 
withdraw  a  portion  of  the  liquid  by  a  grooved  needle  or  hypodermic  syringe. 
A  soft  pad  should  then  be  applied  to  produce  gentle  compression.  If  no 
unfavorable  symptoms  occur,  the  puncture  may  be  repeated  after  a  day  or 
two.  This  operation  has  been  employed  with  a  satisfactory  result  by  Sir 
Astley  Cooper  among  others ;  but,  simple  as  it  is,  it  is  not  devoid  of  danger, 
for  the  removal  of  the  liquid,  if  carried  beyond  a  certain  point,  may  produce 
dangerous  nervous  symptoms,  especially  convulsions.  In  performing  the 
operation  the  puncture  should  never  be  made  in  the  median  line,  on  account 
of  the  danger  of  wounding  the  cord,  which  lies  against  the  median  portion 
of  the  sac.     The  veins,  also,  should  be  avoided. 

Another  mode  of  treatment  is  by  iodine  injections.  They  are  preferable 
to  other  methods  if  the  neck  be  long  and  pedunculated,  so  as  to  be  easily 
compressed.  If  the  tumor  be  sessile,  and  the  aperture  into  the  spinal  canal 
be  free,  these  injections  involve  great  danger,  and  are  not  to  be  recommended; 
for  more  or  less  of  the  solution  will  inevitably  enter  the  .spinal  canal  and 
give  rise  to  spinal  meningitis.  Iodine  injections  have  been  employed  with 
success  by  Professor  Brainard  of  Chicago,  who  states  that  he  "  perfectly  and 
permanently  cured "  three  of  seven  cases ;  and  by  Velpeau  of  Paris,  by 
whose  method  five  in  ten  operations  were  successful,  and  by  many  others. 
Professor  Brainard  withdrew  some  of  the  liquid  contents,  and  then  injected 
half  an  ounce  of  water  containing  2J  grains  of  iodine  and  7i  grains  of  iodide 
of  potassium.  In  a  few  seconds  this  was  allowed  to  flow  out,  and  the  sac 
was  then  washed  out  with  tepid  water.  Then  a  portion  of  the  cerebro-spinal 
fluid,  which  had  been  kept  warm,  was  returned  into  the  sac.  When  he  had 
withdrawn  six  ounces  of  this  fluid  he  returned  two  ounces.  In  employing 
the  iodine  or  any  other  irritating  injection,  it  is  necessary  to  compress  the 
pedicle,  so  that  the  liquid  does  not  enter  the  spinal  canal.  Velpeau  employed 
one  part  of  iodine,  one  of  iodide  of  potassium,  and  ten  of  distilled  water. 

During  a  debate  in  the  Societe  de  Chirurgie,  M.  Debont  recommended 
the  evacuation  of  only  a  little  of  the  fluid,  and  the  injection  of  two  or  three 
drops  of  the  tincture  of  iodine  diluted  with  an  equal  quantity  of  water.  T. 
Smith,'  by  the  injection  of  one  drop  of  the  tincture,  produced  an  amount 
of  inflammation  which  nearly  obliterated  the  .sac.  Since  statistics  show  so 
good  a  result  of  iodine  injections,  this  mode  of  treatment  seems  preferable 
to  any  other  for  certain  cases,  and  as  one  drop  has  produced  general  inflam- 
mation of  the  sac  and  nearly  obliterated  it,  it  seems  safest  and  best  to  begin 
with  so  .small  a  quantity. 

If  there  be  reason  to  believe,  from  the  small  size  of  the  orifice  and  other 

^  Holmes's  Surg.  Dis.  of  Children. 


104  MALFORMATIONS. 

anatomical  characters,  that  neither  the  cord,  cauda  equina,  nor  any  of  the 
spinal  nerves  lie  within  the  sac,  it  may  be  thought  best  to  remove  the  tumor. 
It  has,  indeed,  been  proposed  to  open  the  tumor,  immersed  under  warm  water, 
sufl&ciently  to  observe  the  relation  of  the  nervous  elements,  and  to  press  them 
back  gently  into  the  canal  if  they  lie  within  the  sac.  If  it  be  decided  to 
remove  the  spina  bifida,  a  clamp  or  elastic  band  is  placed  around  the  pedicle 
so  snugly  as  to  cause  firm  adhesion  of  the  walls  of  the  pedicle,  and  excite 
sufficient  inflammation  in  them  to  produce  agglutination,  but  without  causing 
strangulation  or  suppuration. 

After  a  time,  perhaps  two  or  three  days,  when  it  is  evident  that  agglutina- 
tion has  occurred  from  the  fact  that  the  liquid  cannot  be  returned  within  the 
spinal  canal  by  compressing  the  sac,  the  tumor  may  be  removed  by  the  knife 
or  ecraseur.  Statistics  do  not  show  so  favorable  a  result  of  this  operation  as 
of  the  iodine  treatment,  and  the  reason  is  obvious,  for  it  is  only  in  excep- 
tional cases  that  the  tumor  can  be  removed  without  injury  to  the  nervous 
tissue,  and  incision  of  a  portion  of  the  cord  or  of  important  nerves  either 
produces  death  or  a  condition  to  which  death  would  be  a  relief. 

Spina  bifida  has  also  been  treated  by  opening  the  sac  on  its  side,  pressing 
back  the  spinal  cord  or  its  nerves  into  the  spinal  canal,  uniting  the  edges  of 
the  wound,  and  then  applying  pressure  to  prevent  protrusion,  but  the  result 
has  not  been  favorable.  Treatment  by  simple  puncture,  followed  by  com- 
pression, and  if  it  fail,  as  it  probably  will,  the  cautious  use  of  iodine  injec- 
tions, is  the  preferable  mode  of  treating  ordinary  cases  of  spina  bifida  which 
require  surgical  interference. 

Congenital  Abnormalities  in  the  Circulatory  System. 

Rarely  the  position  of  the  heart  is  abnormal,  and  the  most  common  mal- 
position is  its  location  on  the  right  side  of  the  chest  (dextro-cardia).  This 
occurs  with  or  without  misplacement  of  other  organs.  In  cases  of  dextro- 
cardia the  liver  usually,  says  Niemeyer,  occupies  the  left  hypochondrium, 
and  the  spleen  the  right.  In  this  misplacement  of  the  heart  the  aorta  ordi- 
narily crosses  the  right  bronchus  and  passes  along  the  right  side  of  the  ver- 
tebrae, but  occasionally  it  crosses  the  spine  and  lies  in  its  usual  position  on 
the  left  side  of  the  vertebrae.  The  heart  in  this  malposition  is  sometimes 
imperfect  and  sometimes  well  formed.  In  mesocardia  the  heart  is  situated 
nearer  the  median  line  than  usual,  corresponding  in  this  respect  with  the 
position  which  it  occupies  in  the  first  months  of  foetal  life.  A  rare  malposi- 
tion is  the  location  of  the  heart  outside  the  thoracic  cavity  (ectocardia  extra- 
thoracica) — a  condition  accompanied  by,  and  perhaps  due  to,  deficiency  in 
the  sternum  or  sternum  and  ribs.  In  other  instances  equally  rare  a  part 
of  the  diaphragm  has  been  deficient,  and  the  heart  has  lain  in  the  abdomen  ■ 
and  in  other  instances  still  it  has  been  located  at  the  base  of  the  neck. 
Breschct  and  others  have  cited  examples  of  these  various  forms  of  ectopia 
cordis. 

Symptoms — Prognosis. — If  the  heart  be  well  formed  and  complete,  its 
abnormal  position  within  the  thorax  may  not  give  rise  to  symptoms,  and  is 
not  incompatible  with  prolonged  life.  If  it  be  located  without  the  thoracic 
cavity  or  be  within  the  cavity  and  be  defective,  early  death  is  probable. 

Malformations  op  the  Heart. 

Malformation  of  the  heart  occurs — 1st,  from  arrested  development  early 
in  foetal  life,  so  that  the  organ  remains  rudimentary ;  2d,  from  arrested 
development  at  a  more  advanced  stage,  when  the  cavities,  septa,  and  ves- 


MALFORMATIONS  OF  THE  HEART.  105 

sels,  though  incomplete,  are  partially  formed ;  3d,  from  malposition  of  the 
parts  of  the  heart  or  of  the  vessels  in  immediate  relation  with  the  heart. 
The  cause  of  malformation  in  the  heart  and  the  vessels  pertaining  to  it  is 
obscure.  It  is  supposed  sometimes  to  be  a  myocarditis  or  endocarditis,  which 
causes  the  arrest  of  growth  or  abnormal  development. 

Perhaps  strong  mental*  excitement  sometimes  has  a  causal  relation,  what- 
ever may  be  its  modus  operandi,  just  as  it  causes  external  malformations. 
In  a  case  related  by  Dr.  Peacock '  the  mother  stated  that  when  pregnant  she 
was  greatly  frightened  by  the  appearance  of  a  man  who  was  dying  of  asthma. 
In  another  instance  the  only  assignable  cause  was  fright  of  the  mother  at 
seeing  a  child  killed,  and  she  did  not  recover  from  the  shock  ;"'  in  another 
case  the  mother  was  greatly  alarmed  at  the  fifth  month  of  gestation,^  and  in 
the  fourth  instance  the  mother  four  or  five  months  before  her  confinement 
was  greatly  frightened  by  her  husband,  who  was  insane,  standing  over  her 
two  hours  with  a  loaded  pistol.*  But  these  are  exceptional  instances.  In  a 
large  majority  of  cases  of  malformation  of  the  heart  inquiry  fails  to  elicit  any 
unusual  mental  excitement  of  the  mothers  during  their  gestation. 

Occasionally  the  malformation  appears  to  be  due  to  some  vice  or  taint  in 
the  system  of  one  or  both  parents.  Thus  in  a  case  quoted  in  the  Gazette 
medicalf  for  Dec.  28,  1850,  the  mother,  who  had  rachitis  in  early  life,  lost 
five  children  soon  after  their  birth,  all  of  whom  had  lividity  as  the  most  promi- 
nent symptom.  Persistent  lividity  in  the  newly-born  indicates,  almost  with- 
out exception,  malformation  at  the  centre  of  circulation.  In  the  history  of 
a  case  which  was  communicated  to  Cooper  by  Farre  "  vices  of  conformation 
of  the  heart  appear  to  have  been  inherent  in  the  family.  Of  12  infants  only 
4  survived,"  the  death  of  the  8  being  apparently  from  cardiac  malformation. 
A  patient  treated  by  Mr.  Leonard  was  the  sixth  who  had  died  at  about  the 
same  age  with  symptoms  of  cyanosis.  Ordinarily,  however,  infants  who  have 
cardiac  malformations,  as  indicated  by  the  cyanotic  hue,  belong  to  healthy 
families;  neither  parents,  brothers,  nor  sisters  exhibit  any  taint  of  system 
which  could  sustain  a  causal  relation  to  any  form  of  malformation. 

The  opinion  is  expressed  by  Gintrac  that  the  number  affected  with  car- 
diac malformation,  as  indicated  by  cyanosis,  to  the  entire  population  varies 
in  different  countries.  It  is  probable  that  its  occurrence  is  not  greatly,  if  at 
all,  afi"ected  by  the  nationality,  but  it  is  certainly  dependent  to  a  considerable 
extent  on  the  condition  of  society.  It  appears  from  statistics  to  be  less  fre- 
quent in  a  community  in  comfortable  circumstances  and  engaged  in  quiet  and 
wholesome  occupations  than  in  those  whose  occupations  produce  undue 
mental  excitement  and  worriment  and  irregularities  in  the  mode  of  life. 
Pure  air  and  outdoor  exercise,  plain,  nutritious  diet,  freedom  from  caves  and 
anxieties — in  fine,  causes  which  promote  the  physical  well-being — diminish 
the  liability  to  a  malformed  and  cyanotic  off"spring ;  and,  on  the  other  hand, 
impure  air,  improper  and  insufficient  diet,  grief,  etc.  increase  the  percentage 
of  cardiac  malformations  and  cyanosis.  Hence  the  blue  disease  is  rare  in 
the  rural  districts  and  comparatively  frequent  in  the  cities,  especially  in  a 
large  city  like  New  York,  which  contains  a  numerous  indigent  and  careworn 
population,  living  from  year  to  year  in  the  midst  of  agencies  which  operate 
stealthily  but  certainly  to  enervate  the  system  and  undermine  the  health. 

These  remarks  are  abundantly  substantiated  by  statistics.  In  New  York 
City,  during  the  period  of  six  years,  1  death  resulted  from  cyanosis  to  436 
deaths  from  all  causes,  and  in  Brooklyn  the  proportion  estimated  for  two 
years  was  about  the  same.  On  the  other  hand,  in  the  State  of  Kentucky, 
which  contains  few  large  cities,  there  was,  during  a  period  of  five  years,  1 

^  Malformations  of  the  Heart,  p.  57.  ^  Ibid.,  p.  37. 

»76i(i.,  p.  41.  * /6jc/.,  p.  43. 


106  MALFORMATIONS. 

death  from  malformation  of  the  heart  to  2469  from  all  causes.  In  the  State 
of  South  Carolina,  for  three  years,  1  death  resulted  from  cyanosis  to  5018 
from  all  causes.  In  the  State  of  Massachusetts,  for  two  years,  there  was  1 
death  from  cyanosis  to  1136  from  all  causes,  and  two-thirds  of  the  cyanotic 
cases  occurred  in  the  counties  of  Suffolk,  Essex,  and  Worcester,  which  con- 
tain large  cities,  In  London  1  death  occurred  from  cyanosis  to  755  from  all 
causes  during  a  period  of  three  years.  On  the  other  hand,  in  England, 
including  the  city  of  London,  there  was,  for  the  ten  years  ending  with  1857, 
1  death  from  cyanosis  to  1589  from  all  causes;  and  in  the  rural  districts  of 
Monmouth  and  Wales  only  1  death  occurred  from  cyanosis  to  5578  deaths 
from  all  causes  during  a  period  of  two  years. 

Malformations  of  the  heart  derive  their  seriousness  and  importance  from 
the  fact  that  the  heart  is  the  central  organ  of  circulation,  so  that  when  from 
malformation  it  is  inadequate  to  perform  fully  its  function,  not  only  is  the 
nutrition  seriously  interfered  with,  but  the  flow  of  blood  through  the  lungs 
is  insufficient.  The  blood  is  not  properly  oxygenated,  and  it  is  overcharged 
with  carbonic  acid,  which  imparts  to  it  the  deeply  venous  or  livid  color. 
Cyanosis  therefore,  as  indicative  of  an  imperfect  heart,  a  persistent  defect 
in  the  circulation,  and  a  permanently  abnormal  state  of  the  blood,  is  an 
important  disease. 

Cyanosis. 

As  stated  above,  the  cause  of  cyanosis  when  occurring  in  infants  is  at 
the  centre  of  circulation,  and  is  a  malformation  with  very  few  exceptions. 
The  diagnosis  can  be  made  with  certainty  if  there  have  been  no  symptoms 
indicating  an  antecedent  disease.  In  rare  instances  in  infants  above  the  age 
of  five  or  six  months  lividity  of  the  surface  occurs  from  disease  in  the  lungs, 
such  as  extensive  emphysema,  a  pleuritic  exudation  compressing  both  lungs, 
caries  of  the  vertebrse.  with  consequent  depression  of  the  ribs  so  as  to  pre- 
vent proper  inflation  of  the  lungs.  But  such  causes  do  not  exist  or  are  very 
rare  under  the  age  of  six  months. 

The  blue  disease,  being  so  manifest,  attracted  attention  at  an  early  age. 
It  appears  from  the  remarks  of  Boerhaave  that  the  common  people  believed 
that  the  cyanotic  were  possessed  by  evil  spirits.^  It  was  evidently  impos- 
sible to  understand  its  cause  and  nature  prior  to  the  discovery  of  Harvey  in 
the  seventeenth  century,  and  most  of  the  exact  or  scientific  knowledge  pos- 
sessed by  the  profession  in  reference  to  the  etiology  and  nature  of  cyanosis 
has  been  achieved  since  the  present  century  commenced.  Boerhaave  and 
Vieussens  had  observed  eases  and  propounded  theories  in  reference  to  it,  but 
the  knowledge  of  physicians  concerning  it  remained  vague  and  indefinite. 
No  better  idea  can  be  given  of  the  prevailing  ignorance  in  reference  to  cya- 
nosis, even  after  the  present  century  commenced,  than  by  quoting  from  a  case 
related  by  Ribes  in  1814.^  The  patient  had  some  time  previously  received 
an  injury  of  the  finger.  "  Many  physicians  of  Amsterdam,"  says  he,  "  were 
at  different  times  consulted  on  the  subject  of  this  affection,  no  one  of  whom 
understood  its  true  cause,  its  essential  character.  One  considered  it  as  par- 
taking of  the  nature  of  epilepsy,  and  caused  by  the  irritation  in  the  nervous 
system  which  the  wound  in  the  finger  had  produced.  Others  attributed  it  to 
the  presence  of  intestinal  worms.  Some  physicians  pronounced  it  an  injury 
to  the  liver  or  spleen.  Many  held  it  to  be  a  scorbutic  affection.  One  only 
believed  it  to  be  the  result  of  an  unknown  organic  disease."  In  the  present 
century  numerous  carefully  observed  cases  of  cyanosis  published  in  the 
medical  journals,  and  the  writings  of  Seller,  Louis,  Bouillaud,  Farre,  Chev- 
1  Diseases  of  the  Humors.  ^  Bull,  de  la  Fac.  de  Med.,  1815. 


CYANOSIS.  107 

ers,  Peacock,  Marston,  Stille,  and  others,  have  contributed  to  a  better  under- 
standing of  the  nature  and  anatomical  characters  of  cyanosis. 

Sex. — Whatever  may  be  the  explanation,  the  following  statistics  show  an 
excess  of  male  infants  affected  with  cyanosis : 

T.VBLE    1. 

180  cases  collated  by  Aberle     ....  two-thirds  males. 

44     "  "  '"   Gintiac    ....  28  males,  16  females. 

41     "  "  "   tSlille 21       "       10       '■ 

134     "  "  "   J.  Lewis  Smith  .  78      "       56       " 

Table  2. — Deaths  from  Cyanosis. 

Males.  Females. 

In  London,  England,  in  two  years  ....  418  273 

In  New  York  City,  in  five  years 117  90 

Time  op  Commencement. — It  is  an  interesting  and  somewhat  remark- 
able fact  that  cyanosis,  though  dependent  on  a  malformation,  does  not  always 
commence  at  birth,  or -at  least  does  not  exist  in  degree  sufficient  to  produce 
the  cyanotic  hue  till  some  time  has  elapsed  after  birth.  In  138  of  the  cases 
of  cyanosis  which  I  have  collected  the  time  at  which  lividity  was  first  observed 
is  stated  as  follows :  In  97  it  was  within  the  first  week,  and  generally  within 
a  few  hours  of  birth.     In  the  remaining  41  cases  i-t  commenced  as  follows: 

In  3  at  2  weeks.  !  In  6  from  2  years  to  5  years. 

"  1  "  3      "  !    "   1     "     5      "      "10      " 

"  2  "  1  month.  "  6     "    10      "      "20      " 

"  7  from  1   to  2  months.  "   1     "   20      "      "  40      " 

"5     "     2   "    6       "  "   1  over  40  years. 

"5     "      6    "12       "  77",  ,  , 

«   o      <(      1  i    o  41,  total. 

3  1  year  to  2  years,    i  ' 

In  these  41  cases,  in  which  blueness  did  not  occur  till  after  the  age  of  one 
week,  if  the  patient  were  less  than  two  years  old  when  it  commenced  there 
was  frequently  no  obvious  exciting  cause,  but  above  this  age,  with  three 
exceptions,  such  a  cause  is  known  to  have  been  present.  It  is  interesting  to 
observe  how  trivial  the  exciting  cause  frequently  is,  and  equally  interesting 
to  note  how  long  patients  have  enjoyed  good  health,  not  having  the  least 
lividity,  although  the  anatomical  vice  to  which  the  final  development  of 
cyanosis  was   due  had  existed  from  birth. 

Dr.  Theophilus  Thompson  relates^  the  history  of  a  lady,  thirty-eight  years 
old,  who  was  well  till  an  attack  of  Asiatic  cholera,  after  which  her  health 
was  permanently  impaired.  Two  years  before  her  death  she  passed  through  a 
course  of  fever,  and  from  this  time  was  cyanotic.  In  the  Philadelphia  Med- 
ical Examiner,  June,  1850,  Dr.  Waters  relates  a  case  in  which  cyanosis  began 
at  the  age  of  six  years  in  an  attack  of  measles.  In  a  case  published  by  Mr. 
Napper  in  the  London  Medical  Gazette,  1841,  the  child  fell  at  the  age  of  six 
months,  and  from  this  time  had  eyano.sis.  A  female  whose  history  is  given 
by  Prof.  Tommasini  of  Bologna,  and  quoted  by  Bouillaud,  became  cyanotic 
at  the  age  of  twenty-five  in  consequence  of  difficult  parturition,  In  the  Lon- 
don Lancet,  1842,  Mr.  Stedman  relates  a  case  in  which  cyanosis  began  at  the 
age  of  ten  weeks  in  an  attack  of  convulsions.  In  the  American  Journal  of 
Medical  Sciences,  in  1847,  Dr.  John  P.  Harrison  published  the  history  of  a 
baker,  twenty  years  old,  in  whom  cyanosis  began  five  years  previously  after 
great  effort  in  carrying  wood.  Louis  and  Bouillaud  quote  from  M.  Caillot 
the  case  of  a  child  who  became  cyanotic  at  the  age  of  two  months  in  an 
attack  of  whooping  cough.     Louis  also  narrates  a  case  in  which  whooping 

'  Medico-Chir.  Trans.,  vol.  xxv. 


108  MALFOBMA  TIONS. 

cougli  had  the  same  effect  at  the  age  of  twelve  years.  Ribes  treated  a  child 
in  whom  the  blue  disease  began  at  the  age  of  three  years  from  a  severe  con- 
tusion of  the  fingers.  In  a  case  by  Marx  it  commenced  at  the  age  of  ten 
months  from  a  blow  on  the  back  inflicted  by  the  mother.  In  the  Medical 
Times  and  Gazette,  for  1855,  Mr.  Speer  gives  the  history  of  a  female  who  at 
the  age  of  thirteen  years  was  put  in  a  place  requiring  considerable  exertion, 
and  from  this  time  was  cyanotic.  A  patient  whose  case  was  related  by 
Cherrier  fell  into  a  deep  ditch  in  the  winter  season,  and  immediately  after 
had  a  low  fever,  from  which  the  blue  disease  commenced.  In  a  case  pub- 
lished by  Tacconus  the  exciting  cause  was  believed  to  be  fright  in  conse- 
quence of  a  fall  from  a  great  height,  and  in  another,  related  by  Bouillaud,  it 
was  a  blow  received  on  the  epigastrium  after  the  patient  had  passed  the  age 
of  fifty  years.     Similar  cases  are  related  by  Mayo  and  Peacock. 

It  will  be  seen  that  the  exciting  cause  of  cyanosis  is  usually  such  as  pro- 
duces a  profound  impression  on  the  system  and  affects  the  action  of  the  heart. 
Precisely  in  what  way  it  operates  to  develop  the  disease  has  not  been  satis- 
factorily explained.  Mr.  Mayo  conjectures  that  in  the  case  related  by  him 
there  was  previously  some  compensation  which  ceased  or  became  inadequate 
in  consequence  of  some  change  produced  in  the  economy.  Although  cya- 
nosis may  not  appear  for  months  or  even  years,  there  is  rarely  improvement 
when  it  is  once  established.  Appearances  of  amendment  are  deceptive.  The 
disease  when  not  stationary  is  progressive,  and  this  explains  the  fact  that  few 
survive  the  middle  period  of  life. 

Symptoms. — The  symptoms  in  cyanosis  vary  in  intensity  in  different 
patients,  and  in  the  same  patient  at  different  times,  being  milder  if  he  be 
quiet  and  the  mind  calm,  more  severe  if  active  or  if  the  mind  be  agitated. 
In  mild  cases,  in  a  state  of  rest,  they  nearly  or  quite  disappear,  so  that  a 
stranger  would  not  suspect  that  there  was  any  serious  ailment.  They  are 
aggravated  by  any  cause  which  accelerates  the  action  of  the  heart.  In  some 
patients  cyanosis  is  increased  by  the  most  trivial  disturbing  influences,  among 
which  may  be  mentioned  nursing,  dentition,  crying,  coughing,  and  slight 
emotions  of  joy,  sorrow,  or  anger.  In  more  than  one  case  it  has  been  per- 
ceptibly increased  by  the  stimulus  of  digestion,  the  color  being  deeper  after 
a  full  meal  than  before. 

The  cyanotic  hue  varies  in  different  individuals  from  duskiness  to  a  deep 
purple,  almost  black,  color.  It  is  usually  most  marked  in  the  visage,  especially 
the  palpebrse,  cheeks,  nose,  and  lips,  in  the  ears,  fingers,  and  upon  the  mucous, 
surfaces.  It  is  sometimes,  without  any  assignable  cause,  confined  to  a  por- 
tion of  the  body.  In  a  case  related  by  Mr.  Steel  in  the  London  Lancet^ 
1838,  the  upper  part  of  the  body  was  livid  and  oedematous,  and  the  lower 
part  pallid  and  shrunken,  and  yet  the  malformation  was  of  the  kind  which  is- 
commonly  present  in  cyanosis.  In  the  London  Medical  Times,  March  8, 1845, 
copied  from  the  Gazette  medicale,  is  the  history  of  a  child,  six  years  old,  in 
whom  the  color  was  deeper  on  the  right  than  left  side.  There  had  been, 
however,  hemiplegia  of  this  side  in  infancy,  but  this  had  entirely  passed  off. 
On  the  other  hand,  in  a  case  of  rare  malformation  communicated  by  Cooper 
to  Farre,  in  which  the  upper  part  of  the  system  was  supplied  chiefly  by 
arterial  and  the  lower  by  venous  blood,  the  discoloration  was  general.  In 
exceptional  instances  livid  maculae,  like  those  of  purpura,  have  been  observed 
upon  the  skin. 

Those  affected  with  cyanosis  have  generally  at  birth  been  well  formed 
and  of  the  usual  size,  and  in  most  cases  for  a  considerable  period  after  birth 
the  appetite  is  good,  bowels  regular,  and  the  system  well  nourished.  But 
when  cyanosis  becomes  so  severe,  as  it  does  sooner  or  later,  that  its  symptoms; 
are  rarely  absent,  digestion  is  imperfectly  performed  and  the  body  becomes 


CYAXosrs.  109 

either  emaciated  or  stunted  and  puny.  It  may  be  stated,  as  a  rule,  that 
nutrition  is  in  inverse  proportion  to  the  gravity  of  cyanosis.  In  33  out  of 
41  cases  in  which  the  condition  of  the  system  as  regards  nutrition  was 
recorded  either  a  short  time  previously  to  death  or  at  the  autopsy,  the  body 
was  either  considerably  emaciated  or  else  diminutive,  and  those  who  were  well 
nourished  were  usually  such  as  had  died  early  or  of  some  intercurrent  disease. 

In  this  connection  may  be  mentioned  two  abnormalities  which  have  been 
observed  in  the  cyanotic.  The  chest  is  often  flattened  laterally  with  a  pro- 
jecting sternum,  so  as  to  present  an  appearance  generally  described  in  the 
records  as  •■pigeon-breasted."'  Sometimes  the  most  prominent  part  is  directly 
over  the  heart,  and  in  one  or  two  cases  the  sternum  was  observed  to  be 
■deflected  toward  the  left.  In  the  majority  of  the  records,  however,  no  men- 
tion is  made  of  the  external   appearance  of  the  chest. 

The  other  abnormality  is  frequently  observed  in  chronic  diseases  of  the 
heart  and  lungs,  in  which  there  is  sluggish  circulation  and  consequent  altered 
nutrition  in  the  fingers  and  toes.  In  28  of  the  cases  collated  by  myself  it  is 
stated  that  the  tips  of  the  fingers  or  toes,  or  both,  were  bulbous.  This 
hypertrophy,  if  slight,  is  likely  to  be  overlooked,  and  that  it  was  observed 
and  recorded  in  so  many  cases  renders  it  probable  that  it  was  present  in  a 
much  larger  number.  In  one  case  the  anatomical  character  of  this  enlarge- 
ment was  examined,  and  was  found  to  consist  chiefly  of  hypertrophied  con- 
nective tissue. 

The  nails  are  often  incurvated  over  the  deformity.  At  a  meeting  of  the 
London  Pathological  Society  in  1859,  Mr.  Ogle  narrated  the  history  of  a 
laborer,  fifty  years  old,  who  had  swelling,  numbness,  and  lividity  of  the  left 
arm  from  pressure  of  an  aneurism,  and  the  fingers  on  this  side  were  clubbed 
as  in  cyanosis.  A  patient  whose  history  is  related  in  the  Glasgow  JleJical 
Journal,  and  who  was  believed  to  be  cyanotic  in  consequence  of  a  highly 
emphysematous  state  of  the  lungs,  had  a  similar  development  of  the  tips  of 
both  fingers  and  toes. 

An  interesting  feature  in  cyanosis  is  the  low  grade  of  animal  heat.  The 
temperature  of  the  body  is  in  all  cases  below  that  of  health.  This  is  espe- 
cially noticeable  in  the  extremities.  There  has  not  been  a  sufficient  number 
of  accurate  thermometric  observations  to  determine  whether  the  internal  heat 
is  usually  reduced.  The  following  only  have  been  recorded  :  Mr.  Fletcher 
relates  the  history  of  a  young  man  in  the  Mech'co-Chir.  Trans.,  vol.  xxv.,  in 
whom  the  thermometer  placed  in  the  mouth  did  not  stand  above  80°  Fahr. 
Hodgson  reports  the  case  of  a  man.  twenty-five  years  old.  in  whom  the 
thermometer  placed  under  the  tongue  rose  to  100°.  Perhaps  a  more  thorough 
examination  might  have  disclosed  an  intercurrent  malady  to  cause  the  fever. 
In  an  examination  recorded  by  Xasse  the  instrument  placed  in  the  mouth  fell 
little  if  at  all  below  the  healthy  standard  ;  applied  to  external  parts,  it  stood 
at  about  21°  Reau.  =  79.2°  Fahr. 

The  lack  of  heat  is  a  source  of  great  discomfort  to  a  cyanotic  patient. 
In  mild  weather  he  requires  a  fire  to  keep  him  warm  or  an  amount  of  cloth- 
ing which  to  others  would  be  uncomfortable,  and  in  cold  weather  slight 
exposure  strikes  him  with  a  chill.  Xor  can  he  increase  his  heat  by  active 
exercise,  since  his  infirmity  disqualifies  him  for  this. 

Although  the  temperature  of  the  surface  is  so  low,  the  occurence  of  per- 
spiration, sometimes  profuse,  is  mentioned  in  several  of  the  records. 

In  severe  cases  of  cyanosis  the  generative  system  is  imperfectly  devel- 
oped. In  the  female  menstruation  is  scanty  or  delayed,  and  in  the  male  signs 
of  puberty  are  feebly  manifest.  If  the  disease  be  so  mild  that  the  symptoms 
are  absent  when  the  patient  is  in  a  state  of  repose,  these  organs  attain  nearly 
or  quite  their  normal  development.     The  catamenia  have  appeared  as  early 


110  MALFORMATIONS. 

as  the  age  of  sixteen  years,  and  a  cyanotic  patient  treated  by  Cherrier  had 
two  children,  but  they  both  died  of  scrofulous  affections. 

The  action  of  the  heart  is  necessarily  much  involved.  In  mild  forms 
of  the  disease,  if  the  patient  be  quiet,  this  organ  may  beat  with  considerable 
slowness  and  regularity,  but  in  all  cases  exercise  or  excitement  which  in 
a  state  of  health  would  scarcely  have  any  appreciable  effect  on  the  pulse 
embarrasses  its  movements  and  produces  palpitation.  In  severe  cases  pal- 
pitation is  rarely  absent,  and  the  pulse  is  frequent,  feeble,  and  often  inter- 
mittent. In  a  large  proportion  of  patients  bruits  are  produced  by  the  irreg- 
ular circulation  through  the  heart. 

The  respiration  corresponds  with  the  action  of  the  heart.  It  is  accele- 
rated in  proportion  to  the  frequency  of  the  pulse.  The  suffering  in  this 
disease  is  largely  due  to  paroxysms  of  palpitation  and  dyspnoea.  These 
occur  sometimes  without  any  apparent  exciting  cause  and  when  the  patient 
is  quiet,  but  they  are  commonly  induced  by  those  causes,  which  we  have 
already  mentioned  as  aggravating  the  symptoms  of  cyanosis.  They  come 
on  suddenly,  and  are  attended  by  increase  of  lividity,  distension  of  the  jug- 
ulars, and  sometimes  of  the  cutaneous  veins,  and  by  a  sensation  of  present 
suffocation.  They  last  only  a  few  minutes,  and  are  succeeded  by  great 
depression  of  the  vital  powers.  In  infants,  on  account  of  greater  nervous 
irritability  and  feeble  power  of  endurance,  these  paroxysms  often  end  in  con- 
vulsions, which  occasionally  are  fatal.  A  cough  is  sometimes  present,  but 
is  usually  slight. 

Pain  is  not  a  common  symptom.  Some  of  the  patients  complain  occasion- 
ally of  headache,  with  or  without  vertigo,  and  occasionally  also  of  pain  in 
the  chest,  but  it  is  uncertain  to  what  extent  or  whether  these  symptoms  are 
dependent  on  the  cyanotic  disease.  The  secretions  do  not  appear  to  be  affect- 
ed, so  far  as  has  been  ascertained.  The  same  may  be  said  of  the  intellectual 
and  moral  faculties.  In  a  case  related  by  Dr.  Cheevers  the  child  was  even 
said  to  be  precocious.^  The  mind  is  capable  of  steady  application  and  acqui- 
sition, as  in  health,  provided  that  the  emotions  are  not  unduly  excited. 

The  cyanotic  are  liable  to  various  forms  of  hemorrhage,  but  the  records 
show  that  this  liability  is  greater  in  youth  and  adult  life  than  in  infancy.  In 
2  cases  blood  was  vomited,  in  1  passed  by  stool,  in  1  it  escaped  from  the  gums,, 
in  2  from  the  mouth,  in  8  from  the  nostrils,  and  in  16  it  was  expectorated. 
Pulmonary  phthisis  was,  however,  usually  present  in  these  last  cases.  In 
the  Western  Journal  of  Medicine  for  1829  an  interesting  case  is  related  by 
Dr.  William  M.  Voris  of  a  girl  nine  years  old  in  whom  hemorrhage  occurred 
under  the  scalp,  producing  great  tumefaction  and  nearly  closing  the  eye- 
lids. An  incision  was  made,  from  which  a  pint  and  a  half  of  dark  blood 
escaped,  and  it  was  estimated  that  more  than  half  a  gallon  was  lost  during 
the  ensuing  two  weeks,  at  the  expiration  of  which  time  the  incision  closed. 
The  patient  recovered  from  the  hemorrhage,  but  not  from  the  cyanosis. 

Toward  the  close  of  life  more  or  less  anasarca  occasionally  occurs,  espe- 
cially around  the  ankles,  sometimes  in  the  eyelids  and  face,  and  rarely  to  a 
certain  extent  over  the  whole  body.  In  certain  patients  it  coexists  with 
effusion  in  the  serous  cavities. 

It  is  evident  that  one  who  is  affected  with  the  severer  form  of  cyanosis  is 
disqualified  for  the  duties  of  active  life.  The  sports  of  childhood  and  the 
useful  labors  of  mature  years  require  an  exertion  for  which  he  is  physically 
unfit.  He  has  not  the  ability  even  to  engage  in  animated  conversation,  for 
he  is  overcome  by  emotions,  whether  of  joy  or  sorrow.  He  lives  almost 
an  idle  spectator  of  the  world  around  him,  prevented  by  his  infirmity  from 
engaging  in  its  pursuits. 

^  Load.  Med.  Gaz.,  vol.  xxxviii. 


CYANOSIS. 


Ill 


Intercurrent  diseases,  especially  those  of  childhood,  are  badly  tolerated, 
but  whooping  cough  is  the  one  which  these  patients  are  especially  ill-fitted  to 
endure.  Still,  they  sometimes  pass  safely  not  only  through  whooping  coiigh, 
but  through  some  of  the  most  dangerous  febrile  diseases.  It  is  a  question 
of  interest,  but  about  which  little  is  known  with  certainty,  whether  these 
intercurrent  maladies  are  influenced  by  the  cyanotic  or  venous  condition  of 
the  blood.  The  symptoms  of  these  maladies  are  no  doubt  more  alarming, 
mainly  on  account  of  the  embarrassed  action  of  the  heart,  and  not  on  account 
of  the  state  of  the  blood  ;  still,  it  is  reasonable  to  suppose  that  malignant 
and  a.sthenic  diseases  are  rendered  worse  by  the  lack  of  oxygen  and  excess 
of  carbonic  acid  in   the  circulating  fluid. 

Probably  cyanosis  does  not  furnish  immunity  from  any  other  disease, 
although  this  statement  has  been  made  by  a  high  authority.  Rokitansky 
says :  ''  All  forms  of  cyanosis,  or  rather  all  the  diseases  of  the  heart,  great 
vessels,  and  lungs  adapted  to  produce  cyanosis  in  a  greater  or  less  degree, 
cannot  coexist  with  tuberculosis.  Cyanosis  affords  a  complete  protection 
against  it,  and  in  this  circumstance  may  be  found  an  explanation  of  the 
immunity  from  tuberculosis  which  many  conditions  of  the  system,  appa- 
rently very  different  in  their  character,  afford."'  This  opinion  of  the  dis- 
tinguished pathologist,  notwithstanding  his  ample  opportunities  for  observa- 
tion and  known  accuracy  as  an  observer,  is  not  substantiated  by  statistics. 
So  far  from  its  being  true,  the  low  degree  of  vitality  in  cyanosis  appears  to 
favor  the  occurrence  of  tubercles.  I  have  records  of  26  cases  of  cyanosis 
in  which  tuberculosis  was  also  present,  in  several  of  which  the  lungs  con- 
tained cavities.  This  is  about  13  per  cent,  of  the  whole  number  in  my 
collection — a  large  proportion,  since  so  many  die  in  early  infancy,  at  which 
period  the  tubercular  disease  seldom  occurs.  Cyanosis  appears  also  to  favor 
the  development  of  cerebral  diseases,  especially  congestion  and  coma,  as  will 
be  seen  presently. 

Prognosis. — This  is  unfavorable.  Most  cyanotic  individuals  die  young. 
The  age  which  they  attain  has  been  made  the  subject  of  statistical  inquiry 
by  Aberle.  He  states  that  in  an  aggregate  of  159  cases,  57,  or  35  per 
cent.,  died  before  the  end  of  the  first  year;  108,  or  more  than  two-thirds, 
died  before  the  age  of  eleven  years ;  30  between  the  ages  of  eleven  and 
twenty-five  years;  and  of  the  remaining  21,  only  5  lived  more  than  forty- 
five  years. 

The  age  at  which  death  occurred  is  given  in  186  of  the  cases  collected  by 
myself,  as  follows : 


In  17  under  the  age  of  1  week. 
"  10  from  1  week  to  1  month. 


12 

1  month    to    .3  months 

11 

.3  months  to    6       " 

17 

6       "         to  12       " 

12 

1  year  to  2  years. 

21 

2  years  to  5     " 

In  21  from  5  years  to  10  vears. 
"  41     "    10      "     "     20"  •' 
"  20     "    20      "     "     40     " 
"_ 4  over  40      " 

186,  total. 


67,  then,  or  more  than  one-third,  died  before  the  close  of  the  first  year;  121, 
or  more  than  three-fifths,  before  the  age  of  ten  years ;  only  24  survived  the 
age  of  twenty  years,  and  4  the  age  of  forty  years.  Of  course  the  dura- 
tion of  life  depends  on  the  nature  and  extent  of  the  malformations.  Some 
of  these  are  such  as  render  a  speedy  death  inevitable. 

Mode  op  Death. — The  mode  of  death  is  reported  in   95  cases,  as  fol- 
lows: 

1  Handb.  der  Path.  Anat,  Bd.  ii. 


112  MA  LFORMA  TIONS. 

19  died  in  a  paroxysm  of  dyspnoea. 

10  "  suddenly  (the  exact  manner  not  stated). 

14  "  in  convulsions  (infants). 

2  "  of  apoplexy. 

7  "  from  hemorrhage. 

6  "  of  phthisis  (though,  as  we  have  seen,  20  others  had  this  disease). 

2  "  of  exhaustion,  without  hemorrhage. 

10  "  of  coma. 

2  "  of  abscesses  in  the  brain. 

One  died  of  each  of  the  following  diseases  :  cerebral  irritation,  congestion 
of  brain,  eflFusion  in  the  cranial  cavity,  acute  hydrocephalus,  paralysis  from 
acute  softening  of  the  brain,  dysentery,  inflammation  of  heart,  syncope, 
mucus  in  the  air-passages,  thoracic  inflammation,  choleraic  diarrhoea,  pneu- 
monitis, bronchitis,  scarlet  fever,  croup ;  1  died  in  trying  to  walk,  1  after  a 
spasmodic  cough  in  pertussis,  1  after  a  long  agony,  1  after  an  agony  of  ten 
or  eleven  hours ;  1  is  reported  to  have  died  gradually  and  3  quietly. 

The  10  who  are  stated  to  have  died  suddenly  probably  died  in  paroxysms 
of  palpitation  and  dyspnoea,  which  are  easily  excited  and  of  common  occur- 
rence in  cyanosis.  If  so,  this  was  the  mode  of  death  in  29  cases.  Infants 
with  few  exceptions,  so  far  as  appears  from  the  records,  died  in  convulsions. 
19  died  of  cerebral  affections,  exclusive  of  convulsions,  and  in  13  of  these 
the  cause  of  death  was  congestion,  apoplexy,  or  coma.  The  hemorrhage  of 
which  7  died  was  probably,  in  most  instances,  dependent  on  phthisis,  and  6 
are  said  to  have  died  directly  of  phthisis.  We  may,  then,  regard  paroxysms 
of  palpitation  and  dyspnoea,  convulsions,  congestive  affections  of  the  brain, 
and  phthisis  as  common  modes  or  causes  of  death  in  cyanosis. 

The  malformations  of  the  heart  and  great  vessels  which  give  rise  to 
cyanosis  are  quite  numerous.  The  following  table  exhibits  their  character 
and  relative  frequency: 

Cases. 

1.  Pulmonary  artery  absent,  rudimentary,  impervious,  or  partially  obstructed     97 

2.  Eight  auriculo-ventricular  orifice  impervious  or  contracted 5 

3.  Orifice  of  the  pulmonary  artery  and  the  right  auriculo-ventricular  aperture 

impervious  or  contracted 6 

4.  Right  ventricle  divided  into  two  cavities  by  a  supernumerary  septum    .    .  11 

5.  One  auricle  and  one  ventricle 12 

6.  Two  auricles  and  one  ventricle 4 

7.  A  single  auriculo-ventricular  opening ;  interauricular  and  interventricular 

septa  incomplete 1 

8.  Mitral  orifice  closed  or  contracted _ 3 

9.  Aorta  absent,  rudimentary,  impervious,  or  partially  obstructed 3 

10.  Aortic  and  the  left  auriculo-ventricular  orifice  impervious  or  contracted  .  1 

11.  Aorta  and  pulmonary  artery  transposed   . 14 

12.  The  cavse  entering  the  left  auricle _ 1 

13.  Pulmonary  veins  opening  into  the  right  auricle  or  into  the  cavae  or  azygos 

veins 2 

14.  Aorta  impervious  or  contracted  above  its  point  of  union  with  the  ductus 

arteriosus ;  pulmonary  artery  wholly  or  in  part  supplying  blood  to  the 
descending  aorta  through  the  ductus  arteriosus 2 

Total 162 

From  the  above  table  it  appears  that  in  more  than  one  half  of  the  cases 
of  cyanosis  the  congenital  vice  which  gives  rise  to  it  is  located  in  the  pul- 
monary artery.  It  is  located  also,  in  general,  in  that  part  of  the  artery  which 
is  nearest  the  heart.  Its  character  is  different  in  different  cases.  Sometimes 
there  is  an  arrested  development  of  this  vessel,  and  in  its  place  we  find  simply 
a  ligamentous  cord  extending  from  the  heart  as  far  as  the  ductus  arteriosus, 
while  beyond  this  point  the  artery  and  its  branches  are  pervious ;  rarely  the 


CYANOSIS.  113 

entire  artery  is  ligamentous,  and  of  course  impervious ;  in  other  cases  this 
vessel  is  open  through  its  whole  extent,  but  the  part  nearest  the  heart  is  so 
small  as  to  be  properly  considered  rudimentary  ;  in  others  still  there  is  adhe- 
sion of  the  valves  to  each  pther  as  the  chief  congenital  defect ;  and  finally, 
in  rare  instances  the  obstruction  in  the  pulmonary  artery  is  due  to  an  adven- 
titious membrane  which  stretches  across  the  vessel  like  a  diaphragm.  These 
last  malformations — namely,  adhesion  of  the  valves  and  the  formation  of  an 
adventitious  membrane — are  doubtless  due  to  inflammation  occurring  in  the 
artery  before  birth,  and  some  attribute  the  arrested  development  and  lig- 
amentous state  of  the  vessel  to  the  same  cause. 

In  most  cases  of  cyanosis  due  to  obstructive  malformations  the  inter- 
auricular  and  interventricular  septa  are  more  or  less  deficient.  This 
deficiency  obviously  results  from  the  obstruction,  for  the  septa  are  formed 
in  the  heart  after  foetal  circulation  is  established,  and  the  blood,  being  pre- 
vented by  the  vicious  formation  from  flowing  in  its  proper  channel,  neces- 
sarily passes  to  the  opposite  side  of  the  heart.  More  or  less  blood  being 
forced  from  one  auricle  or  one  ventricle  to  the  opposite  cavity,  it  is  evident 
that  a  permanent  aperture  mhst  result  in  the  septum.  The  aperture  in  the 
septum  ventriculorum  is  ordinarily  at  its  base  ;  in  the  septum  auriculorum  it 
corresponds  with  the  foramen  ovale. 

In  most  of  the  obstructive  malformations  one,  and  rarely  two,  abnormal 
cardiac  murmurs  have  been  observed.  The  single  murmur  accompanies  the 
ventricular  systole.  As  it  has  been  observed  in  cases  of  complete  as  well 
as  incomplete  obstruction,  it  seems  to  be  due  mainly  to  the  flow  of  blood 
through  a  narrow  or  constricted  pulmonary  artery  or  the  apertures  in  the 
septa. 

Modes  of  Compensation. — In  most  cases  of  cyanosis  the  congenital 
defect  is  partially  obviated  by  modes  of  compensation.  In  the  most  fre- 
quent malformation,  that  in  which  there  is  obstruction  in  the  pulmonary 
artery  and  a  considerable  part  if  not  all  the  blood  flows  directly  from  the 
right  to  the  left  side  of  the  heart,  the  ductus  arteriosus  not  only  remains 
open,  but  is  greatly  enlarged,  through  which  a  current  of  blood  enters  the  pul- 
monary artery  from  the  aorta,  and,  passing  to  the  lungs,  is  oxygenated.  The 
bronchial  arteries  have  also  been  found  greatly  enlarged,  and  it  is  believed 
that  though  they  are  the  nutrient  arteries  of  the  lungs,  the  blood  which  they 
convey  to  these  organs  is  decarbonized  in  its  circuit  through  them.  In  a  case 
published  by  Mr.  Le  Glros  Clark  in  the  MecKco-Chir.  Trans.,  vol.  xxx.,  the 
bronchial  arteries  were  not  only  enlarged,  but  a  "  branch  from  the  internal 
mammary  artery,  which  accompanied  the  phrenic  nerve,  was  nearly  equal  in 
size  to  the  parent  trunk,  and  expended  itself  principally  in  the  adjacent 
adherent  lung.  Branches  of  the  intercostal  arteries  have  also  been  found 
enlarged,  and  entering  the  lungs  or  connecting  with  vessels  which  enter  the 
lungs.  By  such  modes  of  compensation  cyanosis  is  rendered  milder  and  life 
is  prolonged.  To  these  we  must  attribute  the  fact  that  some  have  very  con- 
siderable malformation,  and  yet  do  not  become  cyanotic. 

Morbid  Anatomy, — This,  as  regards  the  circulatory  system,  has  been 
sufiiciently  dwelt  upon.  No  chemical  analysis,  so  far  as  I  am  aware,  has  yet 
been  made  of  cyanotic  blood.  We  know  that  it  is  dark,  its  coagulability 
feeble — that  it  contains  an  excess  of  carbonic  acid  and  is  deficient  in  oxygen. 
From  the  nature  of  cyanosis  it  would  be  inferred  that  in  many  cases  there  is 
a  degree  of  passive  congestion  in  the  cavities  of  the  heart,  and  consequently 
in  the  capillaries  of  the  systemic  system,  giving  rise  to  more  or  less  serous 
eff'usion.  Statistics  show  that  this  is  so.  The  quantity  of  pericardial  fluid 
is  in  some  patients  increased,  I  have  records  relating  to  this  fluid  in  51  cases. 
Usually  it  was  pure  serum.     In  17  the  quantity  was  half  an  ounce  or  less, 


114  MALFORMATIONS- 

if  we  include  in  the  number  those  in  which  the  amount  is  expressed  in  such 
terms  as  "due  quantity,"  "usual  amount,"  and  "small  amount."  In  24 
cases  the  pericardial  fluid  (serum)  exceeded  half  an  ounce,  usually  estimated 
at  from  1  to  6  ounces,  but  in  2  it  exceeded  the  latter  quantity.  In  1-  of  the 
24  this  fluid  was  stained  with  blood.  In  2  patients  the  records  state  that 
there  was  a  small  quantity  of  pure  blood  in  the  pericardium,  and  in  1  the  two 
pericardial  surfaces  were  agglutinated  by  inflammation. 

In  some  of  the  autopsies  serum  was  found  in  the  pleural  cavities,  usually 
in  connection  with  pericardial  efi"usion,  and  in  at  least  one  instance  this  fluid 
was  tinged  with  blood.  Old  adhesions  between  the  costal  and  pulmonary 
pleura  were  observed  in  a  few  cases.  The  condition  of  the  lungs  was 
recorded  with  more  or  less  minuteness  in  110  cases.  Mention  has  already 
been  made  of  the  large  number  afi"ected  with  tubercular  disease,  which  was 
either  confined  to  the  lungs  or  was  chiefly  exhibited  in  these  organs.  In  35 
patients  the  records  state  that  the  lungs  were  of  small  size,  either  by  com- 
pression or  sometimes,  apparently,  from  the  continuance  of  the  fcetal  state 
over  a  greater  or  less  portion  of  the  organ.  The  compression  was  produced 
either  by  the  distended  pericardium  or  by  eff"usion  in  the  pleural  cavities.  In 
35  cases  the  lungs  presented  a  dark  color.  This  hue  in  some  specimens 
accompanied  the  unexpanded  or  foetal  state  of  the  organ,  but  in  others  there 
was  the  normal  inflation,  and  the  dark  color  was  due  to  engorgement  or  con- 
gestion. In  other  cases  the  lungs  are  stated  to  have  been  natural  except  the 
color.  In  9  emphysema  was  present  in  a  part  of  the  lungs,  in  2  pneumo- 
nitis ;  in  2  the  color  of  the  lungs  was  pale,  in  1  a  bright  crimson ;  in  1  the 
lungs  were  larger  than  natural,  in  1  the  right  lung  was  absent,  and  in  17 
these  organs  were  recorded   healthy. 

I  have  records  of  the  state  of  the  liver  in  26  cases,  in  16  of  which  it  was 
enlarged,  and  in  4  of  these  it  was  congested.  Congestion  of  the  liver  was 
present  in  8  other  cases  in  which  no  mention  is  made  of  its  volume.  The 
substance  of  the  liver  had  a  natural  appearance  in  9  cases,  but  in  some  of 
these  this  organ  was  enlarged.  From  these  statistics  it  is  probable  that  the  liver 
is  commonly  enlarged  in  cyanosis,  and  not  infrequently  congested.  In  a  few 
cases  the  condition  of  the  other  abdominal  viscera  is  mentioned — in  some  as 
healthy,  in  others  as  congested.  Fifteen  examinations  of  the  brain  were 
made,  in  7  of  which  congestion  is  recorded,  and  in  3  abscesses  in  the  cere- 
bral substance,  in  1  of  which  cases  the  lateral  ventricle  was  also  fllled  with 
pus ;  in  2  softening  of  a  portion  of  the  brain  had  occurred,  in  3  the  brain 
was  firm  or  compact,  in  3  the  quantity  of  fluid  in  the  cranial  cavity  exceeded 
the  normal  amount,  and  in  1  it  was  less  than  normal. 

Theories  relating  to  the  Etiology  of  Cyanosis. — Although  in 
nearly  all  cyanotic  patients  there  are  direct  communications  between  the  two 
sides  of  the  heart,  it  is  shown  by  many  observations  that  these  communica- 
tions or  apertures  are  not  sufiicient  in  themselves  to  produce  cyanosis.  This 
opinion  was  expressed  half  a  century  ago  by  Louis,  who  published  an  excel- 
lent monograph  on  the  subject  of  these  communications,  basing  his  remarks 
on  an  analysis  of  twenty  cases.  Since  the  publication  of  this  paper,  the 
belief  has  been  pretty  general  in  the  profession — and  observations  continue 
to  substantiate  it — that  although  the  apertures  may  be  of  considerable  size, 
if  the  two  sides  of  the  heart,  with  their  orifices  and  vessels,  are  in  their  nor- 
mal state,  so  that  they  act  symmetrically  and  without  obstruction,  the  blood 
is  sufiiciently  oxygenated  and  decarbonized,  and  cyanosis  does  not  occur.  In 
proof  of  the  correctness  of  this  opinion  many  cases  might  be  cited  of  a  per- 
vious and  some  of  a  largely  dilated  foramen  ovale  without  the  cyanotic  hue — 
cases  which  have  been  published  in  the  journals  since  the  appearance  of 
Louis's  monograph.     Still,  in  cases  of  obstructive  malformation,  unless  the 


CYANOSIS.  115 

obstruction  be  complete,  cyanosis  is  more  likely  to  occur  in  consequence  of 
these  apertures,  for  were  they  absent  a  larger  amount  of  blood  would  be 
propelled  through  the  narrow  orifice  of  the  pulmonary  artery,  and  a  larger 
amount  consec[uently  be  oxygenated. 

Allusion  has  already  been  made  to  the  two  theories  which  prevail  in  the 
profession  :  the  one  attributing  the  non-oxygenation  of  the  blood  and  its 
highly  venous  character,  so  as  to  cause  the  cyanotic  hue,  to  the  intermingling 
of  venous  and  arterial  blood  ;  the  other  to  obstruction  at  the  centre  of  circu- 
lation, and  consequent  venous  congestion.  There  are  serious  objections  to 
the  acceptance  of  either  theory  as  an  explanation  for  all  cases.  That  admix- 
ture of  the  two  kinds  of  blood  is  not  essential  to  the  production  of  cyanosis 
is  apparent  from  the  following  facts  :  In  one  case  in  the  Fourth  Malformation 
there  was  no  communication  between  the  two  sides  of  the  heart,  and  the 
ductus  arteriosus  was  closed,  so  that  admixture  was  impossible.  Again,  in 
the  Eleventh  Malformation,  or  that  in  which  the  aorta  and  pulmonary  artery 
are  transposed,  the  blue  disease  evidently  does  not  depend  on  the  admixture 
of  the  two  currents.  On  the  other  hand,  in  this  curious  state  of  the  heart 
the  more  the  admixture  the  less  the  cyanosis,  since  the  only  way  in  which 
the  systemic  current  of  blood  can  be  oxygenated  is  by  passing  to  the  opposite 
side  of  the  heart.  An  argument  against  this  doctrine  may  also  be  found  in 
the  fact  that  the  modes  of  compensation  are  not  such  as  in  any  way  to  dimin- 
ish or  obviate  the  admixture.  It  is  admitted  that  in  the  more  frequent 
malformations  cyanosis  is  increased  by  the  apertures,  which  allow  the  inter- 
mingling of  the  venous  and  arterial  currents,  but  it  is  more  reasonable  to 
consider  the  intermingling  and  the  cyanosis  as  the  direct  results  of  the  mal- 
formation, neither  having  the  precedence  of  the  other,  than  to  consider  that 
they  are  related  to  each  other  as  cause  and  effect  or  as  proximate  and  remote 
results.  Viewed  in  this  light,  the  admixture  must  be  considered  simply  a 
concomitant  of  the  cyanosis. 

The  second  theory,  that  of  venous  congestion,  has  numbered  among  its 
advocates  many  who  have  given  special  attention  to  the  subject,  as  Morgagni, 
Louis,  and  Stille,  but  it  seems  to  have  even  less  claim  for  acceptance  than 
the  theory  of  admixture.  It  has  been  seen  that  in  nearly  all  cases  of  cyanosis 
the  two  sides  of  the  heart  communicate  freely,  so  that  if  the  current  of  blood 
meets  with  an  obstruction,  as  it  commonly  does,  it  readily  escapes  to  the 
opposite  side,  where  the  artery  is  large  and  gives  it  free  passage.  In  this 
way  congestion,  if  not  prevented,  is  greatly  diminished.  Again,  it  will  be 
seen  that,  although  certain  of  the  viscera  are  frequently  found  at  the  autopsy 
more  or  less  congested,  congestion  is  not  uniformly  present  in  the  organs,  as 
it  would  probably  be  were  it  the  proximate  cause  in  all  cases  of  cyanosis. 

Moreover,  in  some  patients  the  malformation  is  not  obstructive.  The 
cavities  and  their  orifices  are  of  the  normal  size,  and  cyanosis  is  due  entirely 
to  malposition  of  the  vessels.  It  cannot  be  said  that  in  these  cases  there  is 
venous  congestion  from  arrest  at  the  centre  of  circulation.  If  there  be  any 
congestion,  it  must  be  due  to  the  fact  that  venous  blood  does  not  circulate 
as  readily  as  the  arterial  in  the  capillaries.  It  is  true  that  in  the  paroxysms 
of  dyspnoea  there  is  sometimes  more  or  less  congestion — the  distension  of 
the  jugulars  shows  this — but  it  subsides  with  the  paroxysms,  and  it  prob- 
ably is  no  more  than  usually  occurs  when  respiration  is  greatly  embarrassed. 

In  fine,  attempts  to  express  the  immediate  pathological  state  producing 
cyanosis  in  the  terms  of  a  general  law  have  failed.  However  plausible  the 
above  theories  may  appear  in  regard  to  certain  cases,  there  are  others  to  which 
they  are  manifestly  inapplicable.  Those  who  advocate  these  theories  seem  to 
lose  sight  of  the  obvious  fact  that  the  chief  want  of  the  economy  in  cyanosis 
is  decarbonization  of  the  blood,  and  it  is  hardly  supposable  that  there  can  bo 


116  MALFOBMA  TIONS. 

any  correct  theory  of  its  causation  which  is  not  founded  on  this  fact.  With 
this  physiological  state  in  view,  it  does  not  seem  difficult  to  express  a  theory 
in  comprehensive  terms  which  is  applicable  to  all  cases,  such  as  the  following  : 
Cyanosis  is  due  to  malformations  of  the  heart  and  the  great  vessels  in  imme- 
diate relation  with  the  heart,  which  prevent  the  proper  flow  of  blood  to  and 
from  the  lungs,  so  that  the  oxygenation  and  decarbonization  of  this  fluid  are 
inadequate.  So  comprehensive  a  statement  includes  not  only  cases  of  mal- 
formation and  malposition  of  the  heart  and  its  vessels,  but  also  those  few 
cases  in  which  the  lungs  are  in  fault.  In  most  patients,  as  we  have  seen,  the 
current  of  blood  toward  the  lungs  is  obstructed,  and  the  current  of  blood /row 
the  lungs  is  obstructed  in  those  comparatively  rare  cases  in  which  the  mal- 
formation is  on  the  left  side. 

Treatment. — From  the  nature  of  cyanosis  it  is  evident  that  the  treat- 
ment should  be  more  hygienic  than  medicinal.  The  patient  should  be  warm- 
ly clad  and  kept  in  a  warm  room,  and  all  agencies  calculated  to  embarrass  or 
disturb  the  functions  of  the  body  or  excite  the  emotions,  and  thereby  accel- 
erate the  heart's  action,  should  be  studiously  avoided.  The  diet  should  be 
nutritious,  but  simple  and  easily  digested. 

Those  who  have  attributed  cyanosis  wholly  to  apertures  in  the  interau- 
ricular  and  interventricular  septa,  and  the  consequent  flow  of  blood  from  the 
right  to  the  left  side  of  the  heart,  have  considered  it  an  important  part  of 
the  treatment  to  keep  the  patient  reclining  on  the  right  side,  so  as  to  dimin- 
ish this  flow  by  the  efiect  of  gravitation.  The  reader,  however,  must  be 
convinced  from  the  nature  of  the  malformations  that  little  benefit  can  accrue 
from  following  such  advice.  Still,  patients  are  sometimes  less  cyanotic  and 
more  comfortable  in  one  position  than  another.  In  a  case  reported  by  Mr. 
Howslip  ^  "  the  only  easy  and  indeed  comfortable  position  in  which  the  child 
could  remain  was  that  usual  in  nursing.  When  erect  the  dusky  color  of  the 
face  and  neck  became  a  dark-blue."  In  a  case  related  by  Mr.  Spackman  '^ 
the  patient  was  easiest  on  the  hands  and  knees.  Louis  reports  a  case  ^  in 
which  the  selected  position  was  with  the  head  elevated ;  Wm.  Hunter  a 
case*  in  which  the  patient  avoided  paroxysms  by  lying  on  the  left  side. 
Struthers  and  King  each  report  a  case  in  which  the  patients  seemed  most 
comfortable  while  lying  on  the  right  side  f  but,  on  the  other  hand.  Pro- 
fessor AVhite  of  Bufi"alo  ®  and  Dr.  James  Carson '  report  cases  in  which 
position  on  the  right  side  failed  to  produce  any  alleviation  of  symptoms. 
Other  similar  observations  might  be  cited,  but  enough  have  been  mentioned 
to  show  that  no  one  position  should  be  recommended  for  cyanotic  patients. 
Some  obtain  most  relief  by  lying  on  the  back,  others  on  the  right  side, 
others  on  the  left ;  some  when  on  the  hands  and  knees,  some  when  reclining 
on  either  side  indiff"erently,  while,  finally,  others  sufi"er  least  when  erect. 

There  was  a  time  when  the  paroxysms  were  treated  by  venesection,  but 
depletion  has  long  since  been  abandoned.  Physicians  now  rely  on  stimu- 
lants, antispasmodics,  friction  to  the  chest,  and  mustard  pediluvia  to  relieve 
the  urgent  symptoms,  although  this  treatment  is  but  partially  successful. 
It  is  probable  that  of  all  internal  remedies  digitalis  is  the  most  useful,  from 
the  fact  that  it  is  an  efficient  heart-tonic  and  more  than  any  other  medicine 
gives  strength  and  equality  to  the  heart-beats.  In  the  cities  where  oxygen 
gas  can  be  procured  for  daily  inhalation  the  urgent  symptoms  may  in  some 
instances  be  partially  relieved  by  the  use  of  this  agent. 

1  Edin.  Med.  Jour.,  1813.  ^  ^^onc^.  Med.  Gaz.,  1833. 

^  De  la  Commun.  des  Cav.,  etc.  *  Med.  Obs.  and,  Enq.,  vol.  vi. 

^  Monthly  Jour,  of  Merl.  Sci.  ^  Buf.  Med.  Jour.,  1855. 

'  Amer.  Jour,  of  Med.  Sci.,  1857. 


CEPHA  LMMA  TO  MA .  117 


Caput  Succedaneum. 


During  the  birth  of  the  child  extravasation  of  blood  frequently  occurs 
in  the  part  of  the  scalp  which  presents.  It  results  from  the  passive  conges- 
tion which  occurs  in  presenting  parts,  and  is  greatest  in  amount  when  the 
labor  has  been  protracted  and  the  labor-pains  unusually  severe.  Caput  snc- 
cedaneum  is  the  term  employed  to  designate  the  swelling  thus  produced.  Its 
seat  is  in  the  loose  connective  tissue  between  the  scalp  and  pericranium,  and 
it  consists  partly  of  extravasated  blood,  but  largely  of  serum  which  has 
transuded  from  the  congested  vessels  before  that  degree  of  congestion 
required  to  eflfect  the  transudation  of  corpuscles  or  rupture  of  capillaries 
was  reached.  I  have  repeatedly  had  an  opportunity  to  examine  this  tumor 
in  stillborn  infants  brought  from  the  lying-in  wards  of  the  Nursery  and 
Child's  Hospital,  and  have  found  when  it  was  slight  that  it  consisted  almost 
entirely  of  serum,  but  ordinarily  when  dissected  it  presented  the  appearance 
of  a  bruise,  with  a  large  proportion  of  serum,  the  blood  and  serum  infiltrat- 
ing the  scalp  to  a  greater  or  less  distance  beyond  the  appreciable  limits  of 
the  tumor.  Caput  succedaneum  requires  no  treatment.  As  it  lies  in  the 
loose  connective  tis.sue  of  the  scalp,  its  liquid  permeates  the  open  interspaces 
in  this  tissue  in  every  direction,  and  is  rapidly  absorbed,  while  the  tumor  dis- 
appears.    Its  subsidence  is  usually  complete  within  twenty-four  hours. 

Cephal.^matoma. 

Occasionally  during  birth  blood  is  extravasated  under  the  pericranium, 
detaching  it  from  the  bone.  This  commonly  occurs  in  connection  with  caput 
succedaneum,  and  is  observed  when  the  latter  declines.  Its  common  seat  is 
upon  the  occipital  or  parietal  bone,  near  the  posterior  fontanel,  most  fre- 
quently upon  the  parietal,  where  the  pressure  during  labor  is  greatest.  Prof. 
Henoch  states  that  the  tumor  does  not  obtain  its  maximum  size  iminediately, 
but  gradually  increases  by  the  continued  escape  of  blood  until  the  third  day. 
The  tumor  may  extend  over  the  entire  surface  of  the  bone,  but  it  does  not  pass 
beyond  the  suture ;  the  suture  limits  its  lateral  extension.  Cases  of  bilateral 
cephalaematoma  have  been  reported,  but  they  are  rare.  The  tumor  is  fluctu- 
ating, and  the  skin  covering  it  has  the  normal  appearance  or  a  bluish  tinge, 
or  it  may  exhibit  infiltrations  of  blood  like  a  bruise.  Since  the  pericranium 
elevated  by  the  blood  does  not  lose  its  vitality,  it  begins  to  secrete  from  its 
under  surface  preparatory  to  the  formation  of  bone.  In  a  few  days  we  are 
able  to  detect  by  pressure  with  the  fingers  a  hard  projecting  rim  at  the  border 
of  the  tumor,  the  result  of  the  secretion  and  bony  formation  at  the  point 
where  the  pericranium  is  in  part  detached  and  in  part  adherent.  If  the 
tumor  is  tense,  we  are  unable  to  detect  the  bone  underneath  by  pressure,  and 
the  hard  elevated  rim  resembles  the  edge  of  an  opening  in  the  skull.  The 
cephalaematoma  when  not  disturbed  apparently  causes  little  or  no  suffering, 
but  the  infant  evinces  pain  if  pressure  be  made  upon  it.  Usually  in  the 
second  week  absorption  is  so  far  advanced  that  the  tumor  is  less  tense, 
and  on  pressure  the  bone  can  be  felt  underneath  it.  Complete  absorp- 
tion of  the  blood  which  has  remained  liquid  usually  occurs  in  four  or  five 
weeks. 

Not  infrequently,  when  absorption  occurs  slowly,  a  thin  layer  of  bony 
substance  forms  in  a  few  weeks  on  the  under  surface  of  the  pericranium. 
This  causes  a  creaking  sound  when  pressure  is  made  upon  it  Some  time 
since  a  specimen  was  presented  to  the  New  York  Pathological  Society  by  me, 
showing  a  cephalaematoma  and  the  mode  of  cure.  The  child  died  about 
two  months  after  birth,  and   the  blood  constituting  the  tumor,  which  had 


118  DISEASES  OF  THE  NEW-BORN. 

been  in  great  part  absorbed,  was  completely  encased  by  the  old  bone  below 
and  tbe  new  bony  formation  above.  As  the  blood  becomes  absorbed  the 
pericranium,  having  perhaps  a  bony  formation  on  its  under  surface,  grad- 
ually sinks  ;  the  cavity  at  length  becomes  obliterated ;  and  there  only  remains 
some  thickening  of  that  part  of  the  cranium  which  corresponds  with  the  site 
of  the  tumor. 

A  cephalaematoma  might  be  mistaken  by  the  inexperienced  for  a  con- 
genital meningocele,  since  the  ridge  described  above  which  forms  along  its 
border  resembles  so  closely  the  edge  of  an  opening,  and  both  tumors  are 
fluctuating ;  but  a  meningocele  rarely  occurs  upon  the  part  of  the  head 
occupied  by  the  cephalaematoma  ;  and  if  there  be  any  doubt  in  the  diagnosis 
at  first,  it  will  be  dispelled  in  a  few  days  by  the  changes  which  it  undergoes. 

The  TREATMENT  should  be  expectant,  except  that  a  soft  covering  of  cot- 
ton should  be  placed  over  it  to  prevent  injury.  Experienced  physicians  who 
formerly  opened  these  tumors  by  an  incision  have  abandoned  this  treatment, 
and  recommend  leaving  them  entirely  to  nature. 


CHAPTER    II. 

DISEASES   OF   THE   NEW-BORN. 

Inflammation  of  the  Sterno-cleido-mastoid  Muscle. 

We  sometimes  observe  in  infants,  usually  between  the  ages  of  one  and 
six  weeks,  a  hard  tumor  upon  the  antero-lateral  aspect  of  the  neck  cor- 
responding to  the  site  of  the  sterno-cleido-mastoid  muscle,  and  evidently 
developed  in  this  muscle.  It  is  round  or  more  frequently  elongated,  varying 
from  the  size  and  shape  of  a  pigeon's  egg  to  that  of  the  little  finger,  occupy- 
ing the  anterior  border  of  the  muscle.  Sometimes  the  tumor,  hard  like 
cartilage  to  the  touch,  extends  over  the  anterior  half  of  the  muscle ;  and  it 
is  stated  to  occur  more  frequently  in  the  right  than  in  the  left  muscle.  Prof. 
Henoch  observed  it  on  the  right  side  in  16  cases  and  on  the  left  side  in  5 
cases. 

The  following  was  a   typical   case :  On  July  19,  188*7,  I  attended  Mrs. 

S ,  a  primipara,  in  her  confinement.     Her  labor,  which  was  tedious,  was 

terminated  by  the  forceps,  without  any  appreciable  injury  of  mother  or  child. 
About  one  month  after  her  confinement  the  mother  stated  that  she  had 
observed  during  the  last  two  weeks  an  unusual  swelling  passing  obliquely 
along  the  side  of  the  neck  of  the  child.  I  found  the  anterior  portion  of  the 
sterno-cleido-mastoid  muscle  thickened  and  hard  from  a  point  about  two 
lines  above  its  lower  attachment  nearly  its  entire  length.  The  swelling  was 
of  the  size  and  shape  of  the  little  finger  of  a  child  of  twelve  years.  It  was 
tender  to  the  touch,  never  had  been  red,  and  the  infant's  condition  was  nor- 
mal in  every  other  respect.  At  the  age  of  nine  weeks  the  tumor  was  still 
appreciable,  but  had  nearly  disappeared.  Sometimes  the  tumor  is  not  con- 
tinuous, but  the  muscle  is  thickened  and  hardened  in  two  or  three  diff"erent 
places.  Occasionally  the  child's  head  is  turned  to  one  side,  either  from  the 
pain  in  holding  it  erect  or  because  the  function  of  the  muscle  is  impaired. 

The  etiology  and  nature  of  this  tumor  are  apparent  from  the  history.  In 
a  majority  of  the  cases  the  birth  of  the  infants  aff'ected  with  this  ailment  was 
tedious,  and  in  many  the  presentation  at  birth  was  abnormal.     This  tumor  is 


MASTITIS.  119 

especially  liable  to  occur  after  breech  presentations,  which  necessitate  trac- 
tion upon  the  neck.  In  head  presentations,  when  there  is  delay  in  liberating 
the  shoulders  and  traction  is  made  on  the  head,  and  especially  if  forcible 
rotation  is  made,  the  more  ^superficial  and  exposed  fibres  in  the  sterno-cleido- 
niastoid  muscle  are  liable  to  ruptui'e  ;  and  when  this  occurs  a  local  myositis 
results,  causing  the  tenderness,  infiltration,  and  swelling.  Certain  writers 
state  that  more  or  loss  extravasation  of  blood  takes  place  at  the  time  of  the 
accident,  and  before  the  inflammation  supervenes,  and  hence  the  term  "  hsema- 
toma  "  which  has  been  employed  to  designate  the  disease.  But  I  have  seen 
no  evidence  of  hemorrhage — none  of  the  bluish  discoloration  which  indi- 
cates extravasation  so  common  in  bruises — in  any  of  the  cases  which  I 
have  observed. 

The  PROGNOSIS  is  good.  Suppuration  does  not  occur  unless  under  very 
unusual  circumstances,  and,  though  probably  more  or  less  cicatricial  tissue 
results  at  the  seat  of  injury,  the  function  of  the  muscle  is  not  appreciably 
impaired  when  the  inflammation  and  swelling  abate.  No  perceptible  contrac- 
tion or  deformity  results.  But  little  treatment  is  required ;  indeed,  patients 
do  well  without  treatment.  But  it  is  best  for  the  infant  that  it  maintain  so 
far  as  possible  a  horizontal  position,  with  the  head  resting  on  a  pillow  and 
with  the  avoidance  of  rotation  so  long  as  the  disease  is  in  its  active  stage  and 
the  tumor  is  tender  to  the  touch.  Probably  cool  lotions  recommended  by 
some  are  as  likely  to  do  harm  as  benefit  by  giving  cold  to  the  child  and  pro- 
ducing nasal  or  other  catari'hs.  Inunction  with  an  ointment  of  iodide  of 
potassium  has  been  recommended  for  the  purpose  of  promoting  absorption, 
as  the  following : 

R.  lodidi  potass., 

Aquae,  da.  1  part ; 
Adipis,  2  parts ; 

Lanolin,  6-8  parts. 

But  without  this  treatment  absorption  is  progressive  and  cure  complete 
within  a  few  weeks. 

Mammary  Glands. 

In  newly-born  infants  the  secretion  of  a  milk-like  substance  begins  at  about 
the  fourth  day  in  the  mammary  glands.  It  increases  until  the  tenth  day, 
when  it  gradually  diminishes,  and  disappears  at  about  the  twentieth  day.  It 
is  attended  with  some  swelling  of  the  glands  during  the  period  of  their 
activity,  and  after  the  secretion  ceases  the  enlai'gement  gradually  abates. 
M.  Guillot  states  that  this  secretion  presents  under  the  microscope  the  appear- 
ance of  colostrum.^  A  section  of  the  gland  in  which  this  secretion  has 
occurred,  made  near  the  surface,  shows  epithelium.  At  a  greater  depth  the 
canals  enlarge,  divide,  and  end  in  cavities  which  are  filled  with  a  liquid  hav- 
ing the  appearance  and  character  of  colostrum.  This  glandular  activity,  it  is 
said,  may  begin  before  birth,  and  continue  six  or  eight  weeks  after  birth,  but 
the  period  of  greatest  enlargement  and  most  active  secretion  of  the  gland  is 
usually  between  the  fourth  and  tenth  days  after  birth,  as  stated  above. 

Mastitis. 

In  exceptional  instances  the  enlargement  of  the  gland  and  its  functional 
activity  result  more  seriously.  The  gland  becomes  inflamed,  and  an  abscess 
may  occur  as  in  the  adult  female.     The  nurse  may  produce  this  result  by 

^  Archiv.  de  Med.,  1853. 


120  DISEASES  OF  THE  NEW-BORN. 

rubbing  and  pressing  the  gland,  so  that  rude  manipulation  of  it  should  be 
avoided.  An  abscess  destroys  the  gland-structure,  which  is  a  serious  result 
if  the  infant  be  a  female.  M.  Bouchut,  in  his  practical  treatise  on  diseases 
of  the  newly-born  (p.  719,  1867),  relates  a  fatal  case  of  mastitis  in  which 
the  inflammation  extended  to  the  connective  tissue,  and  ulceration  so  exten- 
sive occurred  that  the  pectoral  muscle  was  exposed,  and  death  resulted  from 
prostration.  Dr.  A.  Jacobi  has  observed  similar  cases. ^  Therefore  in  treat- 
ing the  enlarged  and  secreting  gland  of  early  infancy  very  gentle  and  unirri- 
tating  measures  should  be  employed,  so  that  mastitis  may,  if  possible,  be 
prevented.  The  dress  should  be  loose,  so  as  to  avoid  pressure  on  the  gland. 
If  no  inflammation,  or  inflammation  in  its  commencement,  be  present,  absorb- 
ent cotton  or  cotton  soaked  with  sweet  oil  should  be  applied  and  covered  with 
oil  silk.  It  is  proper  also  to  apply  a  mild  lead  wash  to  the  enlarged  mam- 
mary gland,  especially  if  it  be  hot.  If  it  be  indolent,  iodide  of  potassium  in 
glycerin,  one  part  of  the  former  to  ten  of  the  latter,  may  be  used.  If  the 
gland  be  hot,  and  especially  if  it  be  red,  a  soft  emollient  poultice  should  be 
applied,  as  of  bread  and  milk  or  flaxseed  and  water.  If,  unfortunately,  sup- 
puration occur,  an  early  incision  should  be  made  as  far  as  possible  from  the 
nipple.  In  the  subsequent  treatment  mild  antiseptic  washes,  as  boric  acid  or 
listerine  and  water,  should  be  used.  Corrosive  sublimate  should  not  be 
employed,  as  young  infants  are  readily  poisoned  by  it,  and,  for  the  same  reason, 
carbolic  acid  should  not  be  used  or  be  used  in  a  very  weak  solution.  Iodo- 
form should  also  not  be  used,  or  used  largely  diluted  by  the  addition  of 
starch. 

Conjunctivitis. 

(Ophthalmia  Neonatorum  ;  Purulent  Conjunctivitis  of  the  Newly-born.) — 
Different  forms  of  conjunctival  inflammation  occur  in  the  newly-born. 
In  the  mildest  variety  no  appreciable  swelling  of  the  lids  occurs,  and  only 
a  little  viscid  secretion  collects  between  the  lids,  which  agglutinates  them  in 
sleep,  and  which  the  nurse  readily  removes  by  bathing  them  with  tepid  water 
or  milk  and  water,  and  in  a  few  days  effects  a  cure.  On  the  other  hand,  the 
purulent  form  of  conjunctivitis,  which  is  observed  on  the  second  or  third  day 
after  birth,  and  which  arises  from  the  reception  between  the  lids  of  the  vagi- 
nal secretion  of  the  mother,  always  involves  great  danger  to  the  eye,  speedily 
producing  opacity  or  destruction  of  the  cornea,  unless  promptly  and  properly 
treated  Between  these  two  extremes  conjunctivitis  neonatorum  occurs  in  dif- 
ferent grades  of  severity. 

Mild  or  Catarrhal  Conjunctivitis. — This,  as  the  name  indicates,  is  a 
simple  catarrh,  attended,  as  stated  above,  by  a  slight  viscid  secretion  from 
the  lids  and  by  little  or  no  swelling.  The  secretion  collects  in  the  angles  of 
the  lids  and  along  their  margin.  This  mild  conjunctivitis  requires  very  sim- 
ple treatment.  Warm  water  or  milk  and  water  should  be  gently  applied  by 
a  large  camel's-hair  pencil,  so  as  to  wash  away  the  secretion  as  soon  as  it 
forms,  and  sweet  oil  or  vaseline  should  then  be  applied  between  the  lids. 
With  these  simple  measures  this  mild  conjunctivitis  disappears  in  a  few 
days. 

If  the  secretion  be  more  abundant  and  the  lids  perceptibly  swollen,  more 
active  measures  are  required.  Prof.  Noyes  states  that  there  is  a  variety  of 
catarrhal  ophthalmia  neonatorum  which  requires  active  treatment.  In  the 
cases  alluded  to  the  ocular  surface  is  but  slightly  involved,  having  little  or 
no  hyperaeraia,  but  the  palpebral  conjunctiva  is  hypersemic  and  the  fornix 
thickened  and  swollen.     The  swelling  of  the  fornix  is  the  most  marked  ana- 

^  ArcJdves  of  Pediatrics,  March,  1888. 


CONJUNCTIVITIS.  121 

tomical  character.  The  secretion  has  a  watery  appearance,  and  the  lids  are 
but  slightly  tumefied.  The  cornea  does  not  become  hazy  and  the  sight  is 
not  impaired,  but  the  watery  discharge  and  the  viscid  secretion  on  the  bor- 
ders of  the  lids  continue  foj  weeks,  unless  the  case  be  promptly  attended  to. 
Prof.  Noyes  recommends  for  this  form  of  catarrhal  ophthalmia  neonatorum, 
the  application  several  times  daily  of  the  boric-acid  solution  : 

R.  Acidi  ))orici,  gr.  xv  ; 

AquEe,  ^'.     M. 

He  adds :  "  But  if  a  child  is  a  month  old  and  the  discharge  continue,  and 
the  fornix  exhibit  decided  swelling,  I  have  been  obliged  to  u.se  solutions  of 
tannin  and  glycerin  as  strong  as  3ij,  ad  5J,  before  the  condition  would  yield. 
I  had  tried  nitrate  of  silver  in  mild  solution,  and,  unwilling  to  make  it  more 
caustic,  had  taken  a  solution  of  tannin  gr.  x,  ad  glycerinum  3J,  but  this  had 
only  a  temporary  good  effect,  and  the  disease  was  not  subdued  until  the 
strong  solution  was  applied.  It  was  done  every  second  day  to  the  everted 
lid,  and  was  of  course  quite  painful." 

Purulent  Ophthalmia  Neonatorum;  Gonorrhoeal  Ophthalmia 
Neonatorum. — This  is  one  of  the  most  important  diseases  to  which  the 
neonati  are  liable,  since,  if  not  promptly  and  properly  treated,  it  is  very 
damaging  to  the  eye,  permanently  impairing  or  totally  destroying  vision. 
It  is  produced  by  the  lodgment  in  the  eye  of  irritating  matter,  usually  the 
gonorrhceal  vaginal  secretion  of  the  mother.  A  minute  amount  of  the  viru- 
lent matter  is  sufficient  to  set  up  the  inflammation.  Recent  observations 
seem  to  show  that  in  a  considerable  number  of  cases  the  poisonous  matter 
is  received,  not  during  birth,  but  in  the  washing,  or  subsequently  from  the 
fingers  of  the  nurse  or  mother,  or  through  the  medium  of  soiled  towels  or 
linen.  Dr.  Joseph  A.  Andrews,  in  an  interesting  paper  on  contagious  eye 
disease  published  in  the  Neio  York  Medical  Journal^  1886,  quotes  the  follow- 
ing table  from  Theremin,  showing  the  time  of  commencement  in  476  cases^ 
as  follows : 

First  to  fourth  day  after  birth 57  cases. 

Fourth  to  eighth  day  after  birth 134      " 

Eighth  to  fourteenth  day  after  birth 94     " 

Later      104      " 

When  the  disease  begins  subsequently  to  the  first  week  after  birth,  it  is  evi- 
dent that  the  infection  occurs  post-natum,  the  poison  being  conveyed  to  the 
eyes  through  the  soiled  fingers  or  sponges  or  cloths  employed  in  the  nursery, 
as  stated  above. 

The  infectious  principle  contained  in  the  gonorrhoeal  discharge  of  the 
mother  is  now  admitted  to  be  a  micro-organism,  designated  the  gonococcus, 
discovered  and  described  by  Hallier  in  1869  and  Salisbury  in  1873.  The 
attention  of  the  profession  was  especially  drawn  to  it  by  Herr  Neisser  of 
Breslau  in  1879,  whose  description  of  it  was  more  full  and  accurate  than 
that  of  his  predecessors.  Recently  it  has  been  carefully  examined  with  the 
aid  of  coloring  tests  by  C.  W.  Allen  and  E.  C.  Wendt  of  New  York  City, 
and  their  monograph  relating  to  it  is  one  of  the  best  yet  published.  The 
gonococcus  is  a  "  comparatively  large  "  microscopic  organism,  round  at  first, 
but  becoming  elongated  or  oval,  and  then  dividing  by  fission  so  as  to  become 
a  diplococcus.  Subsequently  division  in  the  opposite  direction  occurs,  and 
this  process  continues  until  the  pus-cell  in  which  the  gonococci  lie  is  filled 
with  these  organisms.     It  is  within  the  pus-cells,  as  we  have  stated,  and  not 


122  DISEASES   OF  THE  NEW-BOBN. 

on  their  exterior,  that  the  segmentation  and  development  of  the  gonocoeeus 
take  place ;  but  diplocoeci  may  be  observed  in  the  intercellular  fluid,  prob- 
ably having  escaped  from  the  pus-cells. 

In  acute  gonorrhoea  usually  no  other  or  but  few  other  bacteria  except  the 
gonocoeeus  are  observed ;  but  in  chronic  gonorrhoea  of  both  sexes  other 
microbes  are  commonly  present  in  addition  to  the  gonocoeeus.  That  the 
contagious  and  virulent  property  of  gonorrhoeal  pus  is  due  to  the  gonocoeeus 
seems  to  be  fully  established,  but  were  the  action  of  this  organism  limited 
to  cases  of  gonorrhoea  it  would  be  less  important  as  a  pathological  factor. 
Microscopic  examinations  show  its  presence  in  the  pus  of  ophthalmia  neona- 
torum, as  well  as  in  the  vulvitis  of  childhood,  when  of  gonorrhoeal  origin, 
and  the  intense  inflammation  and  rapid  destruction  of  sight  in  the  former 
disease  are  believed  to  be  due  entirely  to  its  agency. 

Dr.  Gayet,  professor  of  ophthalmic  surgery,  Lyons,  France,  says  that  the 
detection  of  the  gonocoeeus  in  infected  pus  is  as  simple  and  easy  as  that  of 
albumen  in  albuminuria.  He  places  a  particle  of  pus  on  a  glass  slide,  covers 
it  by  another  slide,  and  presses  the  two  together.  They  are  then  separated,  and 
stained  by  dropping  on  them  an  alcoholic  solution  of  methyl-blue  mixed  with 
an  equal  quantity  of  water.  After  two  minutes  the  slides  are  washed  freely 
with  water,  and  each  leucocyte  is  seen  to  have  two,  three,  or  four  nuclei, ''  this 
being  a  special  character  of  the  disease,  the  increase  in  the  number  of  nuclei 
heralding  the  approach  of  the  gonococci,  which  will  be  observed  as  intensely 
blue  spherical  bodies  in  the  interior  of  some  of  the  leucocytes."^  If  the 
gonocoeeus  be  found  in  a  single  leucocyte,  of  course  the  diagnosis  is 
established. 

Symptoms. — Stellwag  says :  "  The  period  of  incubation  after  successful 
inoculation  of  the  contagious  material  varies  between  some  hours  and  days. 
The  outbreak  of  the  blennorrhoea  follows  the  more  quickly  the  more  favorable 
are  the  conditions  for  the  inoculation — i.  e.  the  more  powerfully  the  secretion 
was  able  to  act."  In  most  instances  when  infection  occurs  during  birth  some 
evidence  of  the  disease  appears  as  early  as  the  second  or  third  day.  The 
inflammation  is  from  the  first  severe.  The  conjunctiva,  ocular  and  palpebral, 
is  intensely  hyperaemic  ;  chemosis  soon  occurs  in  most  instances,  and  an  abun- 
dant muco-purulent  or  purulent  secretion  flows  between  the  lids  mixed  with 
tears.  The  inflammatory  hypersemia  not  only  extends  over  the  entire  con- 
junctiva, but  also  to  the  connective  tissue  and  the  integument  of  the  lids, 
causing  in  the  latter  a  dusky  or  bluish-red  tint.  At  a  later  stage  the  tint 
may  be  yellowish-red.  The  eyelids  swell  rapidly  in  consequence  of  the  loose- 
ness of  their  connective  tissue  and  the  great  amount  of  infiltration,  so  that 
they  appear  as  projecting  tumors  pressing  against  each  other  and  upon  the 
eye,  concealing  the  latter  from  view.  The  ocular  conjunctiva,  from  the  great 
amount  of  serous  exudation  underneath,  rises  up  like  a  circular  wall  around 
the  cornea,  which  appears  sunken  in  the  centre  of  the  swelling,  and  some- 
times only  its  central  part  is  visible  in  consequence  of  the  bulging  of  the 
swollen  conjunctiva  over  it.  The  palpebral  conjunctiva  is  so  swollen  from 
the  serous  infiltration  that  it  bulges  forward  on  attempting  to  separate  the 
lids,  and  eversion  of  them  is  liable  to  occur.  From  the  great  amount  of 
tumefaction  of  the  lids  the  palpebral  fissure  is  closed,  and  the  upper  lid  may 
project  over  the  lower  so  as  to  nearly  cover  it. 

The  danger  to  the  eye  results  chiefly  from  the  chemosis,  or  hard  and  tense 
oedema,  of  the  subconjunctival  areolar  tissue,  which  by  its  pressure  may  ob- 
struct circulation.  The  eye  is  photophobic,  tender  to  the  touch,  and  the  seat 
of  severe  pain.  The  intensity  of  the  inflammation  gives  rise  to  active  fever. 
The  inflammation,  having  reached  its  maximum,  soon  begins  to  abate  under 

*  Ea  Province  medlcale  ;  Loud.  Lane,  June  18,  1887. 


com  UNCTIVITIS.  1 23 

correct  treatment;  the  bright-red  erysipelatous  hue  of  the  lids  changes  to  a 
bluish  color  ;  the  heat  and  tenderness  abate.  The  secretion  is  abundant,  and 
is  constantly  escaping  from  the  conjunctival  sac  and  flowing  over  the  cheek, 
which  is  often  reddened  iji  consequence  of  its  extreme  acridity.  If  in  the 
height  of  the  inflammation  wc  attempt  to  separate  the  lids,  which  are  firmly 
pressed  together  not  only  in  consequence  of  the  great  amount  of  tumefac- 
tion, but  also  from  the  spasmodic  contraction  of  the  orbicularis  palpebrarum, 
the  purulent  secretion  gushes  forth,  consisting  of  greenish  or  grayish  pus — 
a  thick  liquid  containing  flocculi  of  epithelial  cells  and  muco-pus.  Occasion- 
ally, when  the  inflammation  is  intense,  these  flocculi  contain  also  fibrin.  The 
discharge,  consisting  chiefly  of  muco-pus  mixed  with  tears,  has  a  creamy 
appearance,  but  if  the  lachrymation  be  abundant  it  may  resemble  whey  in 
color  and  consistence,  especially  in  the  declining  stage. 

Course  ;  Results. — Purulent  conjunctivitis  of  the  new-born  usually 
begins  in  one  eye,  and  unless  the  sound  eye  be  immediately  and  effi- 
ciently protected,  the  inflammation  ordinarily  soon  attacks  this  eye.  Of 
course  both  eyes  may  be  simultaneously  aff'ected,  but  in  a  large  proportion 
of  patients  there  is  an  interval  of  a  day  or  two  in  the  commencement  of  the 
inflammation  in  the  two  eyes,  that  secondarily  infected  receiving  the  virus 
from   the  one  first  attacked. 

In  the  milder  cases  the  inflammatory  symptoms,  the  hyperaemia,  tumefac- 
tion, heat,  and  secretion  increase  gradually,  and  it  is  not  until  the  fifth  or 
sixth  day  that  they  attain  their  maximum.  In  severe  cases  the  symptoms 
reach  their  height  by  the  close  of  the  second  or  third  day.  The  inflamma- 
tion, having  attained  its  maximum,  as  indicated  by  the  heat,  swelling,  and 
abundant  secretion  which  wells  up  between  the  lids,  soon  begins  to  abate 
under  correct  treatment.  But  several  weeks  elapse  before  the  normal  state  is 
restored,  a  simple  catarrhal  inflammation  continuing  after  the  purulent  and 
infective  secretion  has  ceased. 

The  danger  to  the  eye  depends  upon  the  severity  of  the  inflammation. 
If  the  chemosis  be  not  great,  and  the  swelling  be  more  oedematous  than  indu- 
rated, and  the  amount  of  secretion  moderate,  the  eye  is  usually  saved  by 
timely  and  correct  treatment.  In  severe  inflammation  characterized  by  great 
chemosis,  hyperasmia,  and  heat  and  an  abundant  purulent  discharge,  the 
peril  to  the  eye  is  imminent,  since  the  inflammation  is  likely  to  extend  from 
the  conjunctiva  to  the  cornea,  and  ulceration  result.  When  the  cornea 
becomes  cloudy  in  places  the  danger  to  the  eye  is  extreme,  but  the  sight  may 
be  preserved,  though  abscesses  and  ulcers  occur,  provided  that  they  are  small 
and  involve  only  a  part  of  the  cornea.  Abscesses  and  ulcers  near  the  margin 
of  the  cornea  are  less  dangerous  than  those  in  the  centre,  but  crescentic 
peripheral  ulcers  are  of  bad  import,  since  they  are  likely  to  increase.  If 
marginal  softening  and  a  central  abscess  or  ulcer  coexist,  the  sight  will  prob- 
ably be  lost.  Of  course  the  more  quickly  the  inflammation  is  subdued  the 
better  the  prognosis. 

Preventive  Measures. — Since  purulent  conjunctivitis  of  the  new-born 
is  so  rapid  in  its  progress  and  so  destructive  to  the  eye,  it  is  very  important 
that  its  occurrence  should  so  far  as  possible  be  prevented,  and,  fortunately,  it 
is  a  prevcntible  disease.  The  employment  of  efficient  preventive  measures  is 
one  of  the  recent  achievements  in  midwifery  practice.  Statistics  abundantly 
show  the  need  and  efficiency  of  such  measures.  At  the  meeting  of  the  Blind 
Congress,  held  in  Paris  in  1879,  F.  Dumas  stated  that  of  1178  blind  patients 
whom  he  had  treated,  1070  became  blind  from  curable  diseases,  and  of  this 
number,  817,  or  69  per  cent.,  lost  their  sight  from  ophthalmia  neonatorum. 

According  to  Horner,  of  the  blind  children  treated  in  the  institutions  of 
Germany  and  Austria,  from  20  to  79  per  cent,  lost  their  sight  from  this  dis- 


124  DISEASES  OF  THE  NEW-BORN. 

ease.^  This  was  before  the  efficient  prophylactic  measures  now  in  use  were 
employed. 

Inasmuch  as  this  malady  is  produced  by  the  infective  vaginal  secretion 
of  the  mother  coming  in  contact  with  the  eye  of  the  infant  at  birth,  the  use 
by  the  mother  of  antiseptic  and  disinfectant  vaginal  douches  before  and  dur- 
ing parturition  is  suggested  as  the  appropriate  preventive  treatment  in  case 
she  have  a  muco-purulent  discharge.  For  this  purpose  carbolized  vaginal 
injections  have  been  employed,  with  the  result  of  diminishing  the  number 
of  cases  of  ophthalmia  neonatorum.  Mules^  advises  the  following  very  judi- 
cious and  important  preventive  measures :  "  1st.  Cure  all  cases  of  chronic 
vaginal  discharge  before  labor.  2d.  Irrigation  of  the  vagina  during  the 
second  stage  of  labor  when  vaginitis  is  known  to  exist.  The  solution  used 
for  this  purpose  in  Queen  Charlotte's  Hospital  is  corrosive  sublimate  (1 :  2000). 
The  copious  secretion  of  a  clear  vaginal  fluid  before  and  during  labor,  and 
the  flow  of  the  liquor  amnii  just  before  the  birth,  diminish  the  danger.  3d. 
Assist  the  foetal  eyes  to  pass  beyond  the  perineal  edge  without  resting.  This 
is  easily  done  by  hooking  around  the  perineal  edge  with  the  fingers  and  draw- 
ing it  down.  4th.  By  wiping  the  eyes  with  a  clean  cloth  at  birth  of  head. 
5th.  By  instilling  an  antiseptic  solution  into  the  eyes  at  birth  if  the  mother 
has  a  discharge.  6th.  Crede's  method  :  to  wash  the  face  first,  never  in  water 
in  which  the  body  has  been  washed.  7th.  To  retain  one  sponge  or  flannel 
especially  for  the  child's  face,  and  insist  on  scrupulous  cleanliness.  8th.  The 
nurse  to  wash  her  hands  after  adjusting  the  mother  before  touching  the 
child.  9th.  Not  to  expose  child  unduly  to  draughts,  bright  light,  etc.  10th. 
To  protect  the  child  from  flies  with  a  thin  veil.  11th.  To  remove  carefully 
the  child  from  the  presence  of  another  similarly  aff'ected ;  strict  isolation  of 
an  infected  case.  12th.  To  guard  the  one  eye  if  the  other  is  aff'ected."  The 
10th  and  11th  rules  are  evidently  applicable  to  cases  in  maternity  wards, 
rather  than  to  those  in  private  practice. 

But  in  order  to  gain  the  highest  degree  of  success  by  preventive  meas- 
ures, it  has  been  found  necessary  to  treat  the  eyes  of  the  infant  immediately 
after  birth  if  there  be  the  least  reason  to  suspect  the  presence  of  an  infective 
vaginal  discharge  in  the  mother,  so  as  to  destroy  the  poison  if  it  have  lodged 
in  them.  In  the  lying-in  asylums,  where,  in  consequence  of  the  prevalence 
of  gonorrhoea  in  the  mothers,  ophthalmia  neonatorum  of  a  severe  form  has 
been  prevalent,  antiseptic  treatment  of  the  eyes  of  all  the  newly-born  has 
either  entirely  prevented  this  disease  or  rendered  it  of  rare  occurrence.  To 
Crede  of  Leipzig  more  than  to  any  other  physician  the  credit  belongs  of 
having  established  this  treatment.     Its  efficacy  is  now  universally  recognized. 

Bathing  the  eyes  of  infants  immediately  after  birth  was  previously  prac- 
tised by  Abegg,  who  employed  only  water,  and  by  Olshausen,  who,  through 
Yon  Grraefe's  advice,  employed  a  1  per  cent,  solution  of  carbolic  acid. 
Although  this  treatment  diminished  the  number  of  cases  of  ophthalmia,  it 
was  far  surpassed  in  efficiency  by  that  recommended  by  Crede,  who  in  1880 
began  to  treat  the  eyes  of  the  newly-born  in  the  following  manner :  The 
external  surface  of  the  lids  was  first  washed  with  plain  water  ;  the  lids  were 
then  separated,  and  a  single  drop  of  a  2  per  cent,  solution  of  nitrate  of  silver 
was  allowed  to  fall  upon  the  cornea  from  the  end  of  a  glass  rod.  From  1880 
to  April  1,  1883,  Crede  treated  1160  infants  in  this  way,  and  only  4  became 
affected  with  ophthalmia  neonatorum.  This  treatment  by  nitrate  of  silver, 
employed  in  other  institutions  in  Europe  and  in  this  country,  has  been  fol- 
lowed by  signal  success.  Thus,  Dr.  Glarrigues  of  New  York  employed 
Crede's  treatment  in  the  Maternity  Hospital  on  Blackwell's  Island,  where 
ophthalmia  neonatorum  had  previously  been  of  common  occurrence,  and  of 
^Archivfiir  Gyndkologie,  1883.  ^  Prize  Essay,  Manchester  Chronicle,  Jan.,  1888. 


CONJUNCTIVITIS.  125 

351  infants  born  consecutively  "  not  a  single  one  was  affected."'  Dr.  Gar- 
rigucs  adds  that  in  these  cases  occasionally  a  thin  discharge  like  serum  fol- 
lowed the  application  of  nitrate  of  silver,  due  apparontl}^  to  its  irritating 
action,  and  that  the  first  cases  in  which  he  observed  this  discharge  he  treated 
with  iced  compresses  and  the  instillation  of  a  saturated  solution  of  boric 
acid.  But  afterward  he  found  that  they  quickly  recovered  without  such 
measures.  Occasionally  so  many  drops  of  the  nitrate  were  inserted  by  acci- 
dent that  a  black  ring  was  produced  upon  the  eyelids,  without  any  ill  effect 
to  the  eye.  Dr.  Garrigues  recommends  Crede's  method  of  employing  a  glass 
rod,  to  which  a  single  drop  of  the  solution  adheres,  so  that  there  is  no  risk 
that  more  than  this  amount  will  be  instilled.  The  application  should  be 
made  as  soon  as  the  infant  is  I'emoved  from  the  bed  to  the  lap  of  the  nurse. 
She  should  first  clean  the  eyelids  and  the  face,  and  in  washing  them  should 
be  careful  that  none  of  the  wash  enters  the  eyes.  A  weaker  solution  of 
nitrate  of  silver  has  been  employed  without  the  good  results  which  follow 
the  use  of  the  2  per  cent,  solution.  Crede  made  tentative  use  of  borate  of 
sodium  (1 :  (JO),  and  found  it  greatly  inferior  as  a  preventive  to  the  nitrate 
of  silver.'' 

Of  course  preventive  treatment  of  this  kind  should  not  be  recommended 
in  general  midwifery  practice,  except  when  there  is  evidence  or  strong  sus- 
picion that  the  mother  has  gonorrhoea.  Moreover,  much  can  be  done  toward 
diminishing  the  number  of  cases  of  blindness  resulting  from  ophthalmia 
neonatorum  by  disseminating  among  the  masses  a  knowledge  of  the  immi- 
nent danger  to  the  sight  of  the  newly-born  infant  when  a  purulent  discharge 
occurs  from  its  eyes,  so  that  instead  of  employing  domestic  remedies  the 
parents  will  seek  at  once  the  advice  of  the  accoucheur  or  family  physician. 

Treatment. — No  disease  of  early  life  so  imperatively  requires  early,  per- 
sistent, and  correct  treatment  as  the  purulent  form  of  ophthalmia  neonatorum. 
If  proper  rueasures  be  employed  sufficiently  early  and  persistently,  the  eye 
can  nearly  always  be  saved.  Since  this  malady  has  a  microbic  origin,  it  is 
evident  that  an  efficient  germicide  is  required  in  the  treatment — an  agent  that 
does  not  injure  the  eye,  while  it  destroys  the  cause  of  the  inflammation. 
Various  germicides  have  been  employed  for  this  purpose,  but  the  two  which 
have  been  found  safest,  and  at  the  same  time  most  efficient,  are  corrosive  sub- 
limate and  nitrate  of  silver. 

The  late  Prof.  S.  D.  Gross  long  before  the  microbic  causation  of  the 
infectious  diseases  was  known,  and  before  antiseptic  treatment  had  come  into 
use,  had  in  his  large  clinical  experience  discovered  the  efficacy  of  the  cor- 
rosive-sublimate treatment.  In  his  System  of  Surgery,  published  in  1859,  he 
wrote  :  "  In  the  purulent  ophthalmia  of  infancy  I  have  usually  effected  excel- 
lent and  even  rapid  cures  by  the  injection  every  few  hours  of  tepid  water  or 
milk  and  water,  followed  immediately  after  by  a  solution  of  bichloride  of 
mercury,  from  the  eighth  to  the  twelfth  of  a  grain  to  the  ounce  of  water ;" 
and  again  he  wrote :  "  The  bichloride  of  mercury  is,  of  all  the  local  remedies 
that  I  have  ever  tried  in  this  affection,  the  most  efficacious  in  its  action,  mak- 
ing generally  a  most  rapid  and  decided  impression  upon  the  discharge." 
Oppenheimer  of  Heidelberg  in  his  experiments  on  the  gonococeus,  which  he 
cultivated  in  blood-serum,  found  that  corrosive  sublimate.  1  :  40,000,  retarded 
its  development,  and  1  :  20,000  destroyed  its  vitality.'  Nitrate  of  silver  was 
also  used  in  the  treatment  of  purulent  ophthalmia  neonatorum  long  before 
the  gonococeus  was  discovered,  and  before  the  need  and  efficacy  of  germicide 
remedies  in  the  treatment  of  the  infectious  diseases  were  known  or  recog- 
nized.    Von  Graefe  more  than  thirty  years  ago  everted  the  lids  when  it  was 

^  Amer.  Jour,  of  Med.  ScL,  Oct.,  1884.  ^Arch.f.  Gyndk.,  xxi.  p.  193. 

3  Andrews :  N.  Y.  Med.  Jour.,  Sept.  25,  1886. 


126  DISEASES  OF  THE  NEW-BORN. 

• 

possible,  applied  the  mitigated  stick  of  nitrate  of  silver  to  the  mucous  sur- 
face, washed  it  with  salt,  and  replaced  the  lids.  This  treatment  is  stili 
employed  by  some  specialists  in  ophthalmic  practice.  Dr.  Gayet^  everts  the 
lids  so  as  to  stretch  the  mucous  membrane,  when  he  thoroughly  washes  the 
folds  of  the  conjunctival  sac  by  means  of  a  ball  syringe.  The  lids  are 
replaced,  rubbed  so  as  to  displace  pus-cells  and  force  them  into  the  con- 
junctival sac,  again  everted  and  syringed.  The  mitigated  stick  is  then 
applied  to  the  palpebral  mucous  membrane,  and  the  nitrate  of  silver  imme- 
diately neutralized  and  washed  away  by  a  solution  of  chloride  of  sodium. 
The  lids  are  then  replaced.  In  the  subsequent  treatment  the  mother  or  nurse 
washes  the  eye  with  a  solution  of  corrosive  sublimate  (1  :  6000),  and  frequently 
renews  upon  the  lids  compresses  wet  with  ice-water.  But  most  of  the  lead- 
ing oculists  employ  nitrate  of  silver  in  solution  in  the  manner  presently  to  be 
described. 

We  again  call  attention  to  the  necessity  in  this  disease,  more  than  in 
almost  any  other,  of  employing  faithful  and  attentive  nurses,  who  will  carry 
out  punctually  the  directions  given.  Two  nurses  are  required — one  to  serve 
by  day  and  the  other  by  night — since  it  is  essential  that  the  eye  be  fre- 
quently cleaned  and  the  secretion  washed  away. 

If  the  conjunctivitis  be  purulent,  but  mild,  and  attended  by  a  slight  dis- 
charge and  little  or  no  appreciable  swelling  of  the  conjunctiva,  two  drops  of 
a  2  per  cent,  solution  of  nitrate  of  silver  should  be  instilled  once  between  the 
lids,  and  the  lids  moved  to  ensure  its  flowing  underneath  them : 

B.  Argent,  nitrat.,  gr.  vj  ; 

Aq.  destillat.,  ^v.     M. 

In  the  subsequent  treatment  a  strong  solution  of  boric  acid — some  recom- 
mend a  saturated  solution — should  be  instilled  every  half  hour,  the  lids  being 
drawn  widely  apart.  The  frequent  wide  separation  of  the  lids,  which  can  be 
accomplished  without  undue  pressure  upon  the  eye,  is  useful  in  allowing  the 
pus  to  escape,  as  well  as  in  facilitating  the  application  of  the  wash.  I  prefer, 
however,  unless  the  disease  yields  quickly,  the  use  of  a  weak  solution  of 
corrosive  sublimate  la  place  of  the  boric  acid,  employing  the  following 
formula : 

R.  Hydrarg.  chlor.  corros.,  gr.  j-ij  ; 

Aquae  destillat.,  Oj.     M. 

The  use  of  this  mild  solution  of  the  sublimate  every  second  hour  after  a. 
single  employment  of  the  nitrate  of  silver  usually  suffices  to  cure  mild  cases 
in  a  few  days. 

If  the  disease  be  more  severe,  but  still  mild,  and  accompanied  by  mod- 
erate tumefaction  and  a  moderately  increased  secretion,  a  single  daily  applica- 
tion of  the  nitrate  of  silver  suffices  during  the  active  period  of  the  inflamma- 
tion. In  severe  forms  of  the  disease,  accompanied  by  much  tumefaction  and 
the  frequent  gushing  out  between  the  lids  of  a  thick,  purulent  secretion,  the 
nitrate-of-silver  solution  should  be  used  as  often  as  every  six  hours.  Dr. 
David  Webster  of  the  Manhattan  Eye  and  Ear  Hospital  states  that  he  has 
employed  the  nitrate  of  silver  in  these  severe  cases  five  times  in  twenty-four 
hours  with  great  benefit.  As  regards  the  frequency  of  the  application  of 
nitrate  of  silver,  and  the  time  when  to  desist  from  its  use,  Andrews  writes : 
"  The  only  guide  which  I  know  is  the  condition  of  the  conjunctiva.  When 
there  is  slight  hypersemia  only,  the  slough  produced  by  the  nitrate  of*  silver 
requires  a  long  time  to  be  cast  off","  and  it  is  very  irritating.  But  if  there 
'  La  Province  medicale;  London  Lancet,  June  18,  1887. 


UMBILICAL    VEGETATIONS.  127 

be  a  more  severe  inflammation,  with  much  swelling,  the  slough  is  thrown  off 
in  a  few  hours.  The  use,  therefore,  of  nitrate  of  silver  at  intervals  of  a  few 
hours  should  be  practised  only  in  the  most  severe  forms  of  the  inflammation, 
while  in  the  milder  cases  it  should  be  used  only  once  or  at  long  intervals.  In 
the  declining  period  of  the  (disease  the  application  of  a  solution  of  boric  acid 
or  a  weak  solution  of  corrosive  sublimate,  gr.  1  to  the  pint  of  distilled  water, 
suflices  to  eff"ect  a  cure. 

Umbilical  Vegetations. 

Not  infrequently  small  excrescences  sprout  out  from  the  base  of  the 
umbilical  depression  at  the  time  or  soon  after  the  fall  of  the  cord.  They 
have  the  appearance  of  those  vegetations  which  arise  from  open  sores,  and 
which  have  been  designated,  in  common  parlance,  proud  flesh.  One  of  the 
first,  if  not  the  first,  monograph  on  these  outgrowths  appeared  in  the  Medi- 
cal Dictionary  in  1834  from  the  pen  of  M.  Duges.  They  have  been  desig- 
nated in  diff"erent  languages  by  many  appellations,  as  fungous  excrescence 
of  the  umbilicus  (Condie),  excrescence  of  the  umbilicus  (Cooper  Foster), 
warty  tumor  of  the  umbilicus  (Holmes),  bourgonnement  de  I'ombilie  (De- 
paul),  granulorae  de  I'ombilie  (Dechamber),  vegetation  ombilicale  (Guer- 
sant).  Virchow  has  also  alluded  to  them  in  his  treatise  on  tumors,  and  a 
carefully-prepared  and  instructive  monograph  relating  to  them  appeared  in 
the  Rev.  Mem.  des  Mcdad.  de  V Enfancc,  Juillet,  1886,  from  the  pen  of  M. 
Broussole. 

The  size  attained  by  these  growths  is  always  small.  Many  of  them  are 
not  larger  than  a  pea  in  their  greatest  development.  Their  form  appears  to 
be  determined  in  a  measure  by  the  external  pressure.  Some  are  rounded, 
and  others  are  elongated  or  cylindrical.  French  physicians  have  likened 
them,  as  regards  appearance,  to  a  small  strawberry  or  a  small  cherry,  and 
sometimes,  when  small  and  elongated,  they  have  been  likened  in  shape  to  a 
grain  of  wheat  or  barley.  Guersant  and  Owen  have  described  them  as  hav- 
ing a  nipple-  or  polypus-shape,  according  to  variations  in  their  base.  It  is 
only  in  exceptional  instances  that  they  have  so  red  a  tint  as  a  strawberry  or 
cherry.  Their  color  varies  from  a  pale  red  to  a  red  of  a  deeper  tinge,  accord- 
ing to  the  degree  of  vascularity,  and  they  are  always  moist. 

This  outgrowth  is  distinguished  by  its  irreducibility  and  its  consistence. 
Digital  pressure  may  cause  it  to  disappear  in  the  umbilical  fossa :  it  dis- 
appears by  depressing  the  floor  of  the  fossa.  It  reappears  in  its  entirety  by 
the  resiliency  of  the  walls  of  the  fossa  as  soon  as  the  pressure  is  removed. 
It  has  the  soft  consistence  of  fungous  tissue,  so  that  it  is  depressed  and  flat- 
tened and  its  shape  changed  even  by  slight  pressure.  It  arises  in  most 
instances  from  the  inferior  part  or  floor  of  the  umbilical  fossa,  and  it  con- 
trasts in  appearance  with  the  cutaneous  folds  of  the  umbilicus  by  its  soft- 
ness and  reddish  tinge. 

This  tumor  does  not  exhibit  any  tendency  to  ulceration  or  to  hemorrhage 
in  the  proper  sense  of  the  term,  but  a  sanguinolent  serum  exudes  from  it 
and  stains  the  linen  unless  the  growth  be  small.  The  thin  irritating  dis- 
charge from  the  surface  or  base  of  the  vegetation  sometimes  causes  small 
excoriations  upon  the  edge  of  the  fossa.  In  a  child  of  one  year  and  a  half, 
whose  case  is  detailed  by  Foster,  the  ulceration  from  this  cause  attained  con- 
siderable size.  It  is  said  that  cases  have  been  observed  in  which  the  red- 
ness increased  when  the  infant  cried,  and  other  cases  in  which  the  vascu- 
larity was  such  that  more  or  less  hemorrhage  occurred  when  the  tumor  was 
injured.  In  these  last  cases  umbilical  naevi  may  have  been  mistaken  for 
vegetations. 


128  DISEASES  OF  THE  NEW-BOBN. 

Progress. — This  vegetation  in  the  first  days  or  weeks  increases  more 
rapidly  than  subsequently.  It  may  attain  half  the  size  or  the  full  size  of  a 
pea,  or  even  a  greater  development,  by  successive  sprouting  of  granulations. 
It  may  increase  slowly  during  many  weeks  or  months,  or  it  may  come  to  a 
standstill  and  show  no  tendency  to  diminish  or  atrophy.  In  time,  according 
to  several  writers,  it  is  likely  to  shrivel  and  skin  grow  over  it,  and  thus  be 
cured.     But  more  frequently  surgical  interference  is  required. 

Etiology. — It  is  reasonable  to  suppose  that  some  excoriation  of  the  sur- 
face precedes  the  granulations,  and  afibrds  the  base  on  which  they  arise ;  but 
why  one  child  has  this  outgrowth,  while  another  child,  with  the  same  man- 
agement of  the  cord  and  apparently  the  same  condition  of  the  umbilicus,  is 
free  from  it,  does  not  perhaps  admit  of  explanation, 

-Diagnosis. — This  is  readily  made.  The  small  size,  irreducibility,  red- 
dish hue,  the  serous  oozing  which  stains  the  linen  yellow,  the  softness,  like 
exuberant  granulations  in  other  localities,  and  the  shape,  enable  the  phy- 
sician to  diagnosticate  this  growth  from  any  other  kind  of  acquired  tumor. 
An  umbilical  naevus  has  greater  firmness  and  a  deeper  red  color,  which  dis- 
appears on  pressure  and  becomes  more  pronounced  when  the  infant  cries. 
The  naevus  is  also  less  elevated,  and  it  extends  laterally  and  vertically  far- 
ther than  the  vegetation,  often  passing  beyond  the  umbilicus.  From  other 
tumors  occurring  at  the  umbilicus,  as  adenoma  and  sebaceous  and  other 
cysts,  the  diagnosis  is  easily  made,  since 'tumors  other  than  the  vegeta- 
tions and  naevus  are  covered  with  skin,  are  not  attended  by  the  serous 
oozing  which    stains  linen,  and  most  of  them  are  congenital. 

Histology. — M.  Albarran  and  others  have  made  microscopic  examina- 
tion of  these  vegetations,  and  found  that  they  consisted  of  frail,  feebly-organ- 
ized connective  tissue,  round  cells  with  large  nuclei,  capillaries  with  walls 
consisting  of  swollen  endothelial  cells,  and  vessels  of  larger  size  with  narrow 
lumina  and  with  walls  formed  by  concentric  layers  of  flattened  fusiform  cells. 
In  another  case  examined  microscopically  fasciculi  crossed  each  other,  form- 
ing alveoli  which  contained  cellular  elements  that  were  abundant  in  propor- 
tion to  the  fibrillar  stroma.  The  vegetations  always  contain  numerous  small 
blood-vessels,  true  embryonic  capillaries,  with  walls  consisting  of  young 
cells  arranged  concentrically.  They  are  made  up  of  these  small  vessels, 
frail  connective-tissue  cells,  and  some  granular  intercellular  substance. 

Treatment. — Cauterization  by  nitrate  of  silver  acts  slowly,  but  some- 
times destroys  the  vegetation  if  small.  More  efiicacious  and  preferable 
treatment  is  to  remove  the  growth  by  the  scissors  or  ligature.  Saint-Grer- 
main  operates  as  follows :  The  fold  of  the  skin  surrounding  the  umbilicus 
is  depressed,  while  slight  traction  is  made  on  the  excrescence  by  the  forceps. 
The  pedicle  is  then  strongly  tied  by  a  silk  thread  previously  dipped  in  a  solu- 
tion of  carbolic  acid.  Slight  traction  then  suffices  to  remove  the  growths, 
and  they  sometimes  drop  oif  in  the  tying.  After  the  removal  a  little  iodo- 
form should  be  dusted  into  the  umbilical  fossa,  and  the  umbilicus  covered  by 
a  pledget  of  surgeon's  lint  retained  in  place  by  strips  of  adhesive  plaster. 

Umbilical   Hemorrhage. 

Hemorrhage  occurring  at  birth  or  soon  after  from  too  loose  ligation  of  the 
cord,  or  from  its  laceration,  is  so  well  known  and  its  cause  so  apparent  that  it 
need  only  be  alluded  to  in  this  connection.  Bouchut  relates  a  case  in  which 
death  took  place  from  this  cause  even  before  birth.  The  child  was  attached 
to  the  placenta  by  a  navel-string  so  short  that  it  prevented  delivery  till  it 
parted  by  the  traction  of  the  forceps.  The  bleeding  from  the  umbilical  ves- 
sels was  so  profuse  that  the  child  was  pallid  and  lifeless  when  born. 


UMBILICAL  HEMORRHAGE. 


129 


But  another  form  of  umbilical  hemorrluijre  sometimes  occurs  in  the  new- 
ly-born. The  oozing  takes  place  irom  the  umbilicus  itself,  and  not  from  the 
loosely-tied  or  torn  umbilical  cord.  One  of  the  tirst  cases  on  record  of  this 
hemorrhage  was  published  in  the  Geiiflemans  Gazeffe,  in  April,  1752,  by  Mr. 
Watts  of  Kent,  England ;  but  after  the  publication  of  this  case  a  century 
elapsed  before  umbilical  hemorrhage  attracted  the  attention  which  it  merited. 
In  April,  1852,  Dr.  Francis  Minot  read  a  paper  on  this  disease,  containing 
the  statistics  of  46  cases,  before  the  Boston  Society  for  Medical  Improvement. 
Three  years  subsequently,  in  1855,  Dr.  Stephen  Smith  of  New  York  read  a 
monograph  on  the  same  subject,  containing  the  statistics  of  79  cases,  before 
the  New  York  Statistical  Society.  This  was  followed  in  1858  by  a  statis- 
tical paper  from  the  pen  of  Dr.  J.  Foster  Jenkins,  read  before  the  United 
States  Medical  Association  and  published  in  its  Traiisncfions  for  that  year. 
This  monograh  was  elaborate,  since  the  writer  succeeded  in  obtaining 
the  histories  of  178  cases  from  medical  journals  and  members  of  the 
Association. 

Sex;  Age. — In  the  cases  collated  by  Jenkins,  34:i  per  cent,  were  females 
and  651  per  cent,  males.  However,  it  seems  improbable  that  sex  produces 
any  difference  in  the  liability  to  umbilical  hemorrhage.  The  following  table 
gives  the  ages  at  which  the  hemorrhage  began  in  99  cases : 


Age.  No. 

On  the  1st  day 5 

"      "    2d     "       7 

"      "   3d     " 6 

"      "   4th   "       3 

5th  to  7ih  day,  inclusive 32 


Age.  No. 

8th  to  10th  day,  inclusive 25 

11th  to  15th   "  "  16 

16th  to  21st    "  "  4 

22d  to  56th  "  "  J 

99 


These  statistics  are  interesting  as  showing  the  relation  of  the  hemorrhage 
to  the  umbilical  cord.  In  the  18  cases  in  which  the  hemorrhage  occurred 
under  the  age  of  three  days  it  may  be  assumed  that  the  cord  was  attached, 
and  the  blood  escaped  from  the  walls  of  the  umbilical  fossa  outside  of  the  line 
of  its  attachment.  Immediately  after  the  fifth  day,  or  after  the  time  when 
the  cord  falls,  there  was  a  large  increase  in  the  number  of  cases,  so  that 
from  the  fifth  to  the  fifteenth  day  after  birth  was  the  period  of  greatest 
liability  to  the  hemorrhage.  Since,  as  many  observations  have  shown,  in  a 
large  proportion  of  cases  the  blood  has  feeble  coagulability,  it  seems  probable 
that  the  umbilical  vein  and  the  umbilical  and  hypogastric  arteries  may  not 
have  been  occluded  by  fibrinous  coagula  in  at  least  some  of  these  patients, 
as  they  commonly  are  in  the  healthy,  and  that  the  hemorrhage  occurred  in 
part  from  these  vessels.  This  hypothesis  is  rendered  more  plausible  by  the 
fact  that  from  the  general  ill-health  present  in  many  of  these  infants,  prob- 
ably the  walls  of  the  vein  and  arteries  were  lacking  in  contractility,  so  that 
they  remained  more  patulous  than  in  robust  and  healthy  infants. 

Causes. — Hemorrhage  from  the  umbilicus,  as  well  as  from  other  parts  in 
the  newly-born,  must  be  referred  to  a  faulty  composition  of  the  blood,  espe- 
cially its  feeble  coagulability,  or  to  an  abnormal  state  of  the  walls  of  the 
minute  vessels,  or  to  both  these  causes.  The  hemorrhage  is  sometimes  refer- 
able to  the  hemorrhagic  diathesis  or  haemophilia,  which  may  be  inherited  or 
may  result  from  obscure  causes  in  children  born  of  healthy  parents.  In 
the  New  York  Infant  Asylum  a  well-developed  and  apparently  healthy 
mulatto  woman  gave  birth  to  her  first  infant  on  November  30,  1886.  She 
stated  that  her  family  were  healthy  and  that  the  father  of  the  child  was  also 
in  excellent  health.  The  birth  was  easy  and  natural,  and  nothing  unusual 
was  observed  in  the  infant,  which  weighed  nearly  ten  pounds,  except  a  swell- 
ing from  extravasated  blood  above  and  in  front  of  the  right  ear.      At  7  A.  M. 


130  DISEASES  OF  THE  NEW-BORN. 

on  the  next  day  severe  umbilical  hemorrhage  occurred,  which  was  checked 
by  styptics;  then  slight  epistaxis  took  place.  At  11  A.  M.  bleeding  from  the 
navel  returned,  and  appeared  to  come  from  several  points  at  the  margin  of 
separation  of  the  floor  of  the  umbilicus  from  the  cord.  The  tumor  above 
the  ear  increased,  purpuric  spots  appeared  upon  the  integument,  and  death 
occurred  from  exhaustion  on  December  2d.  The  infant  lost  one  pound  in 
weight  during  the  two  days  of  its  existence.  At  the  autopsy  a  few  small 
superficial  erosions  could  be  made  out  in  the  umbilical  fossa  at  the  point  of 
union  with  the  cord.  The  umbilical  vein,  traced  to  the  liver,  and  the  hypo- 
gastric arteries,  traced  to  the  iliac  arteries,  contained  no  blood,  were  patulous, 
and  apparently  normal.  Extravasations  of  blood  were  found  under  the  skin, 
in  the  abdominal  cavity,  and  at  numerous  points  in  the  lungs,  etc.  The 
organs  had  an  exsanguine  appearance,  and  everywhere  the  blood  was  without 
clots,  its  fluidity  being  a  notable  peculiarity  The  cause  of  the  haemophilia  in 
this  child  was  not  apparent.  Its  parents,  so  far  as  could  be  ascertained,  were 
healthy ;  still,  it  may  have  belonged  to  a  family  of  bleeders,  for  the  hemor- 
rhagic diathesis  sometimes  passes  over  one  generation  and  reappears  in  the 
next. 

Syphilis  is  one  of  the  recognized  causes  of  the  hemorrhagic  diathesis  in 
the  newly-born.  In  1871,  I  was  requested  to  visit  a  neonatus  that  was  a 
bleeder,  whose  father  was  unmistakably  syphilitic,  and  whose  mother  was 
suspected  to  have  contracted  syphilis  from  her  husband.  The  child  was 
fairly  developed,  and  the  cord  separated  on  the  sixth  day.  A  constant 
oozing  of  blood  from  the  navel  commenced  on  the  seventh  day,  on  account 
of  which  T  was  summoned  to  the  case.  I  finally  succeeded  in  arresting  the 
bleeding  by  the  application  of  the  plaster-of-Paris  dressing,  but  immediately 
intestinal  hemorrhage  commenced,  of  which  the  child  died  in  twenty -four 
hours.  The  parents  were  induced  to  take  antisyphilitic  remedies  for  a  con- 
siderable time,  and  they  have  since  had  four  healthy  children.  In  another 
instance  observed  by  me,  an  infant,  puny  and  apparently  premature,  was  at 
birth  observed  to  have  several  blebs  of  pemphigus,  from  which  blood  soon 
began  to  ooze,  but  the  umbilical  hemorrhage  from  which  the  child  died  did 
not  begin   until  about  the  fourteenth  day. 

Two  elements  or  factors  appear  to  be  present  in  producing  hemorrhagic 
syphilis  in  the  newly-born.  We  have  already  alluded  to  abnormal  fluidity 
of  the  blood,  for  when  it  escapes  it  does  not  coagulate  or  its  coagulation  is 
very  inadequate.  The  other  factor  is  abnormalities  in  the  minute  vessels. 
Many  years  ago  the  eminent  obstetrician  Sir  James  Y.  Simpson  of  Edinburgh 
met  cases  of  hemorrhage  in  the  newly-born  which  he  attributed  to  inflamma- 
tion of  the  vessels,  arterial  or  venous,  or  both,  from  which  the  blood  escaped. 
The  inflammation,  in  his  opinion,  caused  thickening  and  infiltration  in  the 
walls  of  the  vessels,  loss  of  tonicity,  and  consequently  a  patulous  state. 
Simpson  does  not  seem  to  refer  in  particular  to  the  hemoi'rhage  due  to  syph- 
ilis, but  to  that  from  other  causes  as  well.  Dr.  Mracek,  lecturer  on  syphilis 
in  the  University  of  Vienna,  reported  19  cases  of  hemorrhagic  syphilis  in 
neonati.^  None  of  the  mothers  had  undergone  antisyphilitic  treatment.  One 
of  the  infants  was  born  dead,  while  the  others  lived  from  half  an  hour  to 
forty-eight  hours.  The  capillaries,  the  vasa  vasorum,  the  venules,  and  arte- 
rioles were  filled  with  morbid  products,  having  caused  local  troubles  of  circu- 
lation and  sanguineous  efi"usions. 

Among  the  first  to  draw  attention  to  hemorrhagic  syphilis  of  the  newly- 
born  was  Behrends  in  1883,  whose  opinions  were  based  on  clinical  observa- 
tions. His  views  received  support  and  confirmation  from  cases  observed  by 
Kassowitz,  Dreahma,  and  Emilio  Shutz.     The  last  physician  made  careful 

1  Berlin,  klin.  Woch.,  No.  46,  p.  807,  Nov.  15,  1886. 


UMBILICAL  HEMORRHAGE.  131 

microscopic  examination  of  the  vessels  in  infants  who  died  of  this  hemor- 
rhage. xVndronico  also  published  an  interesting  paper  on  hemorrhagic  syph- 
ilis of  the  newly-born.^  His  observations  justify,  in  his  opinion,  the  state- 
ment that  hemorrhages  in  sjphilitic  neonati  are  due  not  only  to  "  diminished 
power  of  coagulation  of  the  blood,"  but  to  a  •'  vascular  ectasis,  particularly 
in  the  small  cutaneous  veins." 

Widerhofer,"  remarking  on  hemorrhage  in  the  syphilitic  infant,  attributes 
it  to  the  blood  dyscrasia. 

Bleeding  from  the  navel  also  sometimes  occurs  as  a  symptom  or  complica- 
tion of  jaundice.  Writers  who  have  collected  records  of  this  hemorrhage  have 
remarked  the  frequent  occurrence  of  the  icteric  hue  both  before  and  during 
the  bleeding,  even  in  those  who  do  not  present  the  history  of  syphilis.  It  is 
not  improbable  that  in  certain  instances  the  jaundice  is  hsematogenous,  aris- 
ing from  destruction  of  the  I'ed  globules  and  liberation  of  the  haematin — a 
not  unusual  result  of  a  profound  dyscrasia  even  when  there  is  no  syphilitic 
taint.  In  other  instances  the  jaundice  proceeds  from  the  liver,  and  the  bleed- 
ing occurs  from  the  altered  state  of  the  blood,  which  is  produced  hy  abnor- 
malities in  the  liver  or  its  appendages.  Thus  in  at  least  five  of  the  cases  of 
umbilical  hemorrhage  collated  by  pjenkins  the  marked  jaundice  which  was 
present  was  found  to  be  due  to  congenital  occlusion  of  the  common  bile-duct, 
and  of  course  all  the  bile  secreted  which  did  not  remain  in  the  liver  entered 
the  blood.  The  biliary  acids  in  the  blood  probably  diminish  the  amount  of 
its  fibrin   and  increase  its  fluidity. 

Poor  health  in  the  mother  and  impoverishment  of  her  blood  during  gesta- 
tion, whether  from  chronic  disease,  as  tuberculosis,  or  antihygienic  conditions, 
also  cause  impoverishment  and  increase  the  fluidity  of  the  blood,  and  there- 
fore act  to,a  certain  extent  as  a  predisposing,  if  not  as  a  direct,  cause  of  the 
hemorrhage.  Some  have  supposed  that  the  excessive  use  of  diluent  drinks 
or  alkalies  by  the  mother  during  gestation  also  increases  the  fluidity  of  the 
blood  of  the  foetus  and  renders  it  more  liable  to  hemorrhages  after  its  birth. 

In  exceptional  instances  no  adequate  cause  of  the  bleeding  can  be  detected 
either  in  the  child  or  the  health  of  its  parents.  Thus  in  the  Archives  of 
Pediatrics  for  May,  1884,  Dr.  Seibert  relates  the  case  of  an  infant  whose 
umbilical  dressing  and  clothing  were  saturated  with  blood  at  the  twentieth 
hour  after  birth.  The  bleeding  was  arrested,  but  it  returned,  and  the  child 
died.  No  coagula  of  blood  occurred  either  in  the  pools  or  the  saturated 
clothing.  There  was  no  history  of  hjemophilia  or  syphilis  in  the  parentage 
or  lineage,  and  the  child  at  birth  was  plump  and  apparently  healthy,  having 
no  petechias,  pemphigus,  jaundice,  or  ecchymoses.  The  health  of  the  mother 
had  not,  however,  been  good  during  gestation. 

Ordinarily,  umbilical  hemorrhage  occurs  without  premonition,  but  occa- 
sionally it  is  preceded  by  jaundice.  Jaundice  was  a  prodromal  symptom  in 
41  of  the  178  cases  embraced  in  Jenkins's  statistics,  and,  besides  the  icteric 
hue,  constipation,  clay -colored  stools,  deeply-tinged  urine,  etc.  were  recorded 
in  some  of  the  cases.  Rarely  colicky  pains  and  vomiting  precede  the  hemor- 
rhage. The  blood  oozes  slowly  or  rapidly.  It  seldom  escapes  in  a  jet,  even 
when  its  color  shows  that  its  source  is  more  arterial  than  venous. 

Grandidier  collated  the  histories  of  202  cases,  and  the  examination  of 
these  enables  him  to  make  the  following  statement :  The  hemorrhage  often 
begins  at  night,  so  that  it  may  continue  a  considerable  time  before  it  is 
detected.  He  also  states  that  vomiting,  colicky  pains,  somnolence,  and  espe- 
cially icterus,  with  constipation  or  clay-colored  stools,  sometimes  occur.  In 
135  of  the  cases  embraced  in  Grandidier's  statistics  the  hemorrhage  occurred 

1  Arch.  di.  Pal.  In/an.,  July,  1886. 

^  AUgem.  Wien.  med.  Zeitung,  No.  4,  1883. 


132  DISEASES  OF  THE  NEW-BORN. 

in  38  before  tlie  fall  of  the  cord,  in  26  at  the  time  of  its  separation,  and  in  71 
at  a  later  date. 

Prognosis. — This  is  unfavorable.  Statistics  show  that  5  in  every  6 
perish.  The  prognosis  is  most  unfavorable  when  an  obvious  dyscrasia  is 
present.  Those  who  have  jaundice  or  hasmophilia  with  very  few  exceptions 
perish.  Those  are  most  likely  to  recover  who  have  a  healthy  parentage,  no 
obvious  dyscrasia,  and  in  whom  the  hemorrhage  occurs  late  and  is  not  pro- 
fuse. The  average  duration  of  the  hemorrhage  in  82  cases  in  Jenkins's  col- 
lection was  three  and  a  half  days,  the  minimum  being  only  three  hours. 
Death  usually  occurs  from  exhaustion. 

Treatment. — A  compress  of  surgeon's  lint  or  a  sponge  saturated  with 
the  liquor  ferri  subsulphatis  should  be  firmly  pressed  over  the  umbilicus  and 
retained  by  a  bandage.  If  the  bleeding  do  not  cease,  the  umbilicus  should 
be  covered  by  a  thick  layer  of  plaster  of  Paris,  supported  by  the  hand  until 
it  hardens,  and  then  retained  in  place  by  the  bandage  passing  around  the 
body.  In  the  case  related  above,  occurring  in  my  own  practice,  this  treat- 
ment arrested  the  bleeding  from  the  navel,  but  it  was  followed  by  fatal 
intestinal  hemorrhage.  If  the  hemorrhage  continue,  the  needles  with  lig- 
ature may  be  employed.  Bouchut  indeed  states  that  this  is  the  only  effectual 
treatment.  Two  needles  are  passed  through  the  umbilicus  at  right  angles, 
and  a  waxed  thread  wound  around  each  in  the  form  of  the  figure  8.  If  the 
patient  survive,  the  needles  should  be  removed  in  four  or  five  days  and 
iodoform  or  a  poultice  applied.  It  is  important,  so  far  as  time  will  permit, 
to  treat  the  dyscrasia,  and  a  laxative  is  often  indicated,  especially  if  constipa- 
tion be  present.  A  laxative  is  useful  for  its  eifect  on  the  hepatic  circulation 
and  as  a  derivative.  Both  Smith  and  Jenkins  recommend  calomel  for  this 
purpose.  During  the  continuance  of  the  hemorrhage  four  or  five  drops  of 
brandy  in  breast  milk  frequently  administered  are  useful  as  a  stimulant. 


CHAPTER    III. 

DISEASES  OF  THE  NEW-BOEN   (Continued). 

Icterus  Neonatorum. 
* 
Icterus,  or  a  yellowish  discoloration  of  the  skin,  is  common  in  the  newly- 
born.  It  has  even  been  said  that  in  its  mildest  form  it  is  present  in  the 
majority  of  infants,  and  it  arises  from  a  considerable  number  of  anatomical 
and  pathological  conditions.  It  occurs  in  its  worst  and  most  intractable  form 
when  there  is  congenital  obliteration  of  the  bile-ducts ;  it  is  believed  to  occur 
sometimes  in  the  youngest  infant  from  the  same  cause  as  that  which  produces 
the  usual  form  of  adult  jaundice — to  wit,  catarrh  of  the  duodenum  extend- 
ing by  propagation  into  the  bile-ducts  and  narrowing  or  occluding  their 
lumina.  Congenital  syphilis  is  another  cause,  the  icterus  being  probably 
produced  by  the  newly-formed  connective  tissue  which  compresses  the  bile- 
ducts.  The  modus  operandi  of  the  causes  related  above  is  easily  understood, 
but  a  large  proportion  of  the  neonati  who  have  the  icteric  hue  in  a  slight  or 
mild  form  do  not  appear  sick,  and  fully  recover  after  a  few  days.  The  cause 
in  such  cases  is  probably  of  a  trivial  nature,  else  it  would  produce  a  more 
profound  impression  on  the  system.  West  says  of  these  mild  cases  in  which 
there  is  no  appreciable  impairment  of  the  health  that  the  yellow  tinge  of  the 


ICTERUS  NEONATORUM.  133 

skin  comes  on  about  the  third  day,  deepens  for  a  day  or  two,  and  subsides 
gradually,  "  the  bowels  acting  properly  and  the  urine  not  being  high-colored : 
though  to  this  condition  the  name  of  jaundice  has  been  applied,  it  is  yet  no 
real  jaundice,  but  is  merely  the  result  of  the  changes  which  the  blood  in  the 
over-congested  skin  is  undergoing,  the  redness  fading,  as  bruises  fade,  through 
shades  of  yellow  into  the  genuine  flesh  color."  A  yellow  coloring  of  the  skin, 
the  result  of  cutaneous  hyperaamia,  is  not  accompanied  by  the  diagnostic 
signs  of  true  jaundice,  such  as  a  yellow  conjunctiva,  clay-colored  stools,  and 
biliary  coloring  matter  in  the  urine.  Inasmuch  as  the  liver  and  other  internal 
organs  are  not  concerned  in  producing  this  form  of  icterus.  West  says  it  has 
been  proposed  to  designate  it  by  the  term  "  local  icterus.'"  It  would  be 
interesting  to  ascertain  in  cases  in  which  there  is  a  deposit  of  pigment  in  the 
skin,  while  all  the  other  organs,  including  the  liver,  are  in  their  normal  state 
and  have  their  normal  functional  activity,  whether  there  has  been  a  cutaneous 
plethora  due  to  late  ligature  of  the  cord.  Zweifel  states  that  the  placenta 
before  the  uterus  contracts  after  the  expulsion  of  the  child,  and  the  cord  is 
still  beating,  contains  six  ounces  of  blood,  but  if  the  cord  have  ceased  to 
beat  and  the  uterus  be  firmly  contracted,  half  of  this  amount  of  blood,  or 
three  ounces,  passes  through  the  cord  and  augments  to  this  extent  the  quan- 
tity of  blood  in  the  vessels  of  the  foetus.  Late  ligature,  therefore,  when  there 
is  firm  uterine  contraction,  increases  the  fulness  of  the  blood-vessels  in  the 
child,  and,  according  to  Park,  babies  with  distended  blood-vessels  exhibit  a 
more  intense  jaundice. 

H.  Quincke  advances  another  and  in  some  respects  a  plausible  theory  of 
the  etiology  of  the  common  form  of  icterus  neonatorum.^  He  attributes  the 
jaundice  to  the  continued  patency  of  the  ductus  venosus.  Henry  Ashby 
says^  that  in  a  minority  of  cases  of  jaundice  of  the  new-born  the  clinical  his- 
tory or  post-mortem  examinations  reveal  the  cause,  as  when  it  arises  from 
congenital  defects,  syphilitic  hepatitis  or  cirrhosis,  septicaemia  or  haemaglo- 
binuria.  But  the  usual  form  of  infantile  jaundice,  which  begins  on  the 
second  or  third  day,  and  commonly  ends  favorably,  Ashby  states,  has  nothing 
in  common  with  the  above  fatal  forms.  He  does  not  accept  West's  and 
Murchison's  theory  of  a  merely  cutaneous  icterus,  and  believes  that  Quincke's 
theory  is  the  most  plausible  yet  presented  for  consideration.  The  ductus 
venosus  normally  closes  between  the  second  and  fifth  days  after  birth,  but 
if  it  remain  pervious  and  the  circulation  from  any  cause  be  retarded,  bile, 
according  to  the  above  theory,  enters  the  branches  of  the  portal  vein  and 
finds  its  way  into  the  general  circulation  through  the  ductus  venosus.  In 
one  case,  says  Ashby,  an  infant  had  jaundice  from  the  second  to  the  eleventh 
day,  and  at  the  autopsy  the  ductus  venosus  was  large  enough  to  admit  an 
ordinary  director.  This  theory  also  comports  with  the  fact  that  feeble 
infants  are  more  liable  to  become  jaundiced  than  the  robust,  for  those  vas- 
cular canals  which  pertain  to  the  foetal  state  and  are  obliterated  after  birth 
are  more  likely  to  remain  a  longer  time  pervious  in  the  feeble  than  the 
robust. 

Dr.  Alois  Epstein^  made  many  experiments  in  order  to  determine  whether 
bile-pigment  occurs  in  the  urine  of  icteric  newly-born  infants.  He  agitated 
the  urine  with  lime-water,  filtered  it  with  alcohol,  and  added  sulphuric  acid. 
If  bile-pigment  be  present  a  green  color  results.  He  discovered  in  the  urine 
a  pigment  in  the  crystalline  or  amorphous  state,  and  of  a  yellow  or  yellowish- 
red  color.     It  occurred  in  the  various  forms  of  tufted  needles  or  small  tables, 

'  Archiv  fur  experimentelle  Palholoc/ie  und  Pharmakologie,  xix.  1  and  2. 
^  Lond.  Med.  Times  and  Gaz.,  April  25,  1885. 

'  "  Ueber  die  Gelbsucht  bei  Neugeboren  Kindern,"  Sammlung  klinischer  Vortrage, 
No.  80,  1880. 


134  DISEASES  OF  THE  NEW-BORN. 

yellowish  or  brownish,  and  in  yellowish-red  amorphous  granulations.  Epstein 
was  able  to  distinguish  by  chemical  reactions  this  pigment  from  uric  acid  and 
the  urates.  On  further  investigation  he  states  that  he  found  this  pigment  in 
all  the  organs,  abundantly  in  the  kidneys,  and  also  in  the  blood.  Does  this 
pigment  have  an  hepatic  or  haemic  origin  ?  Epstein  is  led  by  his  investiga- 
tions to  believe  that  this  crystalline  or  amorphous  pigment  results  from 
changes  occurring  in  the  blood,  and  probably  from  the  liberation  of  the 
coloring  matter  by  the  destruction  of  the  red  corpuscles,  which  Neumann, 
Kolliker,  Denis,  Hayem,  and  others  have  shown  to  occur  so  abundantly  in 
the  neonati. 

Epstein  believes  that  any  marked  impairment  of  the  important  functions 
in  the  system  tends  to  increase  the  destruction  of  the  red  corpuscles,  the  con- 
sequent release  of  its  coloring  matter,  and  the  formation  of  the  crystalline  or 
amorphous  pigment  described  above,  which  in  icterus  escapes  into  the  tissues. 
Marked  impairment  of  respiration,  circulation,  and  calorification,  artificial 
alimentation,  prematurity,  protracted  and  difiicult  birth,  taking  cold,  and 
similar  agencies,  in  proportion  as  they  impair  the  general  health  and  pro- 
duce perturbation  in  the  system,  increase  the  destruction  of  red  corpuscles, 
and  thereby  act  as  causes  of  icterus.  Epstein  also  mentions  the  well-known 
fact  that  the  children  of  parents  who  have  grave  constitutional  diseases  or 
live  under  bad  hygienic  conditions  are  especially  liable  to  become  icteric,  and 
that  septic  infection  is  an  important  cause  of  those  alterations  in  the  blood 
which  give  rise  to  icterus. 

The  peculiar  character  of  the  blood  of  the  newly-born  is  believed  by  good 
observers  who  have  investigated  this  subject  to  predispose  to  the  occurrence 
of  jaundice.  According  to  Hofmeier,  the  red  blood-corpuscles  in  the  neonati 
are  more  spherical  than  in  adults,  and  do  not  show  a  tendency  to  form  rou- 
leaux. The  white  corpuscles  are  often  more  numerous  than  in  adults;  they 
are  viscid,  deliquescent,  easily  destroyed,  and  have  a  tendency  to  aggregate 
in  rouleaux.  The  investigations  of  Ponfick  and  Silbermann^  show  that  the 
red  corpuscles  of  the  new-born  readily  part  with  their  coloring  matter,  the 
hsemaglobin,  under  disturbing  agencies,  such  as  syphilis,  burns,  taking  cold, 
injudicious  nursery  management,  and  even  by  the  action  of  certain  medicinal 
agents,  as  glycerin  and  pyrogallic  acid.  The  red  corpuscles,  which  have  lost 
their  coloring  matter  by  its  transference  to  the  plasma,  either  disintegrate 
and  disappear,  or  they  appear  under  the  microscope  as  pale  rings  which  have 
been  designated  shadows.  This  transference  of  the  coloring  matter  from  the 
red  corpuscles  to  the  liquor  sanguinis,  and  the  disintegration  of  red  corpuscles, 
which  characterize  the  first  few  days  of  infant  life,  lead  to  an  increase  of  haema- 
globin  in  the  plasma  (hsemaglobinhgemia)  and  of  fibrin  ferment.  Silbermann 
summarizes  his  views,  derived  from  an  examination  of  the  character  of  the 
blood  and  the  blood-changes  occurring  in  the  newly-born,  as  follows :  "  The 
blood  of  the  newly-born  holds  corpuscles  which  vary  greatly  in  size,  and  also 
the  so-called  shadows :  it  is  richer  in  fibrin  ferment  than  the  blood  of  adults ; 
these  peculiarities  are  due  to  the  liberation  of  hsemaglobin  and  its  transfer 
into  the  plasma ;  the  richness  in  fibrin  ferment  of  the  blood  of  the  newly- 
born  predisposes  to  disease  ;  all  disease-processes  in  the  newly-born  which 
involve  great  destruction  of  the  albumen  in  the  circulation  are  especially  dan- 
gerous to  life."  These  investigations  relating  to  the  blood  will  aid  to  an 
understanding  of  the  views  of  Silbermann  regarding  icterus. 

Dr.  Silbermann  concludes^  an  elaborate  paper  on  icterus  neonati  with  the 
following  aphorisms  :  "  1st.  Icterus  of  the  newly-born  is  an  icterus  of  absorp- 

'  "  Zur  Hiimatologie  der  Neugeborenen,"  Jahrbuch  fur  Kinderheilkunde,  1887. 
^  Archiv  fur  Kinderheilkunde,  1887. 


ICTERUS  NEONATORUM.  136 

tion.  2d.  The  biliary  engorgement  has  its  seat  in  the  biliary  capillaries  and 
the  interlobular  bilo-duct.s,  which  are  compressed  by  the  dilated  branches  of 
the  portal  vein  and  the  capillary  blood-vessels  of  the  liver.  3d.  This  engorge- 
ment in  the  vessels  is  effected  by  the  change  in  the  circulation  of  the  liver  which 
occurs  soon  after  birth,  and  is  one  of  the  indications  of  a  general  change  in 
the  blood-plasma.  -Ith.  This  change,  which  is  induced  by  the  destruction  of 
many  blood-corpuscles  soon  after  birth,  consists  of  a  kind  of  blood-fermenta- 
tion. 5th.  The  more  feeble  the  infant  the  more  intense  will  be  the  icterus, 
for  in  such  a  child  the  destruction  of  corpuscles,  and  the  consequent  blood- 
changes,  will  be  much  more  decided  than  in  a  vigoi'ous  child.  6th.  As  the 
consequence  of  the  destruction  of  so  many  red  corpuscles  there  is  abundant 
material  for  the  formation  of  biliary  coloring  matter,  and  under  the  influence 
of  the  fermentation-process  alluded  to  this  accumulates  in  considerable  quan- 
tity." Therefore,  according  to  this  theory,  free  coloring  matter  in  the  blood, 
derived  from  the  abundant  destruction  of  the  red  corpuscles  which  attends 
the  first  days  of  infancy,  occurs  in  such  quantity  that  it  cannot  be  disposed 
of  in  the  biliary  secretion  or  otherwise  eliminated,  and  is  deposited  in  the  tis- 
sues, causing  the  icteric  hue. 

Birch-Hirschfeld  ^  attributes  icterus  of  the  new-born  to  oedema  of  the 
capsule  of  Glisson.  and  consequent  compression  of  the  bile-ducts.  This 
oedema  he  believes  is  due  to  diminution  of  pressure  in  the  portal  system 
consequent  on  section  of  the  cord. 

That  feebleness,  insanitary  conditions,  and  exposure  are  a  cause  of  jaun- 
dice, however  they  may  act  to  produce  such  a  result,  is  shown  by  many 
observations.  West,  as  we  have  stated  above,  describes  a  local  or  cutaneous 
icterus  resulting  from  plethora  of  the  skin,  and  having  no  special  interest  or 
importance,  and  a  systemic  or  general  icterus,  which  he  states  "  does  not  affect 
perfectly  healthy  children  who  have  been  born  at  the  full  time,  have  been 
nourished  exclusively  at  the  mother's  breast,  and  been  sheltered  from  cold 
without  being  overburdened  with  clothing  or  confined  in  a  vitiated  atmo- 
sphere." In  corroboration  of  this  statement  he  alludes  to  the  fact  that  in 
the  Dublin  Lying-in  Hospital,  where  the  utmost  care  is  bestowed  on  the 
foundlings,  icterus  is  rare,  while  it  is  so  common  in  the  Foundling  Hos- 
pital of  Paris  that  few  escape.  In  the  latter  institution,  as  compared  with 
the  former,  the  exposures  are  much  greater  and  the  conditions  as  regards 
hygiene  are  greatly  inferior. 

M.  Bouchut  says  that  icterus  is  observed  in  80  to  90  per  cent,  of  the 
new-born  ;  that  Levret,  Breschet,  Billard,  and  Valleix  regard  it  as  the  result 
of  ecchymosis  of  the  skin  following  congestion — an  opinion  which  he  con- 
siders erroneous.  He  believes  that  it  almost  always  results  iVom  a  mild  or 
severe  hepatitis  consequent  on  ligature  of  the  cord.  The  ligature,  he  says, 
produces  a  mild  inflammation  which  is  propagated  to  the  liver  and  causes 
obstruction  of  the  bile-ducts.  In  his  articles  on  hepatitis  of  the  new-born 
he  repeats  his  belief  in  this  theory. 

The  obvious  inference  from  the  above  resume  of  opinions  is  that  icterus 
neonatorum  results  from  different  causes  in  different  instances,  and  that  it  is 
a  mild  or  grave  disease  according  to  its  etiology.  The  various  causes  admit 
of  classification  in  two  groups :  1st,  the  hjematogenous ;  2d,  the  hepatoge- 
nous. The  hjBmatogenous  theory,  which  attributes  the  common  form  of 
icterus  of  the  newly-born  to  the  destruction  of  the  red  blood-corpuscles  in 
the  first  days  of  life,  and  the  escape  of  the  coloring  matter  into  the  circulation, 
is  advocated  by  such  men  as  Billard,  Yirchow,  Breschet,  Porak,  Violet,  and 
Epstein.  The  hepatogenous  theory  has  also  advocates  of  equal  reputation. 
The  etiology  of  this  disease  certainly  requires  further  investigation,  and  when 
'  Virchow's  Arch.,  1882,  Band  Ixxxvii. 


136  DISEASES   OF  THE  NEW-BORN. 

it  is  better  understood  it  will  probably  be  seen  that  distinct  pathological 
states  in  the  newly-born  have  been  described  under  the  term  "icterus." 

Prognosis. — This  depends  on  the  nature  of  the  cause  as  well  as  the 
present  state  of  the  infant.  If  the  cause  be  susceptible  of  removal,  as  in 
the  common  mild  form  of  icterus,  a  favorable  prognosis  is  justified.  The 
must  unfavorable  cases  are  those  in  which  there  is  absence  of  the  biliary 
ducts  or  their  permanent  occlusion.  In  severe  forms  of  the  disease  in  which 
the  connective  tissue,  the  secretions,  and  transuded  serum  have  the  yellow 
hue  the  prognosis  should  be  guarded. 

The  common  mild  form  of  icterus,  appearing  on  the  second  or  third  day 
after  birth,  disappears  or  is  scarcely  appreciable  at  the  close  of  the  second 
week.  Severe  icterus,  continuing  longer  without  any  abatement  in  its  inten- 
sity, is  due  as  a  rule  to  permanent  anatomical  conditions  which  prevent  the 
flow  of  bile  into  the  intestine,  and  is  probably  incurable.  In  these  cases 
the  stools  remain  clay-colored,  the  icterus  increases,  and  vomiting  may 
occur. 

The  TREATMENT  is  simple,  and  to  a  considerable  extent  expectant.  Gen- 
tle friction  over  the  liver  may  perhaps  in  some  cases  aid  in  removing  the 
obstructive  disease  in  the  bile-ducts.  The  use  of  hydrarg.  cum  creta  in 
small  doses,  as  recommended  by  West,  is  of  doubtful  efficacy.  It  is  evident 
that  preventive  measures  are  more  important  and  more  efficacious  than  the 
curative,  since  every  measure  which  promotes  a  healthy  parentage  and  the 
health  and  robustness  of  the  infant  tends  to  diminish  the  frequency  of  this 
disease.  Those  who,  like  Porak,  believe  that  congestion  of  the  skin  at  birth 
is  a  common  cause  of  the  simple  form  of  jaundice  recommend  an  early  ligature 
of  the  cord,  when  the  umbilical  arteries  are  still  beating  or  have  just  ceased 
to  beat,  since  when  the  arteries  are  beating  an  equilibrium  is  maintained  in 
the  circulation,  whereas  in  a  late  ligature,  when  the  uterus  is  firmly  con- 
tracted and  the  arteries  have  for  some  time  ceased  to  beat,  a  plethoric  state 
of  the  vessels  is  more  likely  to  occur. 

Sepsis  of  the  New-born.^ 

The  manner  in  which  sepsis  or  septicaemia  occurs  is  sometimes  obscure. 
Leube  in  1878  relates  two  cases ^  in  which  the  examination  failed  to  disclose 
the  source  or  mode  of  infection.  He  designates  such  cases  cryptogenetic, 
expressive  of  the  unknown  or  occult  origin.  Wunderlich  and  Schiitzenberger 
allude  to  similar  cases.  But  in  sepsis  of  the  newly-born  it  is  the  common 
and  apparently  correct  belief  that  the  poison  of  sepsis  usually  enters  the 
system  at  the  umbilicus.  The  cases  which  I  am  about  to  relate  are  in  har- 
mony with  this  theory. 

It  is  not  my  intention  to  discuss  the  nature  of  the  septic  poison,  but  there 
can  be  little  doubt,  from  the  examinations  which  were  made,  that  in  the  fol- 
lowing cases  it  consisted  of  microbes  and  the  ptomaines  or  chemical  agents 
produced  by  microbic  action. 

Cases  of  sepsis  of  the  newly-born  may  be  conveniently  classified  as 
follows : 

First  Group. —  Cases  of  umbilical  pldegmon^  which  is  a  local  sepsis,  the 
poison  entering  the  system  from  an  wmhilical  sore,  and  being  conveyed  by  the 
lymphatics. 

The  New  York  Infant  Asylum  at  Sixty-first  street  and  Tenth  avenue  has, 
during  the  twenty-three  years  of  its  existence,  been  remarkably  free  from 

'  Read  before  the  Psediatric  Section  of  the  New  York  Academy  of  Medicine,  Medi- 
cal News,  Sept.  8,  1888. 

^  Deutsch.  Archiv  fur  klin.  Med. 


SEPSIS  OF  THE  NEW-BORN.  137 

contagious  and  infectious  diseases,  but  since  September  1,  1887,  seven  cases, 
in  which  either  local  or  systemic  sepsis  was  diagnosticated,  occurred  in  new- 
born infants  in  the  maternity  ward  of  this  institution.  It  is  proper  to  state 
that  at  the  same  time  diphtheria  was  epidemic  in  the  asylum,  and  that  five 
of  the  newly-born  infants  had  diphtheria,  the  pseudo-membrane  appearing  in 
its  usual  situation  on  the  pharyngeal,  nasal,  and  laryngo-tracheal  surfaces, 
and,  in  one  or  two  of  the  patients,  also  lining  the  oesophagus.  Moreover, 
two  of  the  five  infants  with  diphtheria  had  umbilical  phlegmon  of  a  few 
days'  duration  when  the  diphtheritic  exudate  appeared  upon  the  faucial 
surface. 

The  question  is  therefore  a  proper  one,  whether  in  these  two  cases  the 
phlegmons  were  a  local  manifestation  of  diphtheria,  or  whether  the  umbili- 
cal phlegmon  and  diphtheria  were  distinct  diseases  having  a  difi'erent  microbic 
origin. 

Case  1. — Victor  M was  born,  after  normal  labor,  on  January,  5,  1888,  and 

the  umbilicus  was  dressed  with  borated  cotton.  The  mother  did  well,  and  was 
able  to  leave  her  bed  on  the  seventh  or  eighth  day.  Nothing  unusual  was  noticed 
in  the  infant  until  January  11th,  when  a  little  suppuration  was  observed  in  the 
umbilical  fossa  at  or  around  the  point  of  attachment  of  the  cord,  and  on  exami- 
nation the  walls  of  the  umbilicus  were  found  thickened  and  indurated.  The 
appearance  indicated  the  commencement  of  an  umbilical  phlegmon,  and  the  skin 
covering  it  was  red  as  in  erysipelas.  The  phlegmon  extended  in  area  until  Jan- 
uary 14th,  when  the  thickening  and  infiltration  reached  to  the  distance  of  about 
one' and  a  half  inches  in  every  direction  from  the  umbilicus,  so  that  the  form  of 
the  phlegmon  was  circular  or  wheel-shape.  Its  thickness  or  depth  near  the 
umbilicus  was  perhaps  three-fourths  of  an  inch,  but  near  its  margin  the  thicken- 
ing and  infiltration  were  less.  The  pulse  on  the  13th  varied  from  132  to  144,  and 
the  rectal  temperature  was  101.8°. 

The  case  was  carefully  watched  by  Drs.  Davis  and  Cook,  the  resident  physi- 
cians, whose  records  I  employ,  and  the  faucial  surface  was  daily  inspected  by 
them.  On  January  14th,  the  baby  being  nine  days  old,  they  observed  for  the 
first  time  the  grayish-white  exudate  of  diphtheria  on  each  side  of  the  fauces,  and 
a  day  or  two  later  also  upon  the  Schneiderian  surface,  so  closing  the  nostrils  that 
respiration  through  them  was  impossible.  The  baby,  on  attempting  to  draw  the 
nipple,  became  cyanotic  and  was  obliged  to  relinquish  its  hold.  During  the  14th 
and  loth  the  temperature  fell  to  98.5°  and  98°,  the  pulse  was  very  feeble  and  too 
rapid  to  be  counted  accurately,  and  the  respiration  varied  from  24  to  48.  Death, 
occurred  on  the  15th  at  the  age  of  ten  days. 

The  autopsy  revealed  a  diphtheritic  pseudo-membrane  upon  the  faucial  sur- 
face on  both  sides,  extending  downward,  so  as  to  cover  both  surfaces  of  the 
epiglottis,  the  entrance  of  the  larynx,  and  the  laryngeal  surface,  completely  con- 
cealing the  vocal  cords  and  the  portion  of  the  larynx  above  them.  The  trachea 
and  bronchial  tubes  were  free  from  the  exudate.  The  lungs  in  nearly  every  part 
were  thickly  mottled  with  points  of  extravasated  blood,  and  less  abundant  extrav- 
asations were  observed  in  and  upon  other  organs.  The  umbilical  phlegmon, 
removed  entire,  and  in  a  frozen  state  from  the  intensity  of  the  cold  in  the  dead- 
house,  was  sent  to  the  laboratory  of  the  College  of  Physicians  and  Surgeons, 
where  it  was  carefully  examined  by  Dr.  Prudden.  He  reports  that  the  umbilical 
vessels  were  in  their  normal  state,  showing  no  evidence  of  disease,  except  the 
mouth  of  the  umbilical  vein  or  that  portion  of  the  vein  which  was  next  to  and 
in  immediate  relation  with  the  umbilicus.  Plugging  the  mouth  of  the  vein  and 
extending  a  few  lines  along  the  lumen  of  this  vessel  was  a  thrombus  or  blood- 
clot,  from  which  Dr.  Prudden  was  able  to  obtain  cultures,  and  in  the  culture-bed 
two  forms  of  cocci  were  developed — to  wit,  the  staphylococcus  pyogenes  aureus, 
occurring  in  the  usual  form  in  groups,  and  the  streptococcus  pyogenes,  producing 
beautiful  and  delicate  chains.  The  portion  of  the  vein  enclosing  the  thrombus 
or  clot  had  preserved  its  integrity,  so  that  the  clot  was  entirely  distinct  from  the 
phlegmon  which  covered  the  vein.  It  did  not  seem  possible  that  microbes, 
ptomaines,  or  elements  of  the  blood  could  pass  from  one  to  the  other,  on  account 
of  the  firm  coats  of  the  vein  which  were  interposed  between  them. 


138  DISEASES  OF  THE  NEW-BOBN. 

Portions  of  the  phlegmon  placed  in  culture  media  developed  the  same  forms 
of  cocci  as  those  produced  from  the  clot  that  plugged  the  mouth  of  the  vein. 
We  infer  that  the  cocci  were  the  septic  agents,  since  no  other  cause  of  the  sepsis 
was  discovered,  and  that  they  were  received  from  the  umbilical  sore.  Some 
entered  the  thrombus,  and  others,  taken  up  by  lymphatics,  entered  the  tissues 
which  surrounded  the  umbilicus  and  gave  rise  to  the  phlegmonous  inflammation. 

It  is  easy  to  understand  how  micro-organisms  may  enter  the  umbilical 
vein  after  the  fall  of  the  cord,  when  there  may  not  be  complete  closure  of 
the  mouth  of  the  vessel.  But  it  can  scarcely  be  doubted  that  in  the  above 
case,  as  well  as  in  cases  which  I  am  about  to  relate,  the  septic  infection  took 
place  through  the  raw  and  denuded  surface  of  the  umbilical  fossa,  the  lym- 
phatics being  the  carriers  of  the  poison.  We  know  how  frequently  granu- 
lations sprout  out  from  the  umbilicus  of  the  new-born,  and  wherever  there  is 
a  surface  denuded  of  cuticle  from  which  these  may  arise  there  is  a  surface 
from  which  microbes  or  toxic  agents  may  be  absorbed.  The  umbilicus,  too, 
is  a  receptacle  in  which  microbes,  conveyed  in  the  floating  dust  of  an  apart- 
ment, in  foul  water  used  for  bathing,  in  dirty  sponges,  or  abdominal  binders 
or  umbilical  dressings,  would  be  likely  to  lodge.  M.  Bouchut,  in  his  remarks 
on  the  fall  of  the  umbilical  cord,  says :  ''  Cords  voluminous,  soft  and  plump, 
dry  slowly  and  often  suppurate  at  their  base  before  they  fall  (les  cordons 
volumineux,  mous  at  gras,  se  dessechent  lentement  et  suppurent  souvent 
a  leur  base  avant  de  tomber)."^  With  conditions  so  favorable  for  septic 
infection  it  is  perhaps  surprising  that  it  does  not  more  frequently  occur, 
especially  in  hospital  or  asylum   wards. 

The  patient  whose  case  I  have  related  evidently  had  systemic  infection 
in  addition  to  the  local  septic  infection  in  the  phlegmon.  The  numerous 
points  of  extravasated  blood  in  the  lungs  and  elsewhere  showed  this.  But 
doubt  must  arise  whether  this  general  infection  occurred  from  the  phlegmon, 
in  which  there  was  intense  hyperaemia  and  an  active  circulation,  as  shown  by 
the  inflammatory  redness  of  the  cuticle,  or  whether  it  resulted  from  and  was 
connected  with  the  diphtheria.  But  we  will  relate  cases  of  systemic  infec- 
tion in  which  there  was  no  diphtheria  and  in  which  the  septic  agent  or  agents 
entered  the  system  through  the  umbilicus. 

The  volume  of  the  Transactions  of  the  London  Pathological  Society  for 
18*79  contains  an  able  and  elaborate  report  of  the  committee  appointed  by 
that  society  to  investigate  pyaemia,  septicaemia,  and  purulent  infection. 
Their  report  is  based  on  the  examination  of  the  records  of  156  cases  occur- 
ring in  the  London  hospitals,  and  it  throws  light  on  the  cause  of  hemorrhagic 
extravasations  occurring  in  cases  of  septic  infection  of  the  system.  They 
remark  :  "  On  microscopical  examination  of  difiierent  organs,  micrococci  were 
found  in  all,  or  at  least  in  some,  of  the  viscera.  They  were  nearly  all  in  the 
blood-vessels,  completely  plugging  the  capillaries  ;  in  masses  which  sometimes 
produced  varicosities,  or  even  rupture  of  the  vessels,  and  extended  into  the 
contiguous  tissues."^ 

Case  2. — Hilda  M ,  born  February  28, 1888,  was  plump  and  robust,  weigh- 
ing eight  pounds  and  seven  ounces.  The  mother  appeared  to  be  well  until  March 
Sd,  when  she  had  fever  and  symptoms  which  were  apparently  due  to  pelvic  cel- 
lulitis, probably  of  septic  origin.  The  infant  was  fretful  on  March  3d  and  4th, 
and  on  March  5th  a  small  ulcer  was  observed  in  the  umbilical  fossa.  The  skin 
surrounding  the  umbilicus,  over  an  area  the  size  of  a  silver  dollar,  had  a  deep- 
red  color,  and  the  tissues  underneath,  constituting  the  abdominal  walls,  were 
infiltrated  and  thickened.  The  phlegmon  gradually  extended  in  every  direc- 
tion from  the  umbilicus,  so  that  on  March  6th  it  nearly  reached  the  ensiform 
cartilage  above  and  the  pelvis  below.     The  fauces  had  been  inspected  daily,  and 

^  Traite  pratique  dei^  Maladies  des  Nouveau-nes,  etc. 
2  Brit.  Med.  Jour.,  January  24,  1880. 


SEPSIS  OF  THE  NEW-BORN.  139 

at  5  P.  M.,  March  6th,  the  grayish-white  exudate  of  diphtheria  was  observed 
for  the  first  time,  covering  the  tonsillar  portion  of  the  fauces  on  each  side.  On 
Marcii  7th  tlie  exudate  had  increased,  the  cry  was  hoarse,  the  fingers  livid  at 
times,  and  fluid  regurgitated  through  the  nostrils.  The  phlegmon  occupied 
nearly  the  entire  abdominal  walls  anteriorly.  March  8th,  surface  cyanotic;  res- 
piratii)n  labored,  and  at  times  accompanied  by  the  expiratory  moan;  a  diphthe- 
ritic pseudo-membrane  in  the  right  nostril.  Death  occurred  at  6.30  A.  M.,  March 
Dth,  at  the  age  of  ten  days,  on  the  fourth  or  fifth  day  of  the  phlegmon  and  on  the 
third  day  of  the  dii)htheritic  exudate  upon  the  fauces.  The  rectal  temjjerature 
varied  from  99.8°  to  102.8°  until  the  last  day,  when  it  was  subnormal,  being 
966°;  the  pulse  varied  from  99  to  112,  and  the  respiration  from  40  to  60.  Both 
the  pulse  and  respiration  gradually  increased  in  frequency  until  death,  this 
increase  being  probably  largely  due  to  the  double  pneumonia.  The  tincture 
of  the  chloride  of  iron  in  glycerin,  brandy,  and  breast-milk  were  given  inter- 
nally, iodoform  and  carbolized  oil  applied  to  the  umbilicus,  and  antiseptic  sprays 
employed  for  the  fauces  and  nostrils. 

Prof  T.  M.  Prudden  kindly  consented  to  conduct  the  autopsy,  which  was 
made  with  sterilized  instruments  and  under  conditions  designed  to  prevent 
access  to  the  body  of  adventitious  germs.     The  following  are  his  notes: 

Autopsy. — The  umbilical  orifice  was  covered  by  a  dry,  brownish  scab,  beneath 
which  was  a  small,  rough-edged  cavity  containing  a  yellowish  semi-solid  mass. 
The  abdominal  wall,  for  about  three  centimetres  around  the  umbilicus  on  all 
sides,  was  hard,  thickened,  and  dusky  red.  A  section  through  the  abdominal 
wall  in  the  line  of  the  umbilicus  showed  that  the  wall  was  thickened  to  about 
1.5  centimetres  immediately  around  the  latter. 

Both  the  umbilical  vein  and  the  hypogastric  arteries,  to  the  distance  of  about 
1.3  centimetres  from  their  attachment  to  the  abdominal  wall,  were  much  thick- 
ened, red  and  hard,  and  their  inner  layers  were  converted  into  a  soft,  yellowish, 
friable  material.  Beyond  this  point  all  of  these  vessels  were  filled  with  blood- 
clots  and  appeared  healthy.  There  was  no  peritonitis,  and  all  of  the  abdominal 
organs  were  normal. 

The  heart  was  normal.  The  pharynx,  larynx,  and  trachea  showed  soft,  red- 
dish friable  patches  of  diphtheritic  membrane  partially  covering  their  free  sur- 
faces. This  membi'ane  did  not  extend  into  the  bronchi.  The  lungs  exhibited 
broncho-pneumonia  in  both  lower  lobes,  with  considerable  consolidation. 

The  microscopical  examination  of  the  parts  about  the  umbilicus  showed  that 
at  the  point  of  attachment  of  the  cord  was  a  small  pus-cavity  whose  walls  were 
infiltrated  with  small  spheroidal  cells,  with  a  few  rod-like  bacteria  and  with  large 
numbers  of  spheroidal  bacteria.  Similar  spheroidal  bacteria  were  found  in  the 
purulent  detritus  contained  in  the  cavity  as  well  as  within  the  lumina,  and  infil- 
trating the  walls  of  the  adjacent  ends  of  the  umbilical  vein  and  the  hypogastric 
arteries. 

The  tissues  of  the  abdominal  walls  about  the  umbilicus  were  infiltrated  with 
serum,  fibrin,  and  a  moderate  amount  of  pus.  Spheroidal  bacteria  were  rather 
scantily  scattered  in  the  lymph-spaces  of  the  swollen  tissues,  being  most  abun- 
dant near  the  umbilical  vessels. 

Biological  examination  of  the  contents  of  the  inflamed  portion  of  the  umbili- 
cal vessel  showed  the  presence  of  several  species  of  bacteria.  The  species  which 
was  by  far  the  most  abundant  was  readily  identified  as  the  staphylococcus  pyo- 
genes aureus. 

The  anatomical  diagnosis,  then,  is  diphtheria  of  the  pharynx,  larynx,  and 
trachea,  with  double  broncho-pneumonia,  localized  septic  inflammation  of  the 
umbilical  vein  and  hypogastric  arteries  and  of  the  abdominal  wall  surrounding 
them. 

As  the  evidence  of  local  infection  is  so  great,  it  seemed  desirable  to  gain  some 
■data  as  to  the  purity  of  the  air  in  the  wards.  Accordingly,  such  analyses  as  time 
permitted  were  made  by  Dr.  T.  M.  Cheeseman,  Jr.,  who  presented  the  following 
report:  "  A  biological  examination  of  the  air  in  the  lying-in  ward  of  the  New 
York  Infant  Asylum,  made  on  March  7,  1888,  showed  a  very  large  number  of 
living  bacteria  of  many  different  kinds.  Among  them  the  staphylococcus  pyo- 
genes aureus  was  of  frequent  occurrence.  A  second  examination,  made  imme- 
diately after  the  usual  sulphur  disinfection,  showed  a  large  number  of  living 
germs." 


140  DISEASES  OF  THE  NEW-BOBN. 

Case  3. — Janse  J ,  born  January  3,  1 888,  was  wet-nursed  by  its  mother,. 

and  apparently  did  well  until  January  16th,  when  the  attention  of  the  resident 
physician  was  directed  to  it,  and  an  umbilical  phlegmon  was  discovered  as  large 
as  a  twenty -five  cent  piece,  the  skin  covering  it  being  intensely  red ;  temperature 
98.5°.  The  dressing,  after  the  discovery  of  the  phlegmon,  consisted  in  dusting 
with  iodoform  and  the  application  of  carbolized  oil  (one  part  of  carbolic  acid  to 
twenty-five  of  sweet  oil).  January  17th,  phlegmon  not  extending  and  its  surface 
less  red.  The  redness,  thickening,  and  infiltration  gradually  abated,  and  on  Jan- 
uary 21st  the  patient  was  removed  from  quarantine.  In  this  case  there  was  no 
record  of  an  umbilical  sore ;  the  fauces  remained  normal,  so  that  the  diagnosis 
of  diphtheria  was  excluded.     The  mother  continued  well. 

Case  4. — George  C was  born  in  the  maternity  ward  January  14th.     On 

January  25th  the  nurse  observed  a  small  vesicle  upon  the  border  of  the  umbili- 
cus, and  removed  the  cuticle  covering  it.  Some  hours  afterward  the  attention 
of  the  resident  physician,  Dr.  Davis,  was  called  to  it,  who  found  thickening  and 
infiltration  of  the  umbilical  wall,  most  marked  on  the  side  which  had  been 
occupied  by  the  vesicle.  The  same  treatment  was  employed  as  in  Case  3.  The 
records  of  January  26th  and  27th  state  that  the  redness  and  infiltration  are  abat- 
ing, and  on  the  29th  the  umbilicus  had  returned  to  the  normal  state. 

Case  5. — John  S ,  born  October  14,  1887,  the  mother  being  a  healthy 

primipara.  The  child  was  well  developed  at  birth,  weighing  nine  pounds  and 
four  ounces.  The  cord  fell  on  the  sixth  day,  and  a  small  ulcer  with  indurated 
edges  was  observed  in  the  umbilical  fossa  at  the  point  of  attachment  of  the  cord. 
The  induration  in  and  around  the  umbilicus  increased  slowly  until  the  ninth 
day.  On  the  ninth  day  the  child  was  restless,  and  on  examination  the  ulcer  was. 
found  enlarged  and  surrounded  by  a  zone  of  inflamed  tissue  half  an  inch  in 
width.  The  inflammation,  accompanied  by  the  usual  infiltration  and  swelling,, 
gradually  extended,  so  that  on  the  15th  the  diameter  of  the  inflamed  area  was 
two  inches.  The  ulcer  had  also  increased.  On  the  twentieth  day  after  birth  the 
ulcer  had  attained  the  diameter  of  two  inches  and  the  depth  of  three-eighths  of 
an  inch,  but  the  induration  had  begun  to  abate.  From  this  time  improvement 
was  progressive,  and  no  notes  were  taken  after  the  twenty-fourth  day.  The  rectal 
temperature,  ascertained  each  day  from  the  ninth  to  the  twenty -fourth  day,  varied 
from  the  normal  to  102°.  During  the  active  period  of  the  phlegmon  it  was 
usually  from  100°  to  101.5°,  and  the  emaciation  was  progressive,  the  loss  of 
weight  being  estimated  at  two  pounds.  The  treatment  consisted  in  dusting  with 
iodoform  and  the  use  of  a  compress  of  absorbent  cotton  soaked  with  a  solution 
of  carbolic  acid.  During  the  second  week,  under  the  advice  of  the  attending 
physician.  Dr.  George  B.  Fowler,  calomel  was  also  dusted  on  the  sore.  On  the 
twenty-fourth  day  the  infant  was  removed  to  the  Post-Graduate  School,  and  its 
subsequent  history  is  unknown.     The  mother  had  no  unfavorable  symptom. 

Case  6. — Joseph  D ,  born  October  22,  1887,  well  developed,  weighing 

seven  pounds  thirteen  ounces.  The  cord  fell  on  the  eighth  day,  leaving  a  small 
ulcer  at  its  point  of  attachment  with  an  indurated  border.  Two  days  later,  the 
tenth  day  after  birth,  the  ulcer  had  increased  slightly,  being  one-quarter  of  an 
inch  in  diameter.  The  surrounding  tissues  to  the  distance  of  one  inch  were 
thickened  and  indurated  from  inflammation.  At  no  time  was  the  temperature 
above  99.1°,  and  the  child,  though  restless,  nursed  well.  The  tumefaction  and 
hardness  surrounding  the  umbilicus  remained  about  the  same  until  the  sixteenth 
day,  after  which  they  gradually  abated.  The  ulcer  had  healed  at  the  end  of  the 
fourth  week.  The  mother  on  the  third  day  after  confinement  had  elevation  of 
temperature  which  continued  four  days ;  and  six  weeks  after  the  birth  of  the 
child  she  had  diphtheria  in  the  usual  form.  During  the  same  month — October — 
twenty-seven  obstetrical  cases  were  under  observation,  but  all  except  this  patient 
convalesced  without  any  unfavorable  symptom. 

Second   Group. —  Cases  in  which  the  septic  poison  prohahly  entered  the 
system  throiigh  the  umbilical  vein. 

Case  1. — In  May,  1884,  an  infant  died  of  sepsis  at  the  New  York  Infant 
Asylum  at  the  age  of  fifteen  days.  It  was  apparently  well  until  about  the  close 
of  the  first  week,  when  the  umbilicus  was  observed  to  be  raw,  and  a  slight  oozing 
of  a  purifoi;m  liquid  occurred  from  it.    During  the  second  week  the  abdomen  was 


SEPSIS  OF  THE  NEW-BORN.  141 

hard  and  tender,  and  peritonitis  was  diagnosticated.  The  cord  fell  on  the  seventh 
day.  During  the  second  week  the  abdomen  was  apparently  painful ;  the  tem- 
perature three  days  before  death  was  100.6°,  and  two  days  before  death  102.4°. 
Examination  of  the  chest  gave  a  negative  result.  The  post-mortem  examination 
was  made  by  Dr.  W.  H.  Welch,  now  professor  of  pathology  in  Johns  Hopkins 
University.  The  abdomen  contained  six  ounces  of  turbid  serum  with  flakes  of 
tibrin.  The  portion  of  the  peritoneum  covering  the  umbilical  vein  and  along  the 
under  surface  of  the  liver,  especially  at  the  transverse  fissure,  was  covered  with 
fibrin,  but  the  jjeritoneum  generally  did  not  exhibit  any  notable  hypersemic  or 
inflammatory  appearance.  Lymphatic  vessels  filled  with  purulent-appearing 
sub.stance  could  be  seen  in  the  under  surface  of  the  diaphragm,  showing  in  what 
way  septic  infection  extends  along  the  lymphatics.  The  lymphatics  of  the  dia- 
j)liragm  open  upon  the  pleural  surface,  and  it  is  probable,  had  the  patient  lived 
longer,  that  septic  pleuritis,  perhaps  on  both  sides,  would  have  occurred.  The 
umbilical  vein  was  filled  from  the  umbilicus  to  the  transverse  fissure  of  the  liver 
with  a  grayish  softened  detritus  consisting  of  broken-down  thrombi  with  a  con- 
siderable proportion  of  pus.  Softened  thrombi  could  be  traced  the  entire  length 
of  the  umbilical  vein,  the  walls  of  which  were  thickened  and  infiltrated  from 
inflammation.  No  thrombi  were  seen  in  the  portal  vein  or  vena  cava  ;  the  peri- 
cardium contained  more  than  the  normal  amount  of  serum  with  flakes  of  fibrin ; 
hemorrhagic  points  were  observed  in  the  posterior  portions  of  the  lungs  under 
the  endocardial  surface,  under  the  peritoneal  coverings  of  the  kidneys  and  mucous 
covering  of  their  calices.  The  mother  did  well,  giving  no  evidence  of  disease  of 
any  kind. 

'  Case  2. — This  infant,  born  in  the  New  York  Infant  Asylum,  the  date  not 
being  given,  was  well  developed  at  birth,  weighing  eight  pounds  six  ounces. 
When  four  or  five  days  old  it  became  feverish,  the  temperature  rising  to  104.6°. 
The  cord  separated  at  the  usual  time,  and  the  umbilicus  seemed  healthy.  At 
the  age  of  two  weeks  an  abscess  appeared  upon  the  scalp,  another  upon  the  back, 
and  another  upon  the  nates,  which  raised  the  suspicion  of  septic  poisoning.  At 
the  age  of  four  weeks  orchitis  on  one  side  occurred,  which  continued  three  weeks, 
when  it  abated.  When  the  child  was  two  months  old  a  prominence  appeared 
about  half  an  inch  above  the  umbilicus,  which  Dr.  Parker,  the  resident  physician, 
punctured,  and  bile  flowed  from  the  incision.  Subsequently  the  incision  closed, 
and  bile  flowed  from  the  umbilicus,  and  continued  to  flow  until  death,  which 
occurred,  in  a  state  of  much  emaciation  and  weakness,  at  the  age  of  eight 
months. 

At  the  autopsy,  made  by  Prof.  Welch,  remains  of  old  abscesses  were  found 
upon  the  trunk  and  extremities,  and  an  abscess  holding  four  drachms  of  pus  was 
found  over  the  occipital  bone.  Underneath  the  abscess  the  bone  was  carious 
and  the  dura  mater  thickened.  The  umbilical  vein  was  much  larger  than  nor- 
mal, its  walls  being  infiltrated  and  thickened,  and  its  lumen  of  about  twice  its 
usual  diameter.  It  contained  thickened  bile.  One  of  the  branches  of  the  vein, 
traced  into  the  liver,  opened  into  an  abscess  the  size  of  a  walnut,  which  contained 
thickened  pus  with  bile.  The  abscess  was  in  the  right  lobe  near  its  posterior 
border.     The  mother  remained  well. 

Case  3. — Lizzie  C ,  born  September   21,  1887,  robust,   weighing  eight 

pounds,  seemed  well,  taking  the  breast  and  having  normal  evacuations,  until 
Sei^tember  28th,  when  she  became  restless  and  refused  the  breast.  Her  tempera- 
ture, rectal,  was  101.4°,  and  her  respiration  was  accelerated  and  accompanied  by 
the  expiratory  moan.  September  20th,  temperature  103.6°  ;  respiration  acceler- 
ated and  painful  and  abdomen  distended ;  no  cough.  The  diagnosis  of  perito- 
nitis, probably  of  septic  origin,  was  made,  but  the  umbilicus  was  of  usual 
appearance,  and  the  desiccation  and  fall  of  the  cord  seemed  normal.  The  ele- 
vation of  temperature,  even  to  104.4°,  the  distension  of  abdomen,  and  the  hurried 
respiration  with  expiratory  moan  continued  until  death,  which  occurred  Sep- 
tember 30th. 

At  the  autopsy  three  ounces  of  sero-purulent  liquid  containing  flakes  of  fibrin 
escaped  from  the  peritoneal  cavity.  All  the  abdominal  organs  were  covered  by 
a  fibrinous  exudation,  the  intestines  being  matted  together  by  it.  The  umbilical 
vein  was  pervious;  it  contained  clots  of  blood  and  dirty-looking  pus,  but  the 
umbilicus  was  apparently  normal.  A  segment  of  the  aortic  valve  was  thickened 
and  rigid,  and  attached  to  it  was  a  fibrinous  mass.     The  appearance  indicated  an 


142  BISEASES  OF  THE  NEW-BORN. 

endocarditis  of  slight  extent.  Under  the  microscope  the  walls  of  the  umbilical 
vein  presented  their  normal  appearance,  but  its  dirty-looking  and  disintegrating 
contents  probably  contained  septic  matter.  The  hepatic  cells  exhibited  the 
peculiar  cloudiness  observed  in  protracted  febrile  diseases.  Otherwise  the  organs 
seemed  healthy.     In  this  case  also  the  mother  remained  well. 

Case  4. — A.  B ,  born  January  22,   1868  ;    father  healthy,  but  mother 

strumous,  though  in  good  health  during  her  gestation.  The  infant,  born  after 
an  easy  labor,  was  apparently  well  at  birth  and  it  had  sufficient  breast-milk. 
When  it  was  thirteen  days  old  I  was  requested  to  visit  it,  as  it  had  not  been  doing 
well,  and  I  found  it  suffering  from  subcutaneous  abscesses.  Abscesses  had 
occurred  upon  both  legs,  in  the  chest-walls  of  the  right  mammary  region,  in  and 
around  the  metatarso-phalangeal  articulations  of  one  foot,  and  over  both  knee- 
joints.  The  child  had  fever,  but  its  respiration  was  good  until  February  8th, 
when  it  suddenly  had  a  severe  attack  of  dyspnoea,  which  continued  until  death, 
ten  hours  subsequently.  On  the  following  day  Dr.  Charles  A.  Leale  and  myself 
made  the  autopsy.  The  body  was  moderately  emaciated.  About  one  ounce  of 
pus  escaped  from  the  right  knee-joint.  Pus  was  also  found  in  the  joint  of  t-he 
great  toe  on  one  side,  and  about  two  ounces  in  an  abscess  under  the  right  pectoral 
muscle.  A  thin  layer  of  tissue  constituted  the  internal  wall  of  the  abscess,  so 
that  had  life  been  prolonged  a  few  days  it  would  probably  have  broken  through 
into  the  pleural  cavity.  The  right  lung  was  completely  collapsed,  and  the  pleura 
lining  this  lung,  as  well  as  that  lining  the  thoracic  walls  on  the  same  side,  was 
covered  by  a  fibrinous  exudation.  The  left  lung  contained  the  normal,  or  per- 
haps more  than  normal,  amount  of  air,  so  that  it  filled  the  pleural  cavity,  but  there 
was  a  small  amount  of  fibrinous  exudate  upon  the  parietal  pleura  in  this  cavity. 

The  trachea  and  lungs  attached  were  removed,  and  on  practising  insufflation 
of  these  organs,  air  escaped  from  three  openings  in  the  posterior  part  of  the  right 
lung.  These  openings,  through  which  air  had  passed  into  the  pleural  cavity,  caus- 
ing collapse  of  the  entire  lung,  were  found  on  examination  to  have  been  produced 
by  small  abscesses  in  the  tissue  of  the  lung  near  its  posterior  surface.  By  the  rup- 
ture of  these  abscesses  the  pus  which  they  contained  escaped  into  the  pleural  cav- 
ity, producing  intense  general  pleuritis  and  pneumothorax.  Numerous  minute 
abscesses  were  found  in  both  lungs,  but  only  the  three  alluded  to  had  been  rup- 
tured. It  seemed  certain  that  had  the  patient  lived  longer  other  abscesses  would 
have  ruptured. 

Case  5. — In  the  following  case  bacteria  were  found  making  their  way  along 
the  umbilical  vein  at  a  distance  from  the  umbilicus,  and  also  in  the  tissues 
involved  in  the  umbilical  phlegmon.  Those  in  the  phlegmon  were  apparently 
derived  from  the  umbilicus  and  conveyed  by  the  lymphatics.  This  case,  there- 
fore, might  be  placed  in  the  first  group  as  well  as  the  second : 

Anne was  born  in  the  New  York  Foundling  Asylum  on  May  18,  1888. 

A  few  days  after  birth,  and  before  the  cord  dropped,  the  umbilicus  was  observed 
to  be  foul  from  secretion  or  exudation  in  it,  indicating  a  sore  at  the  base  of  the 
fossa.  On  the  seventh  day  an  umbilical  phlegmon  was  noticed,  small  and  con- 
fined to  the  umbilical  walls.  Three  white  patches  were  also  observed  on  the  roof 
of  the  palate  near  the  velum,  not  raised  and  apparently  not  diphtheritic,  resem- 
bling superficial  ulcers.  All  the  infants  born  in  the  maternity  ward  of  the  Found- 
ling Asylum  receive  Crede's  treatment,  designed  to  prevent  purulent  conjunctiv- 
itis, one  drop  of  a  2  per  cent,  solution  of  nitrate  of  silver  being  instilled  between 
the  eyelids  of  each  eye.  Although  this  child  was  thus  treated,  she  had  a  pretty 
active  purulent  conjunctivitis  of  the  left  eye,  to  which  our  attention  was  now 
called  for  the  first  time  on  the  seventh  day.  Crede's  treatment  was  immediately 
reapplied  to  this  eye,  one  drop  being  introduced  between  the  lids.  This  was  fol- 
lowed by  the  corrosive-sublimate  treatment  recommended  by  the  late  Prof.  Sam- 
uel D.  Gross.  A  solution  of  the  sublimate,  two  grains  to  the  pint,  was  dropped 
between  the  lids  every  hour  to  two  or  three  hours,  four  or  five  drops  being  used 
each  time.  The  conjunctivitis  rapidly  abated,  and  in  less  than  a  week  had  nearly 
or  quite  disappeared.  But  the  phlegmon  presented  -a  very  angry  appearance,  and 
the  umbilical  walls  were  greatly  swollen,  red,  and  denuded  of  cuticle.  The 
inflamed  area  had  a  diameter  of  about  four  inches,  with  the  umbilicus  at  the 
centre.  Iodoform  and  carbolized  oil  were  applied  to  the  umbilicus  and  iron  and 
stimulants  given  internally.  The  rectal  temperature,  taken  May  26th,  was  98°. 
Death  occurred  May  27th. 


SEPSIS  OF  THE  NEW-BORN.  143 

Anfopny,  by  Dr.  W.  P.  Northrup,  curator,  thirteen  hours  after  death. — Body- 
well  nourished;  no  rigor  mortis;  no  external  lesion  except  the  umbilical ;  the 
jililcamoii  definitely  outlined  and  hard,  its  central  half  brown  and  dry;  the  infil- 
trated aljdominal  wall  had  twice  its  normal  thickness ;  peritoneal  surface  of  phleg- 
mon congested  and  adherent  to  omentum  ;  from  this  point  to  the  transverse  colon 
was  a  leash  of  dilated  vessels,  one  inch  in  width  and  three  or  four  inches  in 
length ;  peritoneum  injected,  and  a  few  petecliije  observed  in  the  parietal  layer 
and  the  mesentery  ;  mesentery  deeply  injected ;  liver  and  spleen  normal ;  kid- 
neys soft  and  flabby ;  points  of  hemorrhagic  pneumonia  in  all  the  pulmonary 
lobes;  abundant  tenacious  mucus  covering  the  surface  of  the  stomach  and  intense 
injection,  showing  acute  gastritis;  cerebral  pia  mater  finely  injected,  but  without 
exudation ;  brain  normal.  Diagnosis :  umbilical  phlegmon,  peritonitis,  acute 
gastritis,  hemorrhagic  pneumonia. 

Microncnpical  and  Biological  Examination,  by  Prof.  Prudden  at  the  Laboratory 
of  the  College  of  Physicians  and  Surgeons. — The  small  ragged  cavity  at  the 
umbilicus  contained  a  moderate  amount  of  pus,  cell-detritus,  and  enormous  num- 
bers of  bacteria  of  various  forms,  the  spheroidal  form  predominating.  The  tis- 
sues of  the  abdominal  wall  about  the  umbilicus  were  infiltrated  with  fluid,  fibrin, 
and  pus;  scattered  about  in  this  exudation-mass  were  small  spheroidal  bacteria. 
The  hypogastric  arteries  and  the  umbilical  vein  were  plugged  with  clots  extend- 
ing from  one-half  to  three-quarters  of  an  inch  from  their  origin;  their  walls  were 
greatly  thickened  by  infiltration  with  inflammatory  exudate.  Both  in  the  lumina 
of  these  vessels,  along  the  sides  of  the  clots,  and  in  the  lymph-spaces  in  their 
walls  were  enormous  numbers  of  small  spheroidal  bacteria.  These  bacteria  were 
present  in  the  umbilical  vein  beyond  the  limits  of  the  clots  in  the  direction  of 
the  liver. 

The  kidneys  showed  moderate  parenchymatous  degeneration.  The  consoli- 
dated areas  in  the  lungs  were  due  to  a  nearly  complete  filling  of  the  air-spaces 
and  the  smaller  bronchi  with  blood. 

Cultures  made  from  the  inflamed  tissue  about  the  umbilicus  and  from  the 
edges  of  the  sloughing  cavity  showed  several  species  of  bacteria  common  in  the 
air  and  in  the  feces  of  children.  In  addition  to  these  the  staphylococcus  py- 
ogenes aureus  was  present  in  large  numbers.  A  set  of  cultures  from  the  inside 
of  the  umbilical  vein,  at  a  little  distance  from  the  sloughing  cavity,  revealed  the 
presence  of  staphylococcus  pyogenes  aureus  and  streptococcus  pyogenes,  together 
with  other  forms.  Cultures  from  the  liver  showed  large  numbers  of  staphylo- 
coccus pyogenes  aureus,  with  considerable  numbers  of  a  stout  bacillus  similar  to 
one  abundant  in  the  sloughing  cavity.  From  the  lung  tissue  from  the  consoli- 
dated regions  enormous  numbers  of  bacilli  developed  in  a  nearly  pure  culture, 
which  corresponded  in  its  biological  characters  to  the  bacterium  lactis  aerogenes 
of  Escherich. 

Remarks. — This  child  would  thus  seem  to  have  been  the  victim  of  infection 
with  the  ordinary  "suppurative  bacteria"  and  with  feces.  We  infer  that  fecal 
matter  in  some  way  came  in  contact  with  the  umbilicus. 

Third  Group. — It  seems  probable  that  in  exceptional  instances  the  septic 
poison  in  sepsis  of  the  newly-born  is  received  in  other  ways  or  other  channels 
than  at  the  umbilicus. 

If  sepsis  of  the  newly-born  occur  through  absorption  from  an  umbilical 
sore,  may  it  not  also  from  a  sore  located  elsewhere  ?  Decomposing  and 
disintegrating  animal  tissue,  wherever  located,  may  be  the  source  of  septic 
infection.  Moreover,  medical  literature  contains  histories  of  epidemics  of 
puerperal  fever  in  which  newly-born  infants  perished  with  what  was  often 
designated  erysipelas,  but  which  the  modern  pathologist  would  unquestionably 
designate  sepsis.  The  disease  which  I  have  described  as  umbilical  phlegmon, 
a  local  sepsis,  was  commonly  regarded  by  the  older  writers  as  a  form  of  ery- 
sipelas. Dr.  Condie,  in  his  Treatise  on  Diseases  of  Children,  described  in  the 
following  lines  what  we  would  now  designate  sepsis : 

"  Erysipelas  of  infants  very  commonly  occurs  during  the  prevalence  of 
epidemic  puerperal  fever.  Children  of  mothers  who  become  affected  with 
the  fever  are  often  born  with  erysipelatous  inflammation  :  others  are  attacked 


144  DISEASES  OF  THE  NEW-BOBN. 

almost  immediately  after  birth.  Whether  in  these  cases  the  disease  is  to  be 
referred  to  a  morbid  matter  applied  to  the  skin  in  the  womb,  or  to  the  same 
endemic  or  epidemic  influence  which  gives  rise  to  the  disease  of  the  parent, 
it  is  difficult  to  say.  According  to  M.  Trousseau,  infantile  erysipelas  is  prin- 
cipally observed  when  puerperal  fever  prevails  in  the  wards  of  the  lying-in 
hospitals  of  Paris." 

The  late  Dr.  Folsom  of  this  city  furnished  me  with  the  following  sketch 
of  cases  which  occurred  in  his  practice  and  that  of  his  partner.  "About 
the  year  1840,  being  then  in  practice  in  New  Bedford,  Mass.,  I  was  called 
to  visit  a  man  who  complained  of  pain  in  the  knee.  The  next  morning  he 
was  easier,  but  the  following  evening  his  symptoms  grew  worse,  and,  as  I 
was  engaged  in  a  case  of  obstetrics,  my  partner.  Dr.  E.  C,  now  dead,  vis- 
ited him.  At  my  call,  next  morning,  I  unexpectedly  found  the  patient 
dying.  The  disease  was  obscure,  and  at  the  autopsy  next  day  no  lesion  was 
discovered.  In  making  the  examination  Dr.  C.  pricked  his  finger,  and,  expe- 
riencing little  inconvenience  from  it  at  first,  he  attended  a  case  of  confinement 
on  the  following  morning.  A  few  hours  subsequently  he  was  taken  sick,  and 
I  took  charge  of  the  lady,  who  died  in  three  days,  having  the  tumid  abdomen 
and  symptoms  of  childbed  fever.  The  infant  of  the  patient  was  seized  when 
two  days  old  with  erysipelas  appearing  on  the  face  and  in  spots  on  the  trunk 
and  limbs,  and  terminating  fatally  in  one  day.  Dr.  C.'s  finger  became  swollen 
and  painful,  and  the  lymphatics  of  the  forearm  and  arm  became  inflamed, 
presenting  red  lines,  and  the  axillary  glands  suppurated.  Though  feverish 
and  much  prostrated,  there  was  no  appearance  of  erysipelas  in  his  case.  In 
about  two  weeks  he  resumed  practice,  and,  as^at  that  time  physicians  in  this 
country  were  not  fully  aware  of  the  danger  of  communicating  puerperal  fever, 
he  attended  two,  three,  or  four  obstetrical  cases  each  week  until  the  number 
reached  fifteen.  All  the  mothers  died  with  symptoms  of  metro-peritonitis, 
and  all  the  infants  had  erysipelas,  commencing  on  the  face  or  some  part  of 
the  body,  generally  on  the  second  or  third  day  after  birth,  and  in  all  termi- 
nating fatally  within  a  week.  This  sad  record  was  finally  ended  by  the  doc- 
tor's temporarily  retiring  from  practice." 

What  better  description  could  be  given  of  a  malignant  form  of  septic  infec- 
tion ?  It  will  be  observed  that  the  unfortunate  doctor  did  not  have  erysipelas, 
but  inflammation  of  the  lymphatics,  occurring  from  the  poisoned  finger,  and 
the  infant  who  first  contracted  the  disease  and  died  of  one  day's  sickness 
exhibited  red  spots  upon  the  trunk  and  limbs  of  an  erysipelatous  appear- 
ance. Did  the  doctor  poison  the  mothers  and  infants  at  the  same  time  by 
his  digital  examinations  ?  did  he  poison  the  mothers  by  his  infected  fingers, 
and  they  in  turn  poison  the  babies  through  the  placental  circulation  ?  or  did 
the  infected  mothers  communicate  the  poison  through  the  breath  or  milk  ? 
This  is  an  interesting  subject  of  inquiry  in  regard  to  which  we  are  in  the 
dark.  Fortunately,  the  profession  are  now  fully  aware  of  the  danger  of  sep- 
tic infection,  so  that  no  intelligent  and  prudent  accoucheur  would  attend  an 
obstetrical  case  after  making  a  post-mortem  examination  or  visiting  a  case 
of  puerperal  fever  without  change  of  clothing  and  thorough  personal  disin- 
fection, and  consequently  cases  belonging  to  our  third  group  are  much  more 
rare  than  formerly. 

It  is  evident  that  sepsis  of  the  newly-born  might  be  prevented  in  a  large 
proportion  of  instances  by  proper  antiseptic  dressing  of  the  navel.  Boric 
acid  is  a  feeble  and  inefficient  antiseptic,  and  the  borated  cotton  which  was 
employed  in  dressing  the  navel  when  the  cases  in  the  maternity  ward  occurred 
which  have  been  related  above  was  inadequate  to  prevent  infection.  Of  the 
powders  which  might  be  prescribed  for  this  purpose,  salicylic  acid  or  deodor- 
ized iodoform  mixed  with  starch   would  appear  to  be  much  more  efficient. 


THRUSH.  145 

Crede's  method  of  preventing  purulent  conjunctivitis  by  instilling  one  drop 
of  a  2  per  cent,  solution  of  nitrate  of  silver  between  the  lids  has  been  very 
effectual.  Probably  in  a  similar  manner  umbilical  phlegmon  might  be  pre- 
vented in  maternity  wards  by  bathing  daily  the  umbilicus  with  a  solution 
of  the  sublimate,  grs.  ij   to'  the  pint. 

When  an  umbilical  phlegmon  has  commenced  we  have  employed  dusting 
with  iodoform,  the  application  to  the  navel  every  two  hours  of  carbolized 
sweet  oil  (1  to  30),  and  bathing  the  navel  with  a  solution  of  corrosive  subli- 
mate, two  grains  to  the  pint  of  distilled  or  boiled  water.  In  some  of  the 
cases  thus  treated  when  the  phlegmons  were  small  the  patients  gradually 
recovered,  but  in  most  of  the  cases  the  phlegmons  were  so  large,  and  the 
microbes  at  such  a  distance  from  the  umbilicus  in  the  tissue  of  the  abdomi- 
nal wall,  that  antiseptics  applied  upon  and  around  the  umbilicus  were  not 
curative.  Newly-born  infants  are  probably  too  young  and  feeble  to  be  satis- 
factorily treated  by  incisions  in  the  phlegmon  and  the  application  of  anti- 
septics to  the  incised  surfiices,  else  this  treatment  might  be  more  efficient 
than  treatment  without  such  incisions. 

Thrush. 

The  terms  thrush,  sprue,  and  muguet — the  last  from  the  French — are 
synonymous.  They  are  used  to  designate  a  form  of  inflammation  of  the 
mucous  surfaces  the  peculiar  feature  of  which  is  the  presence  of  points  or 
patches  of  a  curd-like  appearance  on  the  inflamed  surface.  The  usual  seat 
of  thrush  is  the  buccal  membrane,  but  occasionally  it  occurs  on  the  faucial 
and  oesophageal  surfaces.  It  is  very  rare  in  the  subdiaphragmatic  portion 
of  the  digestive  tube,  but  a  few  such  cases  have  been  reported  by  Billard 
and  others.  It  never  occurs  upon  the  membrane  of  the  nostrils,  larynx,  or 
bronchial  tubes,  and  it  very  seldom  occurs  upon  any  other  surface  without 
also  being  present  upon  the  buccal  mucous  membrane.  Thrush,  then,  is  a 
stomatitis,  pharyngitis,  oesophagitis,  or  gastro-enteritis  with  the  additional 
element  which  I  have  mentioned. 

Causes. — The  younger  the  infant  the  greater  is  the  liability  to  thrush 
when  the  causes  favorable  for  its  occurrence  are  present.  It  is  therefore 
common  in  infants  under  the  age  of  six  weeks,  and  a  majority  of  the  cases 
occur  under  the  age  of  six  months.  The  common  causes  of  this  disease  are 
such  as  ordinarily  develop  a  stomatitis,  prominent  among  which  are  improper 
feeding,  indigestion,  gastro-enteritis,  and  the  cachectic  state,  whether  arising 
from  prematurity,  congenital  weakness,  or  enfeebling  diseases.  The  most 
common  and  obvious  of  the  causes  alluded  to  is  the  use  of  indigestible  and 
improper  food,  which  produces  a  gastro-intestinal  catarrh,  soon  followed  by 
stomatitis.  Thrush  is  therefore  a  common  disease  among  foundlings  in  insti- 
tutions where  these  unfortunates  are  received,  since  they  not  only  breathe 
an  atmosphere  which  is  often  impure,  but  are  deprived  of  the  mother's  milk, 
and  are  so  frequently  given  a  diet  which  is  a  poor  substitute  for  it.  Infants 
in  crowded  tenement-houses  of  the  cities  and  in  destitute  families,  whose 
diet  is  often  very  unsuitable,  are  much  more  liable  to  thrush  than  infants 
well  fed  and  well  cared  for  in  well-to-do  families. 

In  infants  under  the  age  of  three  months  the  cause  of  thrush  is  often 
mild,  and  soon  removed  by  better  hygienic  conditions  and  improvement  in 
the  diet.  An  improper  diet  for  a  few  days,  or  a  slight  gastro-intestinal  catarrh 
which  quickly  subsides  when  the  cause  ceases,  is  sufficient  to  develop  the 
disease.  In  the  newly-born  the  frequent  use  of  sweetened  carminatives  or 
of  sweetened  dietetic  mixtures  administered  by  the  nurse  often  gives  rise  to 
sprue,  which  ceases  when  these  drinks  are  withheld  and  a  proper  mouth-wash 

10 


146  DISEASES  OF  THE  NEW-BORN. 

applied.  But  after  the  age  of  six  months,  and  especially  after  the  age  of 
one  year,  the  condition  giving  rise  to  sprue  is  much  more  serious.  After  the 
age  of  twelve  months  sprue  is  comparatively  rare,  and  when  it  does  occur  it 
is  usually  in  the  later  stages  of  a  protracted  and  exhausting  disease ;  and  in 
such  cases  it  is  an  unfavorable  prognostic  sign.  Under  such  circumstances 
it  occurs  even  in  childhood,  youth,  and  adult  life,  and  is  justly  regarded  as  a 
complication  of  grave  import.  Thrush,  being  a  parasitic  disease,  is  com- 
municable by  contact,  like  the  parasite  skin  diseases.  Thus  in  the  wards  of 
a  foundling  asylum  the  tip  of  a  nursing-bottle  used  by  different  foundlings, 
if  not  properly  cleaned  after  its  use,  may  be  the  means  of  communicating  it. 
Thrush  is  so  common  in  young  infants  when  the  buccal  surface  is  in  a  state 
favorable  for  its  occurrence  that  it  is  probable  that  the  specific  germ  may 
also  be  received  from  the  atmosphere. 

Anatomical  Characters. — The  first  stage  of  thrush  is  that  of  simple 
inflammation  of  the  mucous  surface.  The  mixed  salivary  and  mucous  secre- 
tions in  the  mouth,  which  are  normally  alkaline,  become  acid.  There  next 
appear  upon  the  mucous  surface  minute  semi-transparent  points  or  granules, 
which,  increasing,  soon  become  white  and  opaque.  Some  of  them  remain  as 
points,  while  others,  extending  and  perhaps  coalescing  with  those  adjoining, 
form  patches  of  greater  or  less  extent.  The  white  points  or  patches  are 
unequally  elevated.  Their  central  part,  which  was  first  formed,  is  most 
raised,  while  their  circumference  projects  but  little  above  the  epithelium. 
Their  highest  elevation  is  ordinarily  not  more  than  a  line  above  the  surface. 
They  resemble  closely  in  color  and  consistence  portions  of  curdled  milk,  and 
the  nurse  often  mistakes  them  for  such  and  neglects  to  call  attention  to  the 
state  of  the  mouth.  They  are  readily  detached  by  a  little  force,  when  the 
mucous  membrane  underneath  is  seen  to  be  in  its  integrity.  Their  color  in 
the  first  days  of  sprue  is  white,  and  sometimes  this  color  continues.  In  other 
cases  they  assume,  if  the  disease  be  protracted,  a  yellowish  hue. 

Their  true  nature,  long  unknown,  was  finally  revealed  by  microscopy. 
They  consist  in  part  of  epithelial  cells  and  in  part  of  a  vegetable  growth. 
This  parasite  is  the  Oidinm  albicans,  discovered  by  Berg  of  Stockholm,  but 
more  fully  described  by  Gruby  and  Charles  Robin.  The  roots  of  the  parasite 
are  transparent,  and  they  penetrate  the  epithelial  layer  sometimes  even  to 
the  basement  membrane.  The  branches  arising  from  these  rootlets  divide 
and  subdivide  at  an  acute  angle,  and  under  the  microscope  are  seen  to  con- 
sist of  elongated  cells  with  one  or  two  nuclei.  The  branches  or  the  mycelium 
is  formed  by  the  union  of  the  cells  at  their  extremities.  Numerous  spherical 
or  ovoid  spores  are  also  present  surrounding  the  mycelium  and  covering  the 
epithelial  cells.  Haller  states  that  he  has  identified  this  parasite  with  the 
Olclium  lactis,  which  occurs  in  milk  undergoing  acid  fermentation.  The 
spores  are  primarily  developed,  and  are  found  in  the  scraping  of  the  mucous 
surface  in  the  vicinity  of  the  patches  of  sprue.  In  two  instances  in  examin- 
ing the  product  of  thrush  removed  from  the  oesophagus  I  found  that  the 
parasitic  plant  was  the  PenicilUum  glancmn  or  a  conferva  closely  resem- 
bling it. 

We  have  described  the  ordinary  form  of  thrush  as  it  occurs  in  young 
children,  but  if  the  patches  are  of  large  size  and  abundant,  and  the  buccal 
surface  generally  of  a  deep-red  color,  there  is  usually  some  severe  prostrating 
and  dangerous  disease  on  which  the  thrush  has  supervened.  We  have  already 
alluded  to  the  fact  that  thrush  in  its  severe  forms  often  results  from  and  com- 
plicates some  grave  disease,  as  protracted  gastro-intestinal  catarrh  or  a  chronic 
pulmonary  malady.  Hence  some  writers  who  have  observed  thrush  in  found- 
ling asylums  regard  it  as  one  of  the  most  serious  maladies  of  early  life.  Val- 
leix,  in  a  book  of  more  than  seven  hundred  pages  relating  to  the  diseases  of 


THRUSH. 


147 


children,  devotes  more  than  one-third  of  it  to  Fio.  8. 

the  consideration  of  muguet,  but  those  patho- 
logical conditions  pertaining  to  the  digestive  ap- 
paratus which  most  observer^  regard  as  distinct 
from  sprue,  though  sustaining  a  causal  relation 
to  it,  he  includes  in  the  description  of  muguet. 
Of  24  cases  the  records  of  which  he  publishes, 
22  died,  but  their  death  was  in  most  instances 
due  to  gastro-intestinal  inflammation,  which 
the  author  describes  under  the  term  "  muguet." 
Most  writers  properly  restrict,  as  stated  above, 
the  term  thrush,  sprue,  or  muguet  to  those 
inflammations  of  mucous  surfaces  which  are 
accompanied  by  the  peculiar  parasitic  out- 
growth, regarding  the  severe  subdiaphragmatic 
inflammations  from  which  Valleix's  patients 
died  as  distinct  fi'om  muguet,  though  sus- 
taining a  causal  relation  to  it.  In  the  post- 
mortem examinations  which  I  have  witnessed 
in  the  Nursery  and  Child's  Hospital,  Infant 
Asylum,  and  Foundling  Asylum  of  this  city, 
of  those  having  thrush  at  the  time  of  death,, 
who  for  the  most  part  have  been  infants  un- 
der the  age  of  three  months,  I  have  frequently 
found  evidences  of  inflammation  in  every  di- 
vision of  the  alimentary  canal.  The  parasitic 
growth  was,  however,  never  seen  below  the 
oesophagus.  Parrot,  however,  states  that  he 
has  discovered  it  in  rare  instances  in  the 
larynx,  stomach,  and  intestines. 

Symptoms. — Thrush  in  itself  does  not  give 
rise  to  any  symptoms  except  those  that  pertain  to  the  surface  which  is  the  seat 
of  the  parasitic  growth.  Other  symptoms  are  not  referable  to  it,  but  to  the 
diseases  in  the  course  of  which  it  is  developed  and  which  it  complicates.    Sprue 


Pavement  epithelium  covered  by 
spores  of  the  O'idium  albicans  (Ch. 
Robin). 


Fig.  9. 


Spores  and  Brandies  of  the  O'idium  nlbicuiis  (Ch.  Robin). 


148  DISEASES  OF  THE  NEW-BORN. 

is  preceded  and  accompanied  by  the  symptoms  of  gastro-intestinal  catarrh  or 
some  other  disease  which  affects  the  digestive  apparatus,  and  causes  acidity  of 
the  buccal  surface.  The  mucous  membrane,  upon  which  the  cryptogam  is 
soon  to  appear,  becomes  red,  hot,  tender  to  the  touch.  As  we  have  stated  above, 
it  gives  the  acid  reaction  more  or  less  marked  to  litmus-paper,  and  in  the 
scraping  from  its  surface  placed  under  the  microscope  the  spherical  or  oval 
spores  of  the  O'idium  albicans  are  observed.  A  few  hours  later  small  white 
points  appear,  at  first  scarcely  visible,  produced  by  the  cryptogamic  growth 
and  the  epithelial  and  amorphous  matter  adherent  to  it. 

These  points  enlarge,  and  within  a  day  or  two  present  the  well-known 
appearance  of  small  masses  or  patches  of  curdled  milk.  They  are  fragile 
and  readily  detached,  but  are  soon  replaced  by  others  so  long  as  the  cause 
continues.  In  the  worst  forms  of  thrush  the  surface  upon  which  the  cryp- 
togam appears  not  only  presents  the  ordinary  features  of  severe  inflammation, 
such  as  heat,  redness,  and  tenderness,  but  it  is  sometimes  deficient  in  the 
natural  secretion,  so  as  to  present  a  dry  or  parched  appearance.  In  these 
severe  cases  there  is  usually  in  young  infants  obstinate  and  protracted 
inflammation  of  subdiaphragmatic  portions  of  the  digestive  tube.  The  24 
cases  related  by  Yalleix,  alluded  to  above,  22  of  which  were  fatal,  were  of 
this  kind.  But  the  gravity  of  such  cases,  in  which  thirst,  anorexia,  restless- 
ness, vomiting,  diarrhoea,  and  progressive  emaciation  occur,  is  due,  as  stated 
above,  to  the  primary  disease  which  has  produced  the  conditions  favorable 
for  the  occurrence  of  sprue.  If  sprue  occur,  its  symptoms  should  be  dif- 
ferentiated from  the  more  pronounced  symptoms  of  the  disease  which  it  com- 
plicates. 

Diagnosis. — This  is  not  difiicult,  so  far  as  relates  to  thrush  of  the  buccal 
surface,  for  simple  inspection  reveals  its  presence.  If  a  particle  of  one  of 
the  patches  be  placed  under  the  microscope,  the  mycelium  and  spores  of  the 
O'idium  albicans  are  readily  detected.  Only  the  inexperienced  could  mistake 
the  diphtheritic  exudate  for  the  growth  of  sprue  or  vice  versa.  The  diph- 
theritic pellicle  penetrates  the  mucous  membrane,  from  which  it  is  detached 
with  difficult}',  leaving  underneath  a  raw  and  bleeding  surface,  and  it  is 
thick  and  tough,  contrasting  in  these  particulars  with  the  product  of  sprue. 
Enlargement  of  the  cervical  glands  is  also  common  in  diphtheria  and  is  absent 
in  sprue. 

Particles  of  coagulated  casein  upon  the  tongue  and  gums  bear  a  close 
resemblance  to  the  patches  of  thrush,  but  their  relation  to  the  mucous  mem- 
brane is  simply  that  of  contact,  and  they  are  removed  by  a  spoonful  of 
water. 

Prognosis. — The  duration  of  thrush  varies  according  to  the  duration  and 
nature  of  the  primary  disease  which  it  complicates.  In  young  infants  who 
have  indigestion  or  slight  gastro-intestinal  catarrh  it  is  quickly  cured  by 
appropriate  local  treatment  if  the  nutriment  given  be  of  the  proper  kind  and 
the  stomach  and  intestines  be  restored  to  their  normal  state.  On  the  other 
hand,  thrush  occurring  in  the  course  of  chronic  and  highly  debilitating  dis- 
eases is  not  so  quickly  cured,  or  if  cured  is  likely  to  return.  It  does  not 
materially  increase  the  gravity  of  the  malady  in  the  course  of  which  it 
occurs,  but  when  it  complicates  a  chronic  disease  it  indicates  a  reduced  state 
of  the  system,  an  impairment  of  the  general  nutrition,  which  if  it  continue 
is  likely  to  end  fatally.  As  M.  Bouchut  has  pointed  out,  when  Baron  states 
that  109  out  of  140  patients  with  muguet  died  of  this  disease,  and  Valleix. 
as  I  have  stated  above,  says  that  he  lost  22  out  of  24  cases  from  the  same 
cause,  they  attribute  to  a  comparatively  unimportant  complication  what  was 
really  due  to  a  grave  internal  disease.  Thrush  does  not  itself  cause  death, 
though  it  may  be  a  sign  of  bad  omen.     Death  when  it  occurs  is  from  a  vis- 


THRUSH.  149 

ceral  affection  which  precedes  and  accompanies  the  sprue,  and  is  likely  to 
continue  after  every  vestige  of  the  latter  is  removed  by  local  measures,  unless 
it  receive  appropriate  internal  treatment. 

Sprue  is  a  bad  omen  if  the  tongue  and  buccal  surface  be  dry,  hot,  and 
highly  injected,  the  coating  of  the  tongue  of  brownish  color,  the  infant  fret- 
ful with  the  appearance  of  suffering  in  its  physiognomy,  and  having  progres- 
sive loss  of  flesh  and  strength.  Such  symptoms  indicate  in  most  instances  a 
fatal  form  of  gastro-intestinal  catarrh.  On  the  other  hand,  in  young  infants, 
since  indigestion  and  slight  gastro-intestinal  derangements  are  adequate  to 
cause  an  acid  state  of  the  buccal  surface  and  the  development  and  extension 
of  the  Old! inn  albicans^  the  large  majority  of  the  cases  of  thrush  in  which  the 
general  condition  is  good  and  the  stomatitis  mild  are  quickly  cured  by  appro- 
priate treatment. 

Treatment. — Since  the  common  cause  of  thrush  in  infancy  is  the  use  of 
indigestible  or  improper  food,  the  physician  should  ascertain  the  nature  and 
mode  of  preparation  of  the  infant's  diet,  and,  if  it  be  faulty,  should  direct 
one  that  is  better.  If  the  infant  be  bottle-fed,  the  mother's  milk  or  that 
of  a  wet-nurse  should,  if  practicable,  be  substituted  for  the  artificial  feed- 
ing ;  but  if  this  be  impossible,  a  diet  should  be  selected  which  bears  the 
closest  possible  resemblance  to  the  mother's  milk  in  digestibility  and  nutri- 
tive properties. 

There  is  often  in  thrush  an  excess  of  acidity  in  the  digestive  tube,  and 
an  alkali  is  required.  Trousseau  recommends  the  addition  of  saccharate  of 
lime  to  the  milk.  Children  with  this  disease  should  also  be  taken  from  filthy 
and  damp  apartments  to  those  in  which  the  air  is  pure  and  dry,  and  their 
mouths  and  persons  should  be  kept  clean. 

The  remedy  in  common  use  in  the  treatment  of  thrush,  and  which  is 
usually  effectual,  is  borax.  This,  if  applied  sufficiently  often  to  the  affected 
membrane,  not  only  destroys  the  parasitic  growth,  but  prevents  its  reproduc- 
tion. It  is  commonly  employed  with  honey  or  in  a  powder  with  sugar  or 
dissolved  in  water.  The  officinal  mel  boracis,  consisting  of  one  part  of  borax 
to  eight  of  honey,  is  so  much  used  in  families  that  it  may  be  considered 
almost  a  domestic  remedy.  There  is,  however,  an  objection  to  using  any 
application  for  the  removal  of  thrush  which  contains  either  sugar  or  honey, 
since  either  substance  remaining  in  the  mouth  would  rather  promote  the 
growth  of  the  parasite.  Still,  it  is  desirable  to  employ  a  wash  of  such  con- 
sistence that  it  will  remain  a  longer  time  in  contact  with  the  buccal  surface 
than  will  a  simple  solution  in  water.  I  know  no  better  vehicle  for  the  borax 
than  glycerin,  which  has  the  advantage  of  consistence,  does  not  undergo  any 
chemical  change,  and  has  no  unpleasant  flavor.  The  borax  may  be  used  dis- 
solved in  glycerin,  with  or  without  some  flavoring  ingredient : 

B.  Sodii  borat.,  3J  ; 

Glycerinse,  ^ij ; 

AquEe,  ^vj.     Misce. 

Borax  should  be  used  four  or  five  times  daily,  and  continued  for  a  time  after 
the  disease  has  disappeared  from  sight,  since  the  roots  of  the  plant  must  be 
destroyed  or  the  branches  are  rapidly  reproduced.  It  should  be  applied  by  a 
camel's-hair  pencil  or  with  a  soft  cloth  upon  the  finger  or  a  stick.  It  should 
be  so  freely  used  in  extensive  and  severe  forms  of  the  disease  that  the  infant 
will  swallow  some,  since  the  entire  oesophagus  is  often  also  the  seat  of  sprue 
in  such  cases.  In  the  intervals  between  the  applications  of  borax,  if  the 
buccal  surface  be  hot,  dry,  and  tender,  so  as  to  increase  the  fretfulness  of  the 
infant,  it  is  well  to  use  mucilaginous  washes,  as  the  mucilage  of  acacia  or 


150  HMMATEMESIS  AND  MELMNA  NEONATORUM. 

mallows.  If  the  disease  continue  notwithstanding  the  use  of  these  measures, 
the  mouth  should  he  occasionally  washed  with  a  weak  solution  of  nitrate  of 
silver  or  sulphate  of  zinc  : 

R.  Zinci  sulph.,  gr.  ij-iv; 

Aq.  rosse,  %i].    Misce. 

In  many  cases,  however,  the  treatment  of  thrush  is  of  less  importance 
than  that  of  the  disease  which  the  thrush  complicates.  The  remedial  meas- 
ures which  I  have  mentioned  then  become  subordinate  to  those  employed  for 
the  graver  disease.  When  this  disease  is  relieved  and  the  general  health 
improves,  thrush  is  more  easily  and  permanently  cured  than  during  the  state 
of  feebleness  and  ill-health. 


CHAPTER    TV. 

HMMATEMESIS  AND  MELMNA  NEONATORUM. 

Hemorrhage  from  the  gastro-intestinal  surface  occurs  in  children  from 
various  causes.  It  is  a  common  symptom  of  intussusception  in  infants.  It 
occurs  from  dysentery  and  purpura  and  from  the  syphilitic  dyscrasia.  It 
has  been  observed  in  polypus  of  the  rectum  and  in  anal  fissures.  In  rare 
instances  it  occurs  from  the  irritation  of  lumbrici,  from  foreign  substances 
which  have  been  swallowed,  and  from  the  ulceration  of  typhoid  fever.  Intes- 
tinal hemorrhage  from  such  causes  is  a  symptom  of  constitutional  or  local  dis- 
ease. But  in  newly-born  infants  it  sometimes  occurs  without  other  symptoms 
or  without  other  appreciable  disease,  and  therefore  is  regarded  as  an  essential 
malady. 

Melasna  neonatorum  was  mentioned  by  Storck  in  1750,  and  various  wri- 
ters at  different  times  alluded  to  it  or  briefly  described  it  prior  to  1825.  In 
1825  it  was  more  fully  treated  of  by  Hesse  than  by  any  of  his  predecessors.^ 
The  monograph  published  by  him  was  valuable,  as  it  contained  his  own  obser- 
vations and  those  of  contemporary  physicians  communicated  to  him,  as  well 
as  the  investigations  of  his  predecessors.  Dr.  Rahn-Escher  of  Zurich  (1835), 
Meisner  (1838),  Kiwisch  (1841),  Rumpe  (1841),  Hofiman  (1842),  andHelm- 
brecht  (1843)  published  memoirs  or  related  cases  of  melsena.  Several  of  the 
best-known  authors  on  diseases  of  children,  long  recognized  as  authorities  in 
this  branch  of  practice,  have  also  written  on  intestinal  hemorrhage,  as  Billard, 
Vogel,  Rilliet  and  Barthez,  Barrier,  Bouchut,  West,  Eustace  Smith,  and  Grood- 
hart,  so  that  the  literature  of  this  disease  is  no  longer  meagre. 

Age. — In  the  statistics  of  Billard,  embracing  15  cases,  8  were  between 
the  ages  of  one  and  six  days,  4  between  the  ages  of  six  and  eight  days,  and 
3  between  the  ages  of  ten  and  eighteen  days.  Of  20  cases  embraced  in  the 
memoir  of  Rilliet  and  Barthez,  9  were  at  or  under  the  age  of  thirty-six 
hours  when  the  hemorrhage  began,  5  between  the  ages  of  two  and  four  days, 
2  between  six  and  eleven  days,  and  2  at  the  ages  of  fifteen  and  twenty 
weeks.  Of  50  cases  collated  by  Croom  ^  from  various  sources,  gastro-intes- 
tinal hemorrhage  took  place  in  30  between  the  first  and  sixth  days,  in  8 
between  the  sixth  and  eighth  days,  in  4  between  the  eighth  and  twelfth  days, 
and  in  8  between  the  twelfth  and  eighteenth  days.     The  bleeding  began  in 

■"  Annalen  von  Pierer,  1825,  Heft  6.  ^  Medical  Times  and  Gaz.,  Oct.,  1880. 


ETIOLOGY.  151 

<)  within  the  first  twenty-four  liours.  These  statistics,  which  correspond  with 
those  of  other  observers,  show  that  in  a  large  majority  of  cases  the  hemor- 
rliage  occurs  within  tlie  first  twenty-four  hours.  Htematemesis  also  takes 
place  along  with  the  intestinal  hemorrhage  in  a  considerable  proportion  of 
cases. 

Etiology. — The  cause  of  niehena  of  the  newly-born  is  involved  in  some 
obscurity.  To  a  con.siderable  extent  the  causes  are  the  same  as  in  hemor- 
rhage from  the  umbilicus,  which  we  have  treated  of  in  a  foregoing  page.  A 
predisposition  to  this  and  other  forms  of  hemorrhage  is  sometimes  inherited. 
Dr.  Rahn-Escher  states  that  the  mothers  sometimes  have  digestive  ailments 
or  other  forms  of  ill-health,  which  he  thinks  produce  atony  of  the  vessels  in 
the  infants.  The  infant  sometimes  belongs  to  a  family  of  bleeders  and  inher- 
its haemophilia.  In  the  Medical  Times  imd  Guzetta  for  October,  1880,  Dr. 
Croom  relates  4  cases  in  which  there  appeared  to  be  an  hereditary  tendency 
to  bleeding.  In  1  of  the  cases  the  father  was  subject  to  hemorrhages ;  in 
another  the  pressure  of  the  forceps  produced  extensive  ecchymoses  on  both 
sides  of  the  head.  We  have  stated  in  our  remarks  on  umbilical  hemorrhage 
that  newly-born  infants  aifected  by  syphilis  are  very  liable  to  intestinal 
and  other  forms  of  hemorrhage  from  the  dyscrasia  present  or  from  anatomi- 
cal changes  in  the  walls  of  the  minute  vessels,  or,  as  is  probable,  from  both 
causes.  Our  article  on  umbilical  hemorrhage  contains  the  statistics  of 
Mracek,  who  at  the  autopsies  of  160  syphilitic  infants  observed  internal 
hemorrhages  in  42,  but  in  only  4  of  these  was  extravasated  blood  present  in 
the  intestines. 

But  the  majority  of  the  neonati  who  have  gastro-intestinal  hemorrhage 
do  not  appear  to  have  any  inherited  dyscrasia  or  taint  of  system.  Certainly 
the  instances  are  exceptional  in  which  the  infants  belong  to  families  of 
*'  bleeders"  or  have  the  syphilitic  dyscrasia.  We  must  look  for  other  causes 
apart  from  these.  Billard  attributes  melsena  of  the  newly-born  to  conges- 
tion of  the  vessels.  Says  he :  "I  have  examined  15  cases  of  passive  intes- 
tinal hemorrhage Most   of  them  were   remarkable   for  the  plethoric 

condition  of  their  bodies  and  the  general  congestion  of  their  integuments. 
....  In  all  the  large  abdominal  vessels,  the  liver,  spleen,  lungs,  and  heart 
were  considerably  engorged  with  blood."  He  adds:  "It  cannot  be  too 
strongly  recommended  to  accoucheurs  to  allow  the  umbilical  cord  to  bleed 
when  a  child  is  observed  to  be  in  a  state  of  asphyxia  ;  for  it  has  already 
been  seen  what  serious  effects  follow  from  a  superabundance  of  blood  in 
young  infants."^  Vogel  says:  "The  turgescence  of  the  mesenteric  arteries 
and  their  systems  of  capillaries,  seen  even  in  the  physiological  state,  and 
produced  by  the  sudden  closure  of  the  umbilical  arteries,  so  important  in 
the  foetus,  and  which  arise  directly  from  the  hypogastric  arteries,  may  be 
looked  upon  as  a  cause  of  this  disease.  An  especial  thinness  of  the  walls  or 
friability  of  the  affected  system  of  vessels  must  certainly  play  a  part  here, 
because  otherwise  this,  in  reality,  very  rare  form  of  hemorrhage  would  have 
to  occur  much  more  frequently.  The  closure  of  the  ductus  venosus  Arantii, 
and  especially  that  of  the  branch  of  the  umbilical  vein  opening  into  the 
portal  vein,  deserves  more  frequent  and  stricter  investigation  to  explain  this 
hemorrhage." 

Rilliet  and  Barthez  attach  but  little  importance  to  the  causes  of  melasna 
assigned  by  writers  who  preceded  them,  but  state  that  it  is  easy  to  conceive 
that  hyper^emia  of  the  intestinal  tube,  which  is  normal  in  the  newly-born, 
might  be  increased  by  atony  of  the  vessels  or  impeded  abdominal  circulation, 
through  arrest  of  the  circulation  in  the  portal  vein,  so  that  hemorrhage 
would  be  likely  to  occur.     Incomplete  establishment  of  respiration,  in  which 

^  Treatise  on  the  Diseases  of  In/ants. 


152  H^MATEMESIS  AND  MEL  JEN  A  NEONATORUM. 

congestion  of  organs  occurs,  and  especially  of  the  intestines,  they  regard  as 
a  predisposing  cause.  They  admit  hereditary  influence  in  certain  cases,  as 
when  a  parent  has  been  subject  to  hemorrhage.  M.  Bouchut^  makes  three 
groups  of  cases  of  melaena,  according  to  the  supposed  etiology,  as  follows : 
First,  melsena  from  purpura ;  second,  from  passive  congestion,  the  result  of 
compression  at  birth ;  third,  from  acute  or  chronic  inflammation  of  the  gas- 
tro-intestinal  surface.  Dr.  West  believes  that  tedious  and  difiicult  labor,  in 
which  the  head  of  the  child  is  compressed  and  abdomen  injured,  is  an  occa- 
sional cause  of  intestinal  hemorrhage.  The  tardy  and  difficult  establishment 
of  respiration  he  also  thinks  may  be  a  predisposing  cause,  but  he  adds,  "Very 
often  no  reason  can  be  assigned  for  it."  In  two  post-mortem  examinations 
which  he  made  no  adequate  cause  was  discovered.  Braun  ^  mentions  among 
the  probable  causes  congestion  of  mesenteric  vessels,  pressure  during  birth, 
heredity,  intra-uterine  malnutrition.  Steiner '  believes  that  intestinal  hemor- 
rhage occurs  sometimes  from  a  round  perforating  ulcer  due  to  fatty  degene- 
ration of  the  arteries.  Hecker,  Buhl,  Spiegelberg,  and  Leopold  Landau 
relate  cases,  six  in  all,  in  which  abscesses  or  ulcers  were  observed  in  the 
stomach  or  duodenum,  or  in  both.  Landau  expresses  the  opinion  that  these 
lesions  occurring  in  the  gastro-duodenal  surface  are  produced  by  small  embo- 
lisms. Reinhold*  relates  the  case  of  an  infant  born  May  15th  who  had 
hsematemesis  and  melaena  on  the  first  day,  and  died  May  17th.  There  was 
apparently  epigastric  tenderness.  All  the  organs  were  anaemic,  and  the 
stomach  contained  seven  or  eight  ulcers  with  edges  slightly  raised.  No 
emboli  could  be  discovered,  but  the  umbilical  vein  contained  a  brownish-red 
clot. 

On  the  other  hand,  J.  Halliday  Croom,  lecturer  on  midwifery  and  dis- 
eases of  women  at  the  School  of  Medicine,  Edinburgh,  made  the  autopsy 
of  a  child  that  died  of  melaena  at  the  age  of  half  a  day.  The  gastro-intes- 
tinal  surface  was  carefully  examined,  and  no  abscess,  ulcer,  or  erosion  was 
discovered,  but  some  congestion  was  observed  in  the  lower  part  of  the  intes- 
tine. He  alludes  to  another  case,  described  by  Helmbrecht,  in  which  the  only 
apparent  morbid  condition  was  congestion  of  the  rectum.  In  another  case, 
observed  by  Dr.  Croom,  an  infant  of  three  weeks,  previously  well,  died  of 
hsematemesis  and  melasna.  Both  auricles  contained  firm  clots,  and  in  the 
aorta  was  a  clot  partly  decolorized.  The  only  abnormal  appearance  in  the 
digestive  tract  was  capillary  injection  of  the  duodenal  surface." 

Epstein  of  Prague^  in  an  interesting  monograph  on  melaena  neonatorum 
states  that  hemorrhage  occurs  in  the  newly-born  from  various  causes — from 
disturbance  of  the  circulation  leading  to  congestion,  from  disease  of  the  ves- 
sels, and  from  disease  of  the  blood  itself.  In  infants  born  partly  asphyxiated 
after  tedious  labor,  or  in  weakly  infants  with  atelectasis,  Epstein  says  that 
hypersemia,  hemorrhagic  erosions,  ulcerations,  and  actual  hemorrhage  of  the 
gastro-intestinal  surface  are  likely  to  occur.  He  believes  that  the  most  com- 
mon cause  of  melaena  is  temporary  congestion  of  the  finer  capillary  vessels. 
When  the  surface  of  the  stomach  has  been  spi-inkled  with  ecchymoses,  small 
gastric  ulcers  have  been  present,  caused  by  emboli  in  the  gastro-duodenal 
vessels,  resulting  from  thrombi  in  the  umbilical  vein. 

From  the  above  quite  numerous  observations  we  are  able  to  affirm  that 
hemorrhage  from  the  stomach  and  intestines  in  the  newly-born  occurs  from 
different  causes,  prominent  among  which  are — 1st,  haemophilia;  2d,  inherited 
syphilis  ;  3d,  congestion  of  the  gastro-intestinal  surface  ;  4th,  ulcers  occurring 

^  Traiie  pratique  des  Maladies  des  Nouveaux-nes. 

^  Compendium  des  Kivderheilkunde,  Vienna,  1871. 

^  Diseases  of  Children.  *  Deutsche  med.  Woch.  No.  28,  1881. 

5  Med.  Times  and  Gaz.,  Oct.,  1880.         «  Allgem.  Wien.  Med.  Zeit.,  No.  49,  1882. 


DIARRHCEA    OF  THE  NEWLY-BORN.  153 

especially  in  the  stomach,  whether  produced  by  emboli  resulting  from  throm- 
bosis in  the  umbilical  vein  or  from  other  causes. 

Diagnosis  ;  Prognosis. — If  the  infant  vomit  blood,  the  nipple  of  the 
mother  or  wet-nurse  should,  be  inspected,  for  a  considerable  amount  of  blood 
is  sometimes  drawn  by  suction  from  the  nipple.  If  no  abrasion  or  sore  be 
discovered  upon  or  around  the  nipple  or  upon  the  lips  or  in  the  mouth  of  the 
infant,  we  may  assume  that  hemorrhage  is  occurring  from  the  stomach  or 
upper  part  of  the  intestines  of  the  infant.  The  presence  of  blood  upon  the 
diaper  without  any  fissure  upon  the  anus  or  external  source  of  its  occurrence 
is  evidence  of  intestinal  hemorrhage.  The  blood  is  dark  and  more  or  less 
changed  by  digestion  or  the  action  of  the  intestinal  secretions  if  it  have  lain 
some  time  in  the  intestines.  The  pallor  of  the  infant  and  increasing  feeble- 
ness are  evidence  of  the  loss  of  blood.  But  in  one  instance  myself  and  two 
other  physicians  were  deceived  by  a  midwife  who  had  loosely  ligated  the 
umbilical  cord,  so  that  fatal  hemorrhage  occurred  from  it.  The  case  was 
reported  as  one  of  intestinal  hemorrhage,  and  was  recorded  as  such  in  the 
statistics  of  the  Health  Board.  The  source  of  the  hemorrhage  was  ascer- 
tained by  a  post-mortem  examination  which  we  were  fortunate  in  obtaining. 
The  gastro-intestinal  surface  was  normal  except  its  extreme  bloodlessness 
and  pallor. 

The  PROGNOSIS  is  in  most  instances  unfavorable,  but  if  the  infant  be 
strong  and  the  amount  of  hemorrhage  small,  we  may  hold  out  some  encour- 
agement of  a  favorable  result.  It  is  possible,  indeed,  that  a  considerable 
amount  of  blood  be  lost  and  the  infant  recover.  But  weakly  infants  who 
have  an  abundant  hemorrhage  sink  rapidly.  If  the  bleeding  do  not  cease  in 
twenty-four  hours,  death  will  probably  be  the  result. 

Treatment. — The  child  should  be  nourished  at  the  breast  if  possible, 
and  a  little  ice-water  be  given  with  a  spoon  along  with  the  breast-milk.  If 
the  infant  do  not  have  breast-milk,  peptonized  milk  may  be  employed.  The 
food,  of  whatever  kind,  should  be  given  cool.  It  has  been  recommended  to 
apply  the  ice-bag  over  the  abdomen  while  warm  applications  are  made  to  the 
extremities.  One  grain  of  tannic  or  gallic  acid  dissolved  in  cool  water  may 
be  given  every  hour,  or  one  or  two  drops  of  turpentine.  If  the  child  exhibit 
signs  of  failing  strength,  a  few  drops  of  brandy  should  be  given  at  short 
intervals  in  cold  peptonized  milk. 

DiARRHCEA   OF   THE   NeWLY-BORN. 

The  colostrum,  or  the  first  secretion  of  the  mammary  glands  after  parturi- 
tion, contains  more  oily  matter  and  sugar  than  occur  in  the  subsequent  secre- 
tion. In  consequence  of  this  peculiarity  in  its  composition  the  colostrum 
has  a  laxative  effect  by  which  the  meconium  is  expelled.  If  the  mammary 
glands  continue  to  secrete  colostrum  after  the  first  week,  diarrhoea  is  likely 
to  result.  A  more  common  cause  of  diarrhoea  of  the  newly-born  is  the 
employment  of  various  sweetened  mixtures  by  mothers  or  nurses  in  the 
belief  that  the  breast-milk  is  inadequate,  or  they  are  employed  for  the  pur- 
pose of  relieving  the  supposed  colicky  pains  whenever  the  baby  frets.  Cane- 
sugar  added  to  the  various  mint  teas  not  only  gives  rise  to  diai-rhoea.  but  alsc 
in  time  to  more  or  less  gastro-intestinal  catarrh  and  stomatitis,  with  the  occur- 
rence of  sprue.  Sprue  is  more  common  in  the  newly-born  than  at  any  other 
period  of  life,  and  it  can  usually,  according  to  my  experience,  be  traced  to 
the  use  of  improper  sweetened  mixtures.  The  infant  immediately  after  birth 
may  be  given  a  little  sweetened  water  or  a  teaspoonful  of  sweet  oil  to  aid  in 
the  expulsion  of  the  meconium,  but  subsequently,  in  the  great  majority  of 
cases,  no  carminative  or  nutritive  mixtures  are  required.     The  breasts  of  the 


154  H^MATEMESIS  AND  MELMNA  NEONATORUM. 

motlier  if  she  have  the  usual  health  furnish  all  that  is  needed.  The  neonatus 
requires  almost  no  nutriment  during  the  first  three  days,  and  the  breasts  fur- 
nish but  little  during  this  time,  but  frequent  traction  upon  the  nipple  pro- 
motes the  mammary  secretion,  and  after  the  third  day,  in  ordinary  cases, 
sufiicient  nutriment  is  obtained  from  the  breasts  to  supply  the  wants  of  the 
system  and  promote  a  healthy  growth.  If  what  is  natural  were  left  to  itself, 
and  no  artificial  measures  were  employed,  the  result  in  most  instances  would 
be  good ;  but  the  unfortunate  practice  of  filling  the  infant's  stomach  with 
various  admixtures  disturbs  normal  digestion,  impairs  the  appetite,  causes 
colicky  pains,  vomiting,  and  diarrhoea,  and,  if  persisted  in,  gastro-intestinal 
catarrh.  In  many  cases  green  fermenting  and  unhealthy  stools  cease,  and 
a  more  normal  state  of  the  digestive  apparatus  is  produced  by  forbid- 
ding the  use  of  superfluous  and  injurious  food  and  drinks  which  had  been 
given  to  supplement  wet-nursing  in  the  mistaken  belief  that  more  food  was 
required.  Food  in  excess,  even  if  it  be  of  the  proper  quality,  even  if  it  be 
breast-milk,  usually  causes  diarrhoea  if  it  be  not  vomited,  since,  not  being 
digested,  it  undergoes  fermentative  changes,  and  acts  as  an  irritant  until  it  is 
expelled.  Food  containing  a  large  proportion  of  sugar  is  laxative  in  con- 
sequence of  the  sugar. 

Diarrhoea  in  the  newly-born,  whatever  its  cause,  should  be  immediately 
arrested.  After  the  meconium  is  removed  by  the  action  of  the  colostrum, 
three  daily  evacuations  from  the  bowels  are  sufficient.  A  larger  number  is 
usually  attended  with  loss  of  flesh  and  strength.  The  use  of  sweetened 
mixtures,  which  nurses  are  in  the  habit  of  administering  when  infants  are 
not  well,  as  catnip,  fennel,  or  aniseed  tea,  we  repeat,  must  be  strictly  for- 
bidden. A  mother  with  a  sick  and  fretful  infant  usually  applies  it  to  the 
breast  too  frequently,  even  every  half  hour  during  the  day.  This  should 
also  be  strictly  forbidden.  The  infant,  like  the  adult,  should  take  food  at 
stated  intervals,  so  that  the  digestive  organs  may  have  some  respite  from  the 
task  of  digestion.  The  application  of  the  new-born  infant  to  the  breast  twelve 
times  in  twenty-four  hours  is  sufficient  for  its  nutrition,  and  the  mother's  health 
is  better  preserved  and  her  milk  of  better  quality  than  when  she  is  deprived  of 
the  needed  rest  by  more  frequent  suckling.  If  the  infant  be  unfortunately 
deprived  of  breast-milk  and  be  bottle-fed,  the  utmost  care  is  required  in  the 
selection  and  preparation  of  the  food,  as  well  as  in  determining  the  amount 
of  food  to  be  given  and  the  frequency  of  feeding.  Facts  relating  to  this 
important  subject  have  been  presented  in  preceding  pages.  Young  bottle- 
fed  infants  with  too  frequent  and  unhealthy  stools  sometimes  do  well  with 
peptonized  milk,  especially  if  flour  prepared  by  long  boiling  be  added  to  it. 
The  important  advantage  possessed  by  this  flour  is  that  its  starch  is  con- 
verted into  the  soluble  form,  and  a  considerable  part  of  it  into  dextrin, 
so  that  it  can  apparently  be  digested  by  young  infants  more  readily  than 
ordinary  flour.  A  teaspoonful  of  the  flour  long  boiled  may  be  added  to 
twenty  teaspoonfuls  of  peptonized  milk  for  young  infants  with  diarrhoea. 
The  beneficial  eff"ect  of  the  flour  is  due  largely  to  its  mechanical  action  in 
separating  the  particles  of  casein,  so  that  they  can  be  acted  on  more  readily 
by  the  gastric  juice,  which  in  young  infants  is  secreted  in  small  quantity. 
Sometimes  in  treating  the  diarrhcea  of  young  infants,  if  it  be  severe,  it  is 
better  to  withhold  entirely  milk  in  any  form  a  few  days,  and  give  in  its  place 
a  light  gruel  prepared  by  adding  the  barley  or  wheat  flour,  long  boiled,  to  water 
in  the  proportion  of  one  part  to  twenty.  When  it  is  heated  to  the  boiling- 
point  to  destroy  any  microbes  in  the  water,  place  it  upon  ice  or  in  cool  water, 
and  when  its  temperature  is  reduced  below  blood-heat  the  white  of  an  egg  or 
half  an  egg  may  be  added  with  sufficient  salt.  This  farinaceous  diet  some- 
times aids  materially  in  checking  the  diarrhoea.     Dextrin  can  be  digested  by 


CONSTIPATION  OF  THE  NEWLY-BORN.  155 

the  youngest  infant,  and  tlie  little  patient  may  be  sufficiently  nourished  for  a 
week  or  more  by  the  wheat  or  barley  flour  prepared  in  the  manner  stated 
in  the  chapter  on  infant  feeding,  with  the  salt  and  perhaps  white  of  egg 
added. 

If  the  diarrhoea  do  not  cease  by  the  use  of  the  proper  diet  given  in  suit- 
able quantity  at  proper  intervals,  which  should  not  be  oftener  than  two  and 
a  half  to  three  hours,  medicinal  treatment  is  needed.  I  have  found  the  fol- 
lowing prescriptions  very  useful  for  the  diarrhoea  of  infants  under  the  age  of 
■one  month,  as  well  as  for  those  that  are  older : 

R.  Bismutlii  snbnitrat.,  )5ii.i ; 

Pepsini  puri  in  lamellis,  3j.     Misce. 

Give  as  much  as  goes  on  a  ten-cent  piece  before  each  feeding. 

R.  Bismuthi  subnitrat.,  .^^ij  ; 

Misturte  ci'etse,  ^ij.     Misce. 

Shake  bottle,  and  give  twenty  drops  midway  between  the  feedings  to  a  child 
of  two  weeks.  This  alkaline  mixture  neutralizes  the  lactic,  butyric,  or  other 
injurious  acid  which  may  exist  in  excess  in  the  stomach  or  intestines.  In 
some  instances  one  or  two  drops  of  paregoric,  given  three  or  four  times  daily, 
have  a  salutary  effect  by  diminishing  the  peristalsis. 

Constipation  of  the  Newly-born. 

In  the  infant  constipation  results  from  several  different  causes.  The  most 
serious  and  obstinate  form  of  it,  to  which  the  term  obstipation  is  more  appro- 
priately applied,  arises  from  intestinal  malformations.  In  rare  instances  con- 
genital obstruction  occurs  in  the  small  intestines.  It  is  sometimes  produced 
by  cystic  tumors  or  twisting  of  the  intestine.  Congenital  stenosis  occasion- 
ally occurs  at  the  ileo-csecal  orifice.  Thus,  in  the  Transactions  of  the  London 
Fatholo(jical  Soci.etij  for  1870  is  the  history  of  a  case  in  which  there  was  such 
narrowing  of  the  ileo-cajcal  orifice,  believed  to  be  congenital,  that  a  No.  9 
eatheter  could  barely  be  passed  through  it.  The  patient  lived  until  his 
thirty-second  year,  but  thi-oughout  his  life  suffered  from  constipation  and 
•colic.  After  his  death  the  ileum  next  to  the  ileo-cfecal  valve  was  found  to 
have  a  diameter  of  seven  inches,  while  the  large  intestine  was  much  atro- 
phied and  its  entire  lumen  contracted  from  disuse.  Occasionally  the  stenosis 
occurs  a  little  above  the  ileo-caecal  orifice,  and  rarely  in  the  duodenum  at  the 
point  of  union  of  the  pancreatic  or  bile-duct  with  the  intestine.  The  obstacle 
in  some  instances  appears  to  be  hypertrophied  valvulae  conniventes,  the  edges 
of  two  opposite  folds  being  more  or  less  adherent.  Such  congenital  intestinal 
obstructions — whether,  as  is  probable,  produced  by  inflammations  in  the  foetus 
or  from  simple  perverted  nutrition  ;  whether  arising  from  the  syphilitic  ca- 
chexia or  other  cause — of  course  retard  the  evacuations  according  to  their  loca- 
tion and  the  amount  of  closure.  The  same  degree  of  stenosis  in  the  colon  or 
rectum  obviously  causes  a  more  constipating  effect  than  in  the  small  intes- 
tines, since  the  latter  have  more  mobility  than  the  former  and  their  contents 
are  more  liquid. 

But  the  most  common  of  the  congenital  obstructions  in  the  intestines 
occur  from  malformations  of  the  rectum.  These  malformations  vary  con- 
siderably in  different  cases.  They  may  be  classified  in  at  least  four  different 
groups :  1st.  The  anus  may  appear  normal,  but  instead  of  the  normal  rectum 
two  cul-de-sacs  are  present,  representing  the  upper  and  lower  ends  of  the  rec- 


156  HJEMATEMESIS  AND  MEL  JEN  A  NEONATORUM. 

turn,  and  connected  by  an  occluded  segment  of  the  rectum  or  by  a  firm  fibrous 
cord.  2d.  The  anus  is  absent,  and  the  rectum  has  a  fistulous  opening  in  the 
perineum,  or  through  the  scrotum  in  the  male  or  vulva  in  the  female.  In 
the  embryonic  development  the  outlet  of  the  rectum  was  formed  too  near 
and  encroached  upon  the  sexual  apparatus.  3d.  The  anus  is  absent,  and 
there  is  no  external  fistulous  opening  representing  the  anus,  but  the  rectum 
opens  at  some  point  upon  the  mucous  membrane  of  the  genito-urinary  appa- 
ratus. 4th.  Anus  absent  and  the  entire  lower  part  of  the  rectum  obliterated. 
The  upper  portion  of  the  rectum  terminates  in  a  cul-de-sac  in  the  neighbor- 
hood of  the  promontory.  Some  of  these  malformations  do  not  prevent  the 
discharge  of  fecal  matter,  but  when  there  is  closure  of  the  rectum  and  no 
fistulous  opening,  of  course  no  evacuation  of  the  intestines  can  occur  unless 
relief  be  obtained  by  surgical  measures.  In  the  ordinary  form  of  occlusion 
a  portion  of  the  rectum  is  represented  by  a  cord,  or  a  firm,  unyielding  septum 
shuts  ofi"  the  lower  part  of  the  rectum  from  that  above,  so  that  defecation  is 
impossible.  The  infant  with  this  serious  malformation  takes  the  breast  for  a 
time  like  other  infants,  but  the  intestines  soon  become  distended  with  fecal 
matter,  and  restlessness  from  the  distension  and  vomiting  occur.  The 
only  mode  of  relief  is  by  an  incision  or  puncture  through  the  obstruction  ; 
but  a  large  proportion  of  infants  with  this  obstructive  malformation  die 
whether  operated  on  or  not.  The  incision  or  puncture  should  be  made  as 
soon  as  the  obstruction  is  discovered,  and  if  successful  in  reaching  the  dis- 
tended intestine  above  the  malformation,  the  passage  thus  made  should  be 
kept  open  by  tubing  of  the  proper  size  if  the  infant  live.  If  the  operation 
be  unsuccessful  in  releasing  the  imprisoned  fecal  matter,  an  artificial  anus 
may  be  made  on  the  left  or  right  side. 

The  great  length  of  the  sigmoid  flexure  in  infancy,  and  the  curvatures 
which  occur  in  consequence,  more  in  number  than  in  older  children,  tend  to 
retard  the  descent  of  fecal  matter  and  promote  constipation.  In  the  adult 
numerous  depressions  and  inequalities  in  the  colon  retard  the  downward  move- 
ment of  the  intestinal  contents,  but  in  infancy  the  surface  of  the  colon  is  com- 
paratively smooth  and  even,  and  the  detention,  so  far  as  any  exists,  occurs  from 
the  curvatures  or  loops,  which  are  sometimes  twisted  partially  on  their  axes. 
The  sigmoid  flexure  is  so  long  in  infants  under  the  age  of  ten,  and  especially  of 
six  months,  that  the  curvatures  usually  lie  in  part  to  the  right  of  the  median 
line,  and  even  in  the  right  iliac  fossa.  Those  who  have  witnessed  the  post- 
mortem examinations  of  young  infants  in  the  asylums  flnd  no  diflSculty  in 
accepting  the  statement  of  certain  writers  that  the  curvatures  or  loops  in  the 
sigmoid  flexure,  which  sometimes  extend  as  high  as  the  umbilicus,  and  later- 
ally to  the  right  iliac  fossa,  cause  habitual  constipation  in  some  infants. 

Occasionally  in  young  infants,  as  well  as  in  those  who  are  older,  the 
intestines  act  sluggishly  from  insuflB.ciency  of  food.  Thus  the  infant  some- 
times hangs  an  unusually  long  time  on  the  breast,  and  the  mother  or  wet- 
nurse  believes  it  to  be  a  hearty  nurser,  when  there  is  really  a  deficiency  of 
milk,  and  the  stools  are  scanty  and  infrequent  from  lack  of  material :  under 
such  circumstances  the  infant  is  restless  when  away  from  the  breast,  or,  not 
being  fed,  loses  flesh,  and  soon  has  the  appearance  of  one  in  ill-health.  These 
symptoms  disappear  by  a  more  liberal  allowance  of  food  of  proper  quality. 
Thus,  recently  a  young  infant  was  brought  to  me  suff"ering  from  constipation 
and  fretfulness,  with  progressive  loss  of  flesh  and  strength  and  with  abundant 
urination.  Its  only  food,  prepared  through  the  advice  of  a  physician,  con- 
sisted of  a  teaspoonful  of  condensed  milk  to  one  pint  of  water.  By  a  more 
liberal  supply  of  food  the  constipation  disappeared. 

Again,  a  constipated  state  of  the  bowels  occasionally  occurs  in  infants 
who  nurse  heartily  and  seem  to  obtain  a  sufficient  quantity  of  milk ;  and  the 


CONSTIPATION  OF  THE  NEWLY-BORN.  157 

cause  of  it  appears  to  be  in  the  state  of  tlie  digestive  organs,  and  not  in  the 
milk.  We  find  now  and  then  that  breast-milk  has  a  constipating  effect, 
although  we  discover  nothing  in  the  mother's  diet  or  health  to  cause  this 
result.  The  comparison  of  ordinary  breast-milk  with  colostrum  may  furnish 
an  explanation  of  the  constipation  under  such  circumstances.  Colostrum  is 
known  to  be  more  laxative  than  ordinary  milk,  and  it  differs  from  it  chemi- 
cally in  containing  more  butter,  sugar,  and  salts.  Hence  the  theory  seems 
plausible  that  when  bi"east-milk  is  constipating  these  elements  occur  in  less 
than  the  normal  quantity,  and  we  will  find  that  treatment  suggested  by  this 
theory  tends  to  obviate  the  constipation. 

Constipation  has  also  been  attributed  to  a  deficiency  in  the  intestinal 
secretions  and  to  too  great  viscidity  of  them  from  lack  of  water.  Deficient 
peristalsis,  whether  from  congenital  weakness  or  other  cause,  also  leads  to 
constipation.  The  use  of  starchy  foods  without  sugar  or  with  but  little  sugar 
also  sometimes  has  a  constipating  effect. 

Gautier  of  Geneva,  Switzerland,  states  that  an  anal  fissure  is  a  common 
cause  of  constipation,  whether  in  the  newly-born  or  older  infants.  If  such  a 
fissure  be  present,  pain  in  defecation  might  instinctively  lead  the  infant  to 
resist  the  desire  to  evacuate  the  bowels  and  to  postpone  the  act,  so  as  to  estab- 
lish a  constipated  habit ;  but  if  such  fissures  are  common  in  this  country, 
except  in  the  syphilitic,  they  have  escaped  our  notice. 

Finally,  constipation  has  a  tendency  to  perpetuate  itself,  since  retained 
feculent  matter  becomes  more  consistent  and  firmer,  and  the  contractile  power 
of  the  muscular  tissue  becomes  weakened  by  over-distension. 

Symptoms. — When  there  is  a  mechanical  cause  of  scanty  and  infrequent 
defecation,  the  acuteness  of  the  symptoms  and  the  suffering  are  usually  pro- 
portionate to  the  degTee  of  obstruction.  In  cases  of  complete  obstruction  of 
the  intestines,  as  in  imperforate  rectum,  fecal  accumulation  occurs  above 
the  obstruction.  Under  such  circumstances  distension  of  the  abdomen,  vom- 
iting, fretfulness  apparently  from  the  abdominal  pain,  and  progressive  loss  of 
flesh  and  strength,  indicate  the  serious  nature  of  the  disease. 

In  constipation  from  other  causes — that  is,  without  obstruction  except 
such  as  arises  from  fecal  accumulation — the  condition  of  the  infant  may 
attract  little  attention  at  first ;  but  if  it  do  not  have  jjroper  evacuations  it 
soon  begins  to  suffer  in  its  health.  Fretfulness,  an  unhealthy  physiognomy,  vom- 
iting, and  more  or  less  fever  occur,  until  the  patient  is  relieved  of  the  ailment. 

A  beautiful  and  conservative  provision  in  the  system  is  that  by  which 
vicarious  functions  are  established  to  relieve  organs  which  imperfectly  per- 
form their  part.  While  the  intestinal  surface  is  to  a  great  degree  eliminative, 
so  that  noxious  and  effete  products  are  expelled  from  the  system  in  the  stools, 
it  possesses  also  in  a  high  degree  an  absorbent  function,  as  all  who  employ 
rectal  alimentation  are  aware.  If  the  intestine  fail  to  perform  its  function 
of  defecation,  so  that  feculent  matter  collects  within  it  and  begins  to  exert 
pressure  on  the  intestinal  surface,  more  or  less  of  the  liquid  portion  is  taken 
up  by  the  absorbents,  and,  entering  the  general  circulation,  it  finds  a  mode 
of  escape  through  other  emunctories.  The  general  ill-health  or  languor,  the 
furred  tongue,  foul  breath,  and  pain  in  the  head  which  characterize  these 
cases  are  no  doubt  due  to  the  absorption  into  the  blood  of  noxious  products 
derived  from  retained  feculent  matter.  But  cases  to  which  this  description 
is  applicable  are  not  common  in  early  infancy.  In  the  infant  the  retention 
is  often  only  in  the  rectum  or  rectum  and  sigmoid  flexure,  and  the  symptoms 
are  mild  and  are  relieved  by  free  evacuations,  which  are  easily  obtained. 
Between  these  mild  cases  and  the  graver  forms  of  constipation,  such  as  result 
from  mechanical  obstructions,  there  is  every  intermediate  grade,  attended  by 
symptoms  proportionately  severe. 


158  H^MATEMESIS  AND  MELMNA  NEONATORUM. 

Treatment. — It  is  very  important  that  constipation  in  the  infant  should 
be  detected  and  promptly  treated.  Not  only  its  present  health,  but  future 
well-being,  requires  this,  for  the  longer  the  constipated  habit  continues  the 
more  difficult  is  the  cure  ;  and  an  examination  of  the  records  of  extreme 
constipation  in  adult  life  which  are  found  in  medical  literature  reveals  the 
fact  that  in  many  instances  the  sluggish  state  of  the  intestines  commenced 
in  early  infancy.  The  following  case,  observed  by  Renauldin  and  related  by 
Dr.  Copland  in  his  3Iedical  Dictionary,  may  be  given  as  an  example :  A  med- 
ical officer  in  the  French  service  had  been  constipated  from  birth.  He  ate 
like  others,  but  habitually  had  only  one  stool  in  a  month  or  two  months,  and 
at  the  age  of  forty-two  three  to  four  months  elapsed  between  the  evacuations. 
His  abdomen  was  greatly  distended  and  painful,  and  lie  seldom  passed  more 
than  four  to  six  stools  in  the  year ;  but  he  lived  until  the  age  of  fifty-four 
years.  After  his  death  the  constipatron  was  found  to  be  due  to  a  fibrous 
but  incomplete  septum  only  one  inch  above  the  anus,  the  result,  apparently, 
of  a  malformation  in  the  foetal  development.  Even  when  no  malformation 
is  present  constipation  in  adult  life  can  frequently  be  traced  back  to  infancy. 

Usually  it  is  best  to  commence  the  treatment  of  constipation  by  an  enema, 
which  softens  and  removes  the  hardened  masses  which  have  collected  in  the 
rectum  and  the  adjacent  part  of  the  large  intestine.  For  a  young  infant 
tepid  water  or  tepid  water  containing  a  teaspoonful  of  glycerin  suffices  to 
produce  an  evacuation.  No  possible  harm  can  result  from  rectal  injections 
when  properly  employed ;  and  as  they  commonly  act  promptly,  without 
causing  pain  and  without  any  depressing  effect,  they  constitute  an  import- 
ant part  of  the  treatment  in  all  forms  of  constipation.  I  have  sometimes,  in 
cases  of  habitual  constipation,  ordered  for  young  infants  the  daily  injection 
of  three  teaspoonfuls  of  sweet  oil  and  one  of  castor  oil.  Injections  should 
always  be  prescribed  instead  of  medicine  by  the  mouth  when  there  is  rea- 
son to  believe  that  the  cause  of  the  constipation  is  mechanical,  as  from  the 
great  length  and  many  loops  in  the  sigmoid  flexure.  There  are  cases  of  con- 
stipation from  this  cause  for  which  injections  should  be  employed  daily  for 
many  months,  and  if  given  gently,  with  a  properly  lubricated  instrument,  they 
ultimately  give  complete  relief,  and  without  producing  any  injurious  effect. 
One  of  the  meat  broths  or  a  gruel  of  some  farinaceous  substance  may  some- 
times be  advantageously  employed  for  the  same  purpose. 

In  the  common  forms  of  constipation,  in  which  the  cause  is  feeble  peri- 
stalsis or  scanty  intestinal  secretions  or  the  use  of  food  of  too  constipating  a 
nature,  we  should  endeavor  to  render  the  ingesta  more  laxative.  Professor 
Jacobi  has  recommended  for  this  condition  to  give  a  lump  of  sugar  dissolved 
in  water  at  each  nursing.  I  have  employed  the  sugar  of  milk,  given  in  half- 
teaspoonful  doses,  to  young  infants  also  at  each  nursing,  or  several  times 
through  the  day  if  required.  Manna  dissolved  in  hot  water  is  also  an  old 
remedy  for  the  same  purpose.  Glucose,  into  which  starch  is  converted  in. 
the  process  of  digestion  and  also  by  the  action  of  the  diastase  of  malt,  is  like- 
wise laxative.  The  various  foods  of  the  shops  which  contain  glucose  derived 
from  barley  or  other  flour  by  the  agency  of  malt,  employed  as  directed  by  the, 
late  Baron  Liebig,  are  therefore  useful  in  the  treatment  of  habitual  consti- 
pation in  infants.  Of  four  constipated  infants  in  the  New  York  Infant. 
Asylum  to  whom  Horlick's  "  sugar  of  malt "  was  given,  three  were  relieved. 
Any  of  the  glucose  preparations  can  be  given  quite  freely  to  a  constipated 
infant  without  impairing  the  digestive  function  or  producing  other  ill-effect, 
so  long  as  no  more  than  the  normal  evacuations  are  produced  ;  and  I  consider 
them  among  the  best  and  safest  of  the  foods  for  the  relief  of  constipation  in 
infants.  But  glucose  or  grape-sugar  is  only  feebly  laxative ;  probably  not 
more  so  than  cane-sugar. 


TREATMENT.  159 

The  ordinary  purgatives  should  not  ha  given  habitually  to  relieve  a  con- 
stipated habit.  They  are  likely  to  irritate  the  intestines,  causing  a  catarrh, 
or  else,  the  intestines  becoming  accustomed  to  their  action,  a  large  dose  is 
required.  If  possible,  the  bowels  should  be  kept  open  by  dietetic  and  hygi- 
enic measures.  A  light  oatmeal  gruel,  long  boiled,  mixed  with  salt  and  con- 
siderable sugar,  given  at  or  between  the  nursings,  sometimes  has  the  desired 
effect,  especially  if  in  addition  to  the  salt  it  contain  considerable  sugar.  We 
may  aid  in  increasing  the  peristalsis  and  overcoming  the  constipation  by  the 
massage  treatment  over  the  bowels.  The  fingers,  lubricated  with  any  kind 
of  oil.  should  rub  and  knead  the  abdominal  surfiice.  I  have  seen  the  best 
results  from  this  treatment.  Cold  applications  over  the  abdomen,  so  highly 
recommended  by  Trousseau  in  adult  cases,  cannot  be  safely  employed  in 
infancy,  especially  in  early  infancy.  A  well-known  remedy  in  adult  cases 
is  the  use  morning  and  evening  of  a  tumblerful  of  cold  water.  Water 
may  also  be  added  in  considerable  quantity  to  the  ingesta  of  the  consti- 
pated infant. 

Although,  as  stated  above,  we  deprecate  the  necessity  of  using  habitually 
purgative  medicines  for  constipation,  sometimes  they  are  required,  but  if  a 
laxative  remedy  which  aids  in  the  nutrition  be  prescribed,  there  is  no  objec- 
tion to  its  use.     Such  a  remedy  is  the  following : 

R.  01.  morrrhuse,  5iv; 

Aq.  calcis, 
Syr.  calcis  lactophos.,         da.  ^ij. 

Shake  bottle  and  give  half  a  teaspoonful  three  times  daily  to  young  infants 
But  this  remedy,  useful  in  some  cases,  in  others  disappoints  our  expectations. 
If  it  be  necessary  to  employ  one  of  the  recognized  purgatives,  the  safest  and 
best  in  my  opinion  is  calcined  magnesia,  given  in  the  following  formula : 

R.  Magnesia  calcinat.,         .^j  ; 

Sacchari  lactis,  .^ij.     Misce. 

Fifteen  grains  to  a  drachm,  according  to  the  age,  may  be  given  to  infants,  and 
repeated  as  may  be  found  necessary. 

The  newly-born  infant  when  in  health  ordinarily  has  about  three  stools 
daily,  but  one  free  evacuation  may  be  sufficient.  We  know  that  the  function 
of  defecation  is,  to  a  certain  extent,  under  the  control  of  habit.  Adults  who 
have  evacuations  at  a  certain  hour  feel  the  need  of  them  each  day  as  that 
hour  arrives.  We  should  endeavor  to  encourage  this  habit  in  infancy  and 
childhood. 


CHAPTER  V. 

TETANUS  NEONATORUM. 

Tetanus  or  trismus  is  one  of  the  most  interesting  diseases  of  infancy. 
It  is  one  of  the  first  in  point  of  time  in  the  long  catalogue  of  fatal  maladies. 
It  occurs  suddenly  and  unexpectedly  in  the  robust  as  well  as  the  feeble,  almost 
certainly  destroying  life  within  a  few  hours  under  modes  of  treatment  hereto- 
fore employed.  It  is  more  frequent  in  some  localities  and  conditions  of  life 
than  in  others.  In  New  York  it  is  more  common  in  infancy  than  tetanus  at 
any  other  age,  or,  indeed,  in  all  other  ages,  since  the  mortuary  statistics  of 


160  TETANUS  NEONATORUM. 

this  city  exhibit  a  larger  number  of  deaths  from  this  disease  in  the  first  year 
of  life  than  subsequently.  Infantile  tetanus  occurs,  with  very  few  excep- 
tions, in  the  newly-born. 

Did  we  fully  understand  the  pathology  of  diseases  in  the  new-born,  or 
could  we  more  accurately  ascertain  the  condition  of  organs  at  this  age,  doubt- 
less we  should  occasionally  consider  those  phenomena  which  we  now  designate 
as  a  disease  7:>er  .se,  under  the  title  tetanus,  as  symptoms  of  some  other  affection. 
But  as  tetanic  rigidity  and  spasms  in  the  new-born  occur  so  abruptly,  masking 
all  other  symptoms  and  ordinarily  ending  in  death,  without  our  knowing  cer- 
tainly whether  or  not  there  is  any  antecedent  disease,  it  seems  proper  that 
we  should  recognize  the  state  in  which  such  muscular  rigidity  occurs  with 
such  a  rapid  result  as  an  independent  aifection.  This  explanation  is  required 
from  the  fact  that  I  have  added  to  the  accompanying  table  one  case  from 
Billard  which  this  observer  relates  under  the  head  of  spinal  meningitis.  In 
this  case  an  infant  three  days  old  was  attacked  with  convulsions.  "  His 
limbs  were  rigid  and  violently  bent ;  the  muscles  of  the  face  were  in  a  con- 
tinual state  of  contraction."  On  the  following  day  "the  convulsions  con- 
tinued ;  .  .  .  .  the  body  remained  rigid,  and  the  vertebral  column,  which  the 
weight  of  the  trunk  will  cause  to  bend  with  the  greatest  ease  in  a  young 
infant,  remained  straight  and  immovable  whenever  the  child  was  raised."  At 
the  autopsy,  in  addition  to  meningeal  apoplexy,  which  is  often  present  in  those 
who  die  of  tetanus  infantum,  a  thick  pellicular  exudation  was  found  upon  the 
spinal  arachnoid.  There  is,  therefore,  a  strict  accordance  of  the  symptoms 
and  history  of  this  case  with  those  which  other  observers  describe  as  exam- 
ples of  tetanus  infantum  ;  moreover,  as  a  satisfactory  reason  for  including 
this  case  in  our  statistics,  certain  observers,  as  we  shall  see,  have  reported 
epidemics  of  tetanus  in  which  meningitis  was  the  principal  lesion. 

Fatal  Cases. 

Case    1.  Male ;   taken  when  three  days  old ;  lived  sixty  hours.     Labatt,  Edin. 

Med.  and  Surg.  Jour.,  April,  1819. 
"      2.  Female  ;  taken  when  three  days  old  ;  lived  forty  hours.     Ibid. 
"      3.  Taken  when  five  days  old;  lived  fifty  hours.     Ibid. 
^'      4.  Taken  when  three  days  old  ;  lived  one  day.     Ibid. 
*'      5.  Male ;  taken  when  two  days  old ;  lived  two  days.     Billard,  Treatise  on 

Diseases  of  Children,  Stewart's  trans.,  p.  477. 
"      6.  Male ;  taken  when  three  days  old  ;  lived  two  days.     Romberg. 
"      7.  Male ;  taken  when  six  days  old ;  lived  ninety-three  hours.   Dr.  Imlach, 

Month.  Jour,  of  Med.  Sci.,  Aug.  1850. 
"      8.  Female  ;  taken  at  five  days  ;  lived  four  days.     Caleb  Woodworth,  M.  D., 

Boston  Med.  and  Surg.  Jour.,  Dec.  13,  1831. 
"      9.  Negro  ;  taken  at  seven  days ;  lived  twenty-four  hours.     P.  C.  Gaillard, 

M.  D.,  South.  Jour,  of  Med.  and  Phar.,  Sept.  1846. 
"    10.  Male ;  taken  when  seven  days  old ;  lived  one  day.     Augustus  Eberle, 

M.  D.,  Missouri  Med.  and  Sure/.  Jour.,  1847. 
"    11.  Taken  when  seven  days  old.     D.  B.  Nailer,  N.  0.  Med.  Jour.,  Nov.  1846. 
"    12.  Male ;  taken  when  three  days  old ;  lived  one  day,     N.  0.  Med.  and  Surg. 

Jour.,  May,  1853. 
^'    13.  Negro  ;  taken  when  three  days  old  ;  lived  three  days.     Robert  H.  Chinn, 

M.  D.,  N.  0.  Med.  and  Surg.  Jour. 
*'    14.  Taken  when  two  days  old ;  died  in  four  hours  after  the  doctor's  visit. 

Ibid. 
"    15.  Taken  when  seven  days  old ;  lived  one  day.     C.  H.  Cleveland,  New 
,  Jersey  Med.  Rep.,  April,  1852. 

''    16.  Negro ;  taken  when  seven  days  old  ;  death  finally.     Greenville  Dowell, 

Amer.  Jour,  of  Med.  Sci.,  Jan.  1863. 
■'    17.  Taken  when  twelve  days  old  ;  lived  one  day.     Thomas  C.  Boswell,  com- 
municated to  Dr.  Sims,  Amer.  Jour,  of  Med.  Sci.,  1846. 


PERIOD   OF  COMMENCEMENT.  161 

Case  18.  Taken  when  about  five  days  old;  died  at  about  the  age  of  nine  days. 
B.  R.  Jones.     Ibid. 

"  19.  Taken  at  or  soon  after  birth ;  lived  two  days.  Dr.  Sims,  Amer.  Jour,  of 
Med.  Sci.,  April,  1846. 

"    20.  Taken  at  the  age  of  six  days ;  lived  one  day.     Ibid. 

"    21.  Taken  when  three  days  old ;  lived  two  days.     Ibid. 

"  22.  Male ;  taken  at  the  age  of  eight  days  ;  died  in  three  hours.  Communi- 
cated to  the  writer. 

"  23.  Taken  at  the  age  of  twelve  hours ;  lived  two  days.  Communicated  to 
the  writer. 

"  24.  Female;  taken  when  seven  days  old;  lived  forty-five  hours.  The 
writer. 

"    25.  Male  ;  taken  at  the  age  of  seven  days ;  lived  forty-eight  hours.     Ibid. 

"    26.  Female  ;  taken  at  the  age  of  eight  days ;  lived  three  days.     Ibid. 

"    27.  Female ;  taken  at  the  age  of  five  days ;  lived  three  days.     Ibid. 

"    28.  Female ;  taken  when  four  days  old  ;  lived  two  days.     Ibid. 

"    29.  Taken  when  six  days  old  ;  died  next  day.     Ibid. 

"    80.  Taken  when  five  days  old  ;  lived  twenty-four  hours.     Ibid. 

"    31.  Taken  when  eight  days  old;  lived  two  days.     Ibid. 

"    32.  Male ;  taken  when  five  days  old ;  lived  one  day.     Ibid. 

Favorable  Cases. 

Case    1.  Negro;  female;  taken  when  three  days  old;  recovered  in  a  few  days. 

Robert  S.  Baily,  Charleston  Med,  Jour,  and  Rev.,  Nov.  1848. 
"      2.  Neero ;  taken  at  eleven  days ;  recovered  in  fifteen  days.    W.  B.  Lindsay, 

N.  0.  Med.  Jour.,  Sept.  1846. 
"      3.  Negro ;  taken  when  ten  days  old  ;  recovered  in  thirty-one  days.     P.  C. 

Gaillard,  Charleston  Med.  Jour,  and  Rev.,  Nov.  1853. 
"      4.  Male ;  taken  at  the  age  of  eight  days  ;  recovered  in  twenty-eight  days. 

Ibid. 
"      5.  Negro;   taken  at  seven  days;   recovered   in   fifteen  days.     Augustus 

Eberle,  Missouri  Med.  aiid  Surg.  Jour.,  1847. 
"      6.  Taken  when  eight  days  old ;  recovered  in  four  weeks.     Furlonge,  Edin. 

Med.  and  Surg.  Jour.,  Jan.  1830. 
"      7.  Taken  at  the  age  of  one  week  ;  recovered  in  two  days.     Dr.  Sims,  Amer. 

Jour  of  Med.  Sci.,  April,  1846. 
"      8.  Female  ;  taken  at  the  age  of  three  days ;  recovered  in  five  weeks.    The 

writer. 

Period  of  Commencement. — Finckh,^  who  saw  cases  of  tetanus  of  the 
newly-born  in  the  Stuttgart  Hospital,  states  that  it  began  in  1  case  on  the 
second  day  after  birth,  in  8  on  the  fifth,  and  in  7  on  the  seventh. 

Professor  Cederschjold  of  Stockholm  treated  45  cases  in  hospital  practice 
in  1834,  and  in  these  cases  it  usually  commenced  between  the  ages  of  four 
and  six  days.  Copland^  says  that  it  generally  commences  in  the  first  seven 
or  nine  days  after  birth,  and  rarely  later  than  the  fourteenth.  Romberg 
states  that  it  commences  between  the  fifth  and  ninth  days.  In  200  cases 
observed  by  Reicke  in  Stuttgart  in  the  course  of  forty-two  years,  it  was 
never  found  to  commence  before  the  fifth,  rarely  after  the  ninth,  and  never 
after  the  eleventh  day.  Schneider  says  that  the  disease  occurs  oftenest 
between  the  second  and  seventh,  and  rarely  after  the  ninth,  day.  In  6  cases 
reported  by  Dr.  C.  Levy  of  Copenhagen  it  began  in  2  on  the  third  day,  in  2 
on  the  fifth,  and  in  2  on  the  sixth.  Dr.  G-reenville  Dowell,'  who  has  seen 
much  of  tetanus  neonatorum  among  the  negroes  in  Mississippi  and  Texas,  says 
it  is  almost  sure  to  come  on  between  the  fifth  and  twelfth  days  after  birth. 
In  the  40  cases  embraced  in  the  above  table  the  disease  began  as  follows : 

^  Hecker's  Annalen,  vol.  iii.  No.  3,  p.  304.  ^  Medical  Dictionary. 

^  A^ner.  Jour,  of  Med.  Sci.,  Jan.,  1S63. 
11 


162  TETANUS  NEONATORUM. 

Age.  Cases. 

Under  two  days 2 

Two  days 1 

Three  days - 9 

Four  days 2 

Five  days 6 

Six  days 3 

Seven  days 8 

Eight  days 6 

Ten  days 1 

Eleven  days 1 

Twelve  days 1 

Very  rarely,  as  will  be  seen  hereafter,  tetanus  begins  at  or  so  soon  after 
birth  that  it  may  properly  be  called  congenital. 

Frequency  in  Certain  Localities. — Tetanus  neonatorum  occurs  prob- 
ably in  all  countries,  but  it  does  not  greatly  increase  the  mortality  except 
in  certain  localities.  Some  of  the  British  and  Continental  physicians,  vrhose 
observations  of  disease  have  been  ample,  confess  that  they  have  seen  so  few 
cases  that  they  have  almost  no  personal  knowledge  of  this  malady.  On  the 
other  hand,  there  are  or  have  been  places  in  every  zone  where  it  is  or  has 
been  so  prevalent  as  to  sensibly  check  the  increase  of  population.  The  atten- 
tion of  the  profession  more  than  a  half  century  since  was  directed  to  the 
prevalence  of  tetanus  in  the  island  of  Heimacy,  off  the  coast  of  Iceland. 
On  this  island  scarcely  an  infant  escaped,  while  on  the  mainland  scarcely 
one  was  affected.  Heimacy,  the  product  of  volcanic  action,  of  small  extent 
and  almost  destitute  of  vegetation,  supports  a  scanty  population.  The  inhab- 
itants live  chiefly  on  the  flesh  and  eggs  of  the  sea-fowl,  and  are  filthy  and 
degraded  in  their  habits.  About  the  year  1810  the  Danish  government 
deputed  the  landphysicus  of  Iceland  to  visit  Heimacy  and  ascertain  the 
nature  of  the  disease  which  was  so  destructive  to  the  infants.  Although 
this  gentleman,  from  his  brief  stay,  saw  no  case  himself,  he  obtained  interest- 
ing particulars  in  reference  to  the  disease  from  the  priests  and  parents.  At 
this  time  scarcely  an  infant  escaped.  Again,  according  to  Dr.  Schleisner, 
whose  report  in  reference  to  the  same  locality  was  published  forty  years  later, 
tetanus  was  still  the  most  fatal  of  all  infantile  maladies. 

Tetanus  neonatorum  is  also  represented  as  very  fatal  in  the  island  of  St. 
Kilda,  off  the  coast  of  Scotland.  In  the  temperate  regions  of  America  and 
Europe  cases  are  not  frequent,  except  occasionally  in  the  poor  quarters  of 
cities,  in  foundling  hospitals,  and  rarely  in  country  towns  where  the  condi- 
tions are  favorable  for  its  occurrence.  The  records  of  the  Dublin,  Stutt- 
gart, and  Stockholm  lying-in  asylums  furnish  many  cases.  In  the  town  of 
Fulda,  Germany,  in  1802,  Dr.  Schneider  saw  6  cases  in  fourteen  days,  while 
a  midwife  in  the  same  place  stated  that  she  had  seen  more  than  60  in  nine 
years. 

But  the  greatest  mortality  from  tetanus  neonatorum  is  in  the  warm  climates 
both  of  the  Eastern  and  Western  hemispheres.  In  the  West  Indies,  the  south- 
ern portion  of  the  United  States,  the  equatorial  regions  of  South  America, 
and  in  the  islands  of  Minorca  and  Bourbon,  it  has  in  many  localities  been  the 
most  frequent  and  fatal  of  infantile  maladies. 

It  is  an  interesting  fact  that  in  the  warm  regions  of  the  United  States  the 
victims  are  chiefly  negro  infants.  L.  S.  Grier,  M,  D.,^  of  Mississippi  says : 
"  The  first  form  of  disease  which  assails  the  negro  among  us  is  trismus.  The 
mortality  from  this  disease  alone  is  very  great.  No  statistical  record,  we  sup- 
pose, has  ever  been  attempted,  but  from  our  individual  experience  we  are 
almost  willing  to  afl&rm  that  it  decimates  the  African  race  upon  our  planta- 

^  N.  0.  Med.  and  Surg.  Jour.,  May,  1854. 


CAUSES.  16.3 

tions  within  the  first  week  of  independent  existence.  We  have  known  more 
than  one  instance  in  which,  of  the  birtlis  for  one  year,  one-half  became  the 
victims  of  tliis  disease,  and  that,  too,  in  spite  of  the  utmost  watchfulness  and 
care  on  the  part  of  both  planter  and  physician.  Other  places  are  more  for- 
tunate, but  all  suifer  more  or  less ;  and  the  planter  who  escapes  a  year  with- 
out having  to  record  a  case  of  trismus  nascentium  may  congratulate  himself 
on  being  more  favored  than  his  neighbors,  and  prepare  himself  for  his  own 
allotment,  which  is  surely  and  speedily  to  arrive."  Dr.  Wooten'  says:  "It 
is  a  disease  of  fatal  frequency  on  the  cotton  plantations  in  this  section  of 
Alabama."     He  has,  however,  never  seen  a  white  child  affected  with  it. 

While  tetanus  infantum  prevails  in  regions  wide  apart  and  presenting 
very  diverse  climatic  conditions,  there  is  a  similarity  as  regards  the  personal 
and  domiciliary  habits  of  the  people  who  suffer  most  from  its  occurrence.  It 
occurs  chiefly  among  those  who  are  filthy  and  degraded  in  their  habits — who 
live,  either  from  choice  or  necessity,  in  neglect  of  sanitary  requirements. 
This  fact  aids  us  in  an  understanding  of  the 

Causes. — That  uncleanliness  and  impure  air  are  causes  of  tetanus  is  as 
fully  demonstrated  as  most  facts  in  the  etiology  of  diseases.  The  attention 
of  the  profession  was  forcibly  directed  to  this  cause  by  Dr.  Joseph  Clarke  in 
a  paper  read  before  the  Royal  Irish  Academy  in  1789.  This  phy.sician  was 
in  charge  of  the  Dublin  Lying-in  Asylum,  and  had  rightly  concluded  that 
the  mortality  among  the  new-born  infants  was  due  to  imperfect  ventilation. 
Through  his  advice,  apertures  (twenty-four  inches  by  six)  were  made  in  the 
ceiling  of  each  ward ;  three  holes,  an  inch  in  diameter,  were  bored  in  each 
window-frame  ;  the  upper  parts  of  the  doors  leading  into  the  gallery  were  also 
perforated  with  sixteen  one-inch  apertures,  and  the  number  of  beds  was 
reduced.  The  results  of  these  simple  sanitary  regulations  may  be  seen  from 
Dr.  Clarke's  own  statement.  He  says  :  "  At  the  conclusion  of  the  year  1782, 
of  17,650  infants  born  alive  in  the  Lying-in  Hospital  of  this  city,  2944  had 
died  within  the  first  fortnight — that  is,  nearly  every  sixth  child."  The  disease 
in  nineteen  cases  out  of  twenty  was  tetanus.  After  the  wards  were  better 
ventilated — namely,  from  1782  till  the  time  of  the  preparation  of  Dr.  Clarke's 
paper — 8033  children  were  born  in  the  hospital,  and  only  419  in  all  had  died, 
or  about  one  in  nineteen.  So  impressed  was  Dr.  Evory  Kennedy,  who  at  a 
later  period  had  charge  of  the  same  asylum,  with  the  belief  that  Dr.  Clarke 
had  discovered  the  true  cause,  and  had  been  able  in  great  measure  to  prevent 
it,  that  he  enthusiastically  writes :  "•  If  we  except  Dr.  Jenner,  I  know  of  no 
physician  who  has  so  far  benefited  his  species,  making  the  actual  calculation 
of  human  life  saved  the  criterion  of  his  improvements."  The  cases  occur- 
ring in  my  own  practice  have  almost  all  been  in  tenement-houses,  where 
habits  of  cleanliness  are  not  observed,  and  I  have  not  yet  seen  in  the  prac- 
tice of  others  nor  heard  of  a  case  which  occurred  in  the  better  class  of  dom- 
iciles. The  statements  of  physicians  in  the  Southern  States,  who  .speak  from 
extensive  observation  among  negroes,  are  strongly  corroborative  of  the  belief 
that  the  disease  is  in  great  measure  due  to  uncleanliness  and  lack  of  pure  air. 

Dr.  Greenville  Dowell  of  Texas  states  that  he  has  been  able  to  trace  tetanus 
infantum  to  the  bed-clothes,  saturated  with  excrementitious  matters,  which 
are  found  in  the  negro  cabins.  In  a  paper  published  by  Prof.  John  M.  Wat- 
son -  the  frequency  of  this  disease  among  negroes  is  accounted  for  as  follows  : 
"  When  called  to  see  their  children  we  find  their  clothes  wet  around  their  hips, 
and  often  up  to  their  armpits,  with  urine The  child  is  thus  pre- 
sented to  us,  when,  on  examination,  we  find  the  umbilical  dressings  not  only  wet 
with   urine,  but   soiled,  likewise,   with   feces,  freely  giving  off  an   offensive 

1  iV.  0.  Med.  and  Surg.  Jour.,  May,  1846. 

^  Nashville  Jour,  of  Med.  and  Surg.,  June,  1851. 


164  TETANUS  NEONATORUM. 

urinous  and  fecal  odor,  combined  at  times  with  a  gangrenous  fetor  arising 
from  the  decomposition,  not  desiccation,  of  the  cord." 

Another  cause  is  believed  to  be  some  irritation  in  the  intestines,  as  from 
retained  meconium.  Observers  in  the  Southern  States  and  elsewhere  occa- 
sionally mention  this  as  a  cause.  In  one  case  treated  by  myself  there  was 
obstinate  constipation  immediately  before  the  attack,  and  in  another  diarrhoea 
preceded  and  was  the  only  apparent  cause. 

In  certain  cases  the  assignable  cause  is  exposure  to  wet  or  cold  or  to  a 
variable  temperature,  which,  it  is  known,  occasionally  produces  tetanus  in  the 
adult.  Prof.  Cederschjold  attributed  the  epidemic  which  he  observed  in 
Stockholm  to  a  sudden  change  of  temperature  from  hot  weather  in  May  to 
frosty  in  June.  In  a  case  related  by  Dr.  P.  C.  Gaillard  ^  the  disease  com- 
menced as  follows :  The  nurse  came  in  with  wet  apron  and  clothes  in  the 
evening  ;  a  short  time  after  she  had  taken  the  child  into  her  lap  it  sneezed 
violently  two  or  three  times.  At  10  p.  M.  tetanus  began.  In  certain  local- 
ities on  the  Continent,  where  there  are  no  parish  churches,  the  frequent  occur- 
rence of  tetanus  has  been  attributed  by  physicians  to  the  practice  of  carrying 
infants  to  a  distance  to  be  christened,  thus  exposing  them  to  winds.  In  this 
city  I  have  observed  tetanus  after  a  similar  exposure.  The  influence  of  the 
weather  in  the  production  of  tetanus  of  the  new-born  is  also  shown  by 
facts  observed  in  the  Stuttgart  hospital.  In  an  aggregate  of  25  cases 
treated  in  that  institution,  all  but  3  occurred  in  the  cold  months.  In  the 
island  of  Cayenne,  at  a  hamlet  surrounded  by  mountains  and  dense  forests, 
tetanus  attacked  only  one  in  every  twelve  of  the  new-born  infants.  After  a  great 
part  of  the  forests  had  been  cut  down,  so  as  to  allow  access  to  the  cold  sea- 
winds,  almost  all  the  new-born  infants  fell  victims  to  tetanus  (^Insel.  Cayenne). 

Hein  relates  that  a  citizen  of  Berlin  lost,  successively,  two  children  with 
tetanus  soon  after  birth.  When  the  second  child  fell  ill  he  observed  that  its 
cradle  was  exposed  to  a  current  of  air.  At  the  third  accouchement  the 
position  of  the  cradle  was  changed  and  the  infant  escaped.  Exposure  to  wet 
and  cold  has  been  long  recognized  as  a  cause  of  the  disease.  According  to 
Sauvages,  "  Hie  morbus  hieme  et  cum  aura  humida  saspius  advenit  quam 
sicca  sestate."  ^ 

The  causes  of  infantile  tetanus  enumerated  above  may  be  proximate  or 
remote,  may  produce  the  disease  by  their  direct  effect  on  the  system  or  indi- 
rectly by  causing  a  pathological  state  which  in  turn  leads  to  the  development 
of  the  disease.  There  are  other  direct  causes — namely,  organic  affections. 
In  the  bodies  of  the  new-born  who  die  of  tetanus  lesions  are  observed  which 
doubtless  result  from  the  spasms.  Again,  others  are  found  which  from  their 
nature  could  not  be  a  result,  and  which,  being  observed  in  different  cases,  are 
to  be  regarded  as  causes.  The  most  frequent  of  such  lesions  is  inflammation 
of  the  umbilicus  or  umbilical  vessels. 

Moschion,  who  lived  in  the  first  century  of  the  Christian  era,  stated  in 
writings  still  extant  that  stagnant  blood  in  the  umbilical  vessels  sometimes 
produced  dangerous  disease  in  the  new-born  infant,  and  it  is  supposed,  though 
this  is  doubtful,  that  he  referred  to  tetanus.  In  modern  times  the  attention 
of  the  profession  has  been  more  particularly  directed  to  this  cause  by  a  paper 
published  by  Dr.  Colles.^  The  observations  contained  in  this  paper  were 
made  in  the  Dublin  Lying-in  Hospital  during  a  period  of  five  years.  In  each 
of  these  years  he  witnessed  from  three  to  five  post-mortem  examinations  in  cases 
of  infantile  tetanus,  and  the  lesions,  he  states,  were  in  all  much  alike,  as  fol- 
lows :  The  floor  of  the  umbilical  fossa  was  lined  by  a  membrane  apparently 
formed  by  suppurative  inflammation,  and  in  the  centre  of  this  fossa  was  a  large 

^Southern  Jour,  of  Med.  and  Pharmacy,  Sept.,  1846. 

'  Nosol.  Method.,  vol.  i.  p.  531.  ^  Dublin  Hospital  Reports,  vol.  i.,  1818. 


CAUSES.  165 

papilla.  This  papilla  consisted  of  a  soft  yellow  substance,  apparently  the  prod- 
uct of  inflamnMition,  and  in  all  the  cases  the  umbilical  vessels  were  in  contact 
with  this  substance  and  were  pervious.  In  a  few  instances  superficial  ulcera- 
tions were  found  near  the  mouth  of  the  umbilical  vein,  and  occasionally  the 
skin  surrounding  the  umbilicus  was  raised.  The  peritoneum  covering  the  vein 
was  highly  vascular,  often  not  to  a  greater  distance  that  an  inch  above  the 
umbilicus,  but  sometimes  as  far  as  the  fissure  of  the  liver.  The  peritoneum 
in  the  course  of  the  umbilical  arteries  presented  the  inflammatory  appearance 
in  still  greater  degree,  sometimes  as  far  as  the  sides  of  the  bladder.  The 
connective  tissue  lying  along  the  arteries  and  urachus  anteriorly  was  loaded 
with  a  yellow  watery  fluid.  The  inner  surface  of  the  umbilical  vein  was  not 
inflamed,  but  its  coats  in  general  were  thickened.  On  slitting  open  the  arte- 
ries a  thick  yellow  fluid,  resembling  coagulable  lymph,  was  found  within  their 
coats,  and  in  all  cases  these  vessels  were  thickened  and  hardened  as  far  as 
the  fundus  of  the  bladder. 

Dr.  Finckh,  who  observed  25  cases  in  the  Stuttgart  Hospital,  believes  that 
the  most  frequent  cause  was  suppuration  or  ulceration  of  the  umbilical  cord. 
In  10  of  the  25  cases  the  navel  was  dry  and  cicatrized  ;  in  the  remainder  it 
was  either  wet  or  swollen,  with  a  bluish-red  inflamed  edge  at  the  margin  of 
the  navel ;  a  dirty  viscid  pus  covered  the  umbilical  depression. 

Dr.  Levy,  physician  of  the  Foundling  Hospital  in  Copenhagen,  attended 
22  cases  in  that  institution  in  1838  and  1839.  Of  these,  20  died,  and  15 
were  examined  carefully  after  death.  In  14  there  were  decided  marks  of 
inflammation  of  the  umbilical  arteries,  especially  of  those  portions  lying 
along  the  urinary  bladder ;  in  several  cases  the  peritoneum  over  the  arteries 
was  much  injected,  and  in  3  adherent  either  to  the  omentum  or  intestine  by 
coagulable  lymph  ;  the  coats  of  the  arteries  were  thickened,  their  cavities 
dilated  and  containing  dark  reddish-brown  or  greenish  puriform  matter,  always 
fetid.  Sometimes  the  arterial  tunica  interna  was  found  ulcerated  and  absent 
in  places,  and  there  was  spongy  thickening  of  the  subjacent  connective  tis- 
sue. In  2  cases  the  ulcerative  process  had  extended  from  the  tunica  interna 
to  the  peritoneum,  and  there  was  a  deposit  of  thick  ichorous  matter  around 
the  ulcer ;  in  1  case  both  arteries  were  so  softened  that  their  coats  were 
scarcely  distinguishable,  and  in  another  these  vessels  had  become  gangre- 
nous. The  appearance  of  the  umbilicus  was  unchanged  in  4  cases  ;  in  10 
tho  fundus  was  red  and  filled  with  puriform  fluid,  which  quickly  reappeared 
when  removed,  and,  in  general,  shortly  before  death  the  navel  presented  a 
greenish  color. 

According  to  Romberg,  Dr.  Schbller  made  post-mortem  examinations  in 
18  cases  of  tetanus  infantum,  and  in  15  found  inflammation  of  the  umbilical 
arteries.  These  vessels  were  swollen  near  the  bladder,  in  1  case  to  the  diam- 
eter of  four  lines,  and  were  found  to  contain  pus.  The  lining  membrane  was 
eroded  or  covered  with  an  albuminous  exudation.  Both  arteries  were  not 
always  equally  inflamed,  and  in  3  cases,  only  1  was  afi'ected. 

Schneeman  ^  found  minute  points  of  suppuration  in  the  umbilical  vein  in 
8  cases,  and  pus  throughout  the  course  of  this  vessel  in  1. 

The  observations  mentioned  above  were  made,  for  the  most  part,  in  hos- 
pitals on  tho  Continent,  but  similar  observations  have  been  made  in  private 
practice.  M.  Borian  ^  of  the  isle  of  Bourbon  says  that  he  has  found  in  every 
case  inflammation  around  the  umbilicus.  Dr.  John  Furlonge,^  who  resided 
at  St.  John's,  Antigua,  attributes  the  disease  to  improper  dressing  of  the 

'  Holscher'fs  Annalen,  vol.  v.  p.  484,  1840. 
*  Gazette  medicale,  Paris,  July  11,  1841. 
^  Edin.  Med.  and  Surg.  Jour.,  .Jan.,  1830. 


166  TETANUS  NEONATORUM. 

umbilicus.  The  same  opinion  is  expressed  by  Mr.  Maxwell,^  who  also  saw 
the  disease  in  the  West  Indies.  Dr.  Hansom  ^  states  in  a  communication  to 
Prof.  John  M.  Watson  that  he  has  never  seen  a  case  of  tetanus  of  the  new- 
born in  which  the  umbilicus  was  healthy.  In  a  case  related  by  Robert  S. 
Bailey  ^  there  was  a  hard  scab  on  one  side  of  the  umbilicus,  and  this  part  was 
much  distended.  A  discharge  followed  the  removal  of  the  scab,  and  the 
child  recovered.  In  a  favorable  case  related  by  W.  B.  Lindsay  *  the  umbili- 
cus was  tumid  and  not  disposed  to  heal.  Dr.  H.  0.  Wooten  *  attributes  the 
disease  to  the  condition  of  the  umbilicus  and  umbilical  vessels,  and  states 
that  he  has  found  the  umbilicus  gangrenous.  A  case  has  been  reported  in 
which  the  umbilical  vessels  were  blocked  up  by  purulent  matter.*^  Robert 
H.  Chinn,  M.  D.,''  of  Brazoria,  Texas,  believes  one  cause  of  the  disease  to  be 
improper  tying  and  management  of  the  umbilical  cord,  by  which  a  diseased 
state  is  produced  which  extends  to  the  umbilicus  and  thence  to  the  viscera. 
At  a  meeting  of  the  Obstetrical  Society  of  Edinburgh,  held  April  24,  1850, 
Dr.  Imlach  related  a  case  in  which  there  was  a  dark  and  gangrenous  appear- 
ance on  the  integument  around  the  umbilicus,  and  the  peritoneum  underneath 
was  also  dark,  but  not  inflamed ;  umbilical  vein  healthy ;  a  little  fibrin  in  the 
left  umbilical  artery ;  right  umbilical  artery  much  diseased ;  its  two  inner 
coats  apparently  destroyed,  and  in  their  place  a  yellow  pultaceous  slough  in 
which  pus-globules  were  discovered  with  the  microscope. 

It  is  evident  that  the  pathological  state  of  the  umbilicus  and  umbilical 
vessels  described  above,  and  which  has  been  noticed  by  so  many  observers 
in  different  countries,  cannot  result  from  the  tetanus.  It  is  possible  that  the 
puriform  substance  noticed  in  the  umbilical  vessels  was  disintegrated  fibrin, 
■which  had  coagulated  at  the  time  of  ligation  of  the  cord,  and  the  cells  seen 
by  Dr.  Imlach  and  others  may  sometimes  have  been  white  corpuscles  still 
remaining  from  the  stagnated  blood.^  Still,  the  evidences  of  inflammation, 
in  at  least  a  part  of  the  cases  related  above,  were  of  a  positive  character. 

The  belief  that  umbilical  lesions  occasionally  cause  tetanus  infantum  com- 
ports with  the  well-known  traumatic  causation  of  tetanus  in  the  adult.  This 
belief  is  strengthened  by  the  fact  which  will  appear  farther  on  in  our  remarks 
that  tetanus  of  the  new-born,  from  being  frequent  in  certain  localities,  has 
become  infrequent  through  greater  care  in  dressing  and  managing  the  umbil- 
ical cord. 

But  there  are  cases  of  tetanus  infantum  in  which  there  is  no  disease  in 
or  about  the  umbilicus.  Dr.  Finckh  of  Stuttgart  examined  the  umbilical 
vessels  in  eleven  cases  without  discovering  any  pathological  change.  Dr. 
Samuel  B.  Labatt,"  master  of  the  Dublin  Lying-in  Hospital,  published  a 
paper  entitled  '*  An  Inquiry  into  the  Alleged  Connection  between  Trismus 
Nascentium  and  Certain  Diseased  Appearances  in  the  Umbilicus."  This 
paper  was  designed  as  a  reply  to  the  essay  of  Dr.  Colles.  Dr.  Labatt  relates 
several  cases  in  which  there  was  no  disease  of  the  umbilicus  and  umbilical 
vessels,  and  others  in  which  the  disease  was  so  slight  that  it  probably  pro- 
duced no  injurious  eff'ect  on  the  health  of  the  child.  Dr.  James  Thomp- 
son,^"* who  spent  considerable  time  in  the  tropical  regions,  says :  "  I  have 
myself  examined  nearly  40  cases  of  infants  that  have  sunk  under  this  com- 
plaint.    In  many  I  have  looked  at  no  other  part  than  the  navel,  and  have 

^  Jamaica  Phys.  Jour.,  copied  into  the  London  Lancet,  April  11,  1856. 
■•'  Nashville  Jour,  of  Med.  and  Surg.,  June,  1851. 
^  Charleston  Med.  Jour,  and  Rev.,  Nov.,  1848. 

*  N.  0.  Med.  and  Surg.  Jour.,  Sept.,  1846.  *  Ibid.,  May,  1846. 

«  Ibid.,  May  1,  1853.  '  Ibid.,  Sept.,  1854. 

^  Virchow's  Cellul.  Pathol.  ®  Edin.  Med.  and  Surg.  Jour.,  April,  1819. 

19  Ibid.,  Jan.,  1822. 


CAUSES.  167 

found  it  in  all  states — sometimes  perfectly  healed,  especially  if  the  infants 
had  lived  several  days ;  at  other  times  a  simple  clean  wound.  When  death 
occurred  on  the  fifth  or  sixth  day  the  wound  was  frequently  in  a  raw  state. 
I  never  yet  saw  it  in  a  sphacelated  condition."  This  writer  concludes  from  his 
observations  that  there  are  cases  in  which  the  cause  is  located  elsewhere  than 
in  the  umbilicus  or  umbilical  vessels.  Dr.  John  Breen  ^  remarks :  "  From 
dissections  ....  Ave  have  never  been  able  to  discover  any  peculiar  morbid 
appearance  which  would  justify  us  in  offering  any  explanation  of  the  pathol- 
ogy of  the  disease."  In  my  own  cases  there  was  no  evidence  of  disease  of 
the  umbilicus  or  umbilical  vessels,  so  far  as  could  be  ascertained  by  external 
examination,  and  in  one  (No.  32)  a  careful  post-mortem  examination  dis- 
closed no  lesion  of  these  parts. 

The  inference  from  the  above  observations  is  that,  although  umbilical 
disease  may  be  an  occasional,  probably  not  infrequent,  cause  of  tetanus 
neonatorum,  cases  occur  in  which  such  disease  is  not  present,  and  we  must 
look  for  the  cause  elsewhere.  From  the  nature  of  tetanus  neonatorum,  the 
cerebro-spinal  axis  has  been  from  time  to  time  examined  in  those  who  have 
died  of  this  malady,  and  occasionally  sufficient  cause  has  been  found  in  this 
part  of  the  system. 

I  have  alluded  in  another  connection  to  a  case  from  Billard  in  which 
tetanic  rigidity  occurred  in  an  infant  three  days  old  as  the  result  of  spinal 
meningitis.  That  tonic  spasms  not  infrequently  occur  in  older  children  in 
consequence  of  meningeal  inflammation  is  well  known,  and  in  some  of  the 
reported  epidemics  of  infantile  tetanus  meningitis  was  really  present,  and 
was  doubtless  the  cause  of  the  tonic  spasms.  Such  an  epidemic  was 
observed  by  Professor  Cederschjold  in  Stockholm  in  1834.  Within  a  few 
months  he  treated  42  cases,  and  in  addition  to  the  lesions  which  are  known 
to  result  from  tetanus,  there  was  found  in  the  bodies  examined  a  fibrinous  exu- 
dation at  the  base  of  the  brain.  Finckli  of  Stuttgai't  made  20  post-mortem 
examinations  of  those  who  had  died  of  this  disease,  and  in  9  found  spinal 
meningeal  inflammation. 

Meningitis  in  the  new-born  is,  however,  rare,  and  we  must  regard  it  as 
exceptional  in  cases  of  tetanus. 

In  1846  the  late  Dr.  Marion  Sims  published  a  paper  designed  to  show 
that  tetanus  neonatorum  results  from  injury  of  the  brain  produced  by 
depression  of  the  occipital  bone ;  but  I  am  not  aware  that  this  theory  has 
any  adherents  at  the  present  day.  It  is  true  that  occipital  depression  quick- 
ly occurs  in  cases  of  tetanus,  but  it  appears  to  be  due  mainly  to  the  rapid 
emaciation  of  the  brain  and  diminished  cerebral  circulation  which  attend 
this  disease. 

Finckh  made  post-mortem  inspection  of  20  cases  in  the  Stuttgart  Hospital, 
the  bodies  at  death  having  been  placed  on  their  faces  in  order  to  prevent  any 
deceptive  appearance  from  the  gravitation  of  blood.  In  4  he  failed  to  detect 
any  alteration  in  the  spinal  cord  or  its  membranes,  but  in  the  remaining  16  he 
found  effusion  of  blood  in  considerable  quantity  the  whole  length  of  the 
spinal  cord  between  the  bony  walls  and  the  dura  mater.  It  should  be  stated, 
however,  that  spinal  meningeal  inflammation  was  present  in  9  of  the  16, 
though  the  extravasation  did  not  probably  result  from  the  inflammation,  but 
from  the  tetanus.  The  blood  in  Finckh's  cases  was  verj'  dark — sometimes 
fluid,  at  other  times  coagulated.  In  1  case  no  change  was  observed  in  the 
appearance  of  the  brain  or  its  membranes.  In  the  remaining  19  more  or 
less  extravasated  blood  was  found  on  the  surface  of  the  brain  or  in  its  inte- 
rior. The  substance  of  the  brain  was  healthy,  as  also  its  membranes,  except 
the  congestion.     The  only  abnormal  appearance  observed  in  the  thoracic  and 

1  Dub.  Jour,  of  Med.  and  Chem.  Sci.,  Jan.,  1836. 


168  TETANUS  NEONATORUM. 

abdominal  viscera  was  strong  contraction  of  some  portion  of  the  intestinal 
tube  in  five  cases.  Dr.  West  says :  "  The  most  frequent  post-mortem 
appearances  in  these  cases  " — referring  to  tetanus  neonatorum — "  and  that 
which  I  found  in  the  bodies  of  all  the  four  children  whom  I  observed,  con- 
sist of  effusion  of  blood,  either  fluid  or  coagulated,  into  the  cellular  tissue 
surrounding  the  theca  of  the  cord.  Conjoined  with  this  there  is  generally  a 
congested  state  of  the  vessels  of  the  spinal  arachnoid,  and  sometimes  an 
effusion  of  blood  or  serum  into  its  cavity.  The  signs  of  congestion  about 
the  head  are  less  constant,  though  much  oftener  present  than  absent,  and 
sometimes  existing  in  an  extreme  degree ;  while  in  one  instance  I  found  not 
merely  a  highly  congested  state  of  the  cerebral  vessels,  but  also  an  effusion 
of  blood  in  considerable  quantity  between  the  skull  and  dura  mater,  and 
also  a  slighter  effusion  into  the  arachnoid  cavity."  Dr.  Weber  of  Kiel  also 
placed  on  their  faces  infants  who  had  died  of  tetanus,  and  without  exception, 
found  injection  of  the  capillaries  of  the  cord  and  spinal  meninges  and 
extravasation  of  blood.  M.  Matusynski,  according  to  Bouchut,  "  has 
observed  effusions  of  blood  of  variable  quantity  in  the  cerebral  pia  mater,  in 
the  ventricles,  and  in  the  choroid  plexuses,  with  considerable  injection  of  the 
membranes  of  the  brain.  He  has  also  seen  serous  infiltration  beneath  the 
arachnoid  and  serous  effusion  into  the  ventricles,  accompanied  by  a  diminu- 
tion of  the  consistence  of  the  cerebral  substance."  In  two  cases  examined 
by  myself  there  was  intense  injection  of  the  cerebral  meninges  and  of  the 
meninges  of  the  upper  part  of  the  spine,  but  no  extravasation  was  noticed. 
The  spinal  canal  was  not  opened.  In  a  third  case,  in  which  the  spinal  canal 
was  opened,  there  was  extravasation  in  addition  to  the  congestion ;  this  was 
especially  observed  along  the  spinal  theca. 

Dr.  H.  0.  Wooten  ^  states  that  he  has  made  several  post-mortem  examina- 
tions, and  has  found  the  pathological  appearances  as  uniform  as  in  any  other 
disease,  as  follows :  "  Engorgement  of  the  substance  of  the  brain  and  of  the 
meninges  lining  the  base  of  the  brain,  the  medulla  oblongata,  and  spinal 
marrow  ;  liver  congested." 

In  a  case  related  by  Dr.  Imlach  before  the  Edinburgh  Obstetrical  Society, 
April  24,  1850,  the  upper  part  of  the  lungs  was  healthy,  the  posterior  por- 
tion congested  and  containing  many  dark  points ;  heart  and  liver  healthy ; 
small  intestines  of  a  light-brown  color ;  stomach  and  large  intestines  pallid ; 
there  had  been  umbilical  hemorrhage. 

Romberg  states  that  he  found  in  a  child  whose  death  occurred  from  this 
disease  such  intense  congestion  of  the  veins  and  sinuses  of  the  brain  that  a 
slight  touch  and  the  removal  of  the  cranial  bones  produced  extravasation  of 
the  partly  coagulated  and  partly  fluid  blood.  Dr.  Scholler,  on  the  other 
hand,  found  extravasation  of  blood  in  the  spinal  canal  in  only  1  case  in 
18. 

It  is  seen  from  the  above  observations  that  tetanus  neonatorum  is  ordi- 
narily accompanied  by  extreme  passive  congestion  of  the  internal  organs, 
including  the  cerebro-spinal  axis  and  its  meningeal  investment.  The  embar- 
rassment of  respiration  and  the  retarded  circulation  of  blood  consequent  on 
the  tetanic  rigidity  afford  sufficient  explanation  of  this  state  of  the  vessels. 

We  have  stated  at  length  the  condition  of  the  various  organs  in  those 
who  have  perished  from  tetanus,  as  reported  by  competent  observers  in  different 
localities,  so  that,  if  possible,  light  might  be  thrown  on  the  causation  of  this 
interesting  and  fatal  malady.  But  observations  more  recent  than  those  given 
above  appear  to  show  that  tetanus  is,  sometimes  at  least,  a  microbic  disease 
and  is  communicable  by  inoculation.  Dr.  E.  Riper  of  Greifswalde  {Cen- 
tralhlatt  fiir  3Iedicin,  Oct.  15,  1887)  states  that  parts  of  the  navel  removed 
^  N.  0.  Med.  and  Surg.  Jour.,  May,  1846. 


CAUSES.  IG'J 

with  sterilized  instruments  from  an  infant  having  tetanus  communicated  the 
disease  by  inocuhition  to  six  mice.  Guinea-pigs  inoculated  with  a  little  of 
the  tissue  taken  from  the  wounds  in  the  dead  mice  took  tetanus  five  days 
later.  Dr.  Beumer  (Berliit.  kliii.  Wvch.,  No.  30,  1887)  also  states  that  he 
communicated  tetanus  to  mice  and  guinea-pigs  by  inoculating  them  with  tis- 
sue from  the  umbilicus  of  an  infant  that  died  of  tetanus.  Recently,  Ver- 
neuil  of  France  has  published  two  papers  in  which  he  cites  instances  appa- 
rently showing  that  tetanus  is  sometimes  derived  from  the  lower  animals^ 
especially  the  horse,  and  is  in  other  instances  communicated  by  man  to  the 
lower  animals.  Verneuil  cites  the  following  interesting  example  showing 
the  mode  of  infection  :  A  newly-born  child  died  of  tetanus.  Its  mother 
took  a  nurse-child,  which  soon  perished  from  the  same  disease.  Fifteen  days 
after,  the  family  horse  contracted  the  disease,  which  was  tedious,  but  it  ended 
favorably.  Before  it  recovered  the  woman  also  contracted  tetanus,  which 
was  protracted,  but  not  fatal.  Dr.  T.  B.  Adams,  physician  to  the  Foochow 
Native  Hospital,  states  that  tetanus  is  rare  in  Southern  China,  but  a  patient 
died  of  it  in  one  of  the  hospital  wards  on  Oct.  1,  1887.  On  Oct.  8th  a 
patient  with  bleeding  piles  was  assigned  to  the  same  little  room  in  which 
the  patient  with  tetanus  had  died,  and  the  piles  were  ligated  two  days  later. 
Nine  days  after  the  operation  tetanus  commenced,  and  was  fatal.  In  1886^ 
Rosenbach  produced  tetanus  in  two  guinea-pigs  by  introducing  under  their 
skin  a  little  gangrenous  substance  from  the  sore  of  a  patient  with  tetanus. 
In  1887,  Bonome  had  under  observation  three  patients  with  tetanus  who 
were  wounded  by  the  falling  of  a  church.  In  the  fetid  wounds  of  these 
patients  he  discovered,  in  addition  to  numerous  other  bacteria,  a  slender 
bristle-like  bacillus,  thick,  straighter,  and  longer  than  the  tubercle  bacillus, 
and  with  a  rounded  extremity,  so  as  to  resemble  a  pin.  He  was  unable 
to  cultivate  it,  but  inoculations  with  the  pus  which  contained  it  caused 
tetanus. 

Other  observations  and  experiments  similar  to  the  above  might  also  be 
stated,  so  that  there  is  little  doubt  that  the  tetanus  of  animals  and  that  of 
man  are  identical,  and  that  this  disease  is  inoculable  and  therefore  infectious. 
Dr.  E.  0.  Shakespeare  in  a  recent  paper  on  traumatic  tetanus  arrives  at  the 
following  conclusions  :  "  Traumatic  tetanus  of  animals  and  of  man  is  at  least 
sometimes,  if  not  constantly,  an  infectious  specific  affection,  due  to  the  action 
of  a  specific  infectious  virus  which  exists  in  the  tissues  around  the  seat  of 
the  infection,  in  the  blood,  and  in  the  central  cerebro-spinal  system." 

The  observations  detailed  above  certainly  lend  strong  support  to  the 
theory  that  tetanus  is  produced  by  a  microbe,  but  it  is  stated  that  Brieger 
has  succeeded  in  isolating  a  ptomaine  produced  in  the  cultures  of  the  bacillus 
of  Rosenbach,  which  ptomaine  has  the  formula  Ci^HsoAg.^Oi,  and,  injected, 
hypodermically  in  animals,  produces  tetanic  symptoms  (^Annual  of  the  Univer. 
Med.  Sci.,  vol.  iii.,  1889).  But  even  if  it  be  shown  that  the  immediate  cause 
of  tetanus  is  a  ptomaine,  the  theory  of  its  microbic  origin  is  not  invalidated, 
since  tTie  ptomaine  results  from  microbic  action.  That  the  cause  is  a  micro- 
organism, and  that  it  may  reside  in  the  soil,  has  been  shown  by  the  recent 
observations  of  Prof.  Wm.  H.  Welch  of  Johns  Hopkins  University,  who  in 
his  address  before  the  American  Medical  Association  at  Newport,  June  28, 
1889,  said:  "Among  the  pathogenic  bacteria  which  have  their  natural  home 
in  the  soil,  the  most  widely  distributed  are  the  bacilli  of  malignant  oedema 
and  those  of  tetanus.  I  have  found  some  garden  earth  in  Baltimore  extremely 
rich  in  tetanus  bacilli,  so  that  the  inoculation  of  animals  in  the  laboratory 
with  small  bits  of  this  earth  rarely  fails  to  produce  tetanus."  But  whether 
this  disease  is  produced  directly  by  the  agency  of  a  microbe,  or  by  a  ptomaine 
resulting  from  microbic  action,  or  occasionally  by  other  causes  distinct  from 


170  TETANUS  NEONATORUM. 

either  microbe  or  ptomaine,  it  cannot  be  doubted  that  the  cause  is  the  same 
in  tetanus  neonatorum  as  in  that  of  the  adult.  We  have  seen  that  many 
observers  have  regarded  uncleanliness  as  the  common  cause  of  tetanus 
neonatorum,  since  they  have  remarked  its  occurrence  when  the  umbilical 
dressing  was  filthy  and  ofi"ensive  or  the  apartments  or  the  surroundings  dirty. 
These  observations  are  compatible  with  the  theory  of  the  microbic  origin  of 
tetanus,  for  microbes  find  a  nidus  and  are  propagated  in  greatest  abundance 
where  insanitary  conditions  exist. 

Symptoms. — In  many  cases  premonitory  symptoms  are  absent  or  are  so 
slight  as  to  escape  notice.  In  some  patients  fretfulness  precedes  the  attack, 
but  no  more  than  is  often  observed  in  those  who  continue  in  good  health. 
The  first  symptom  which  alarms  the  parents  and  shows  the  grave  nature  of 
the  commencing  disease  is  inability  to  nurse  or  evident  pain  and  hesitation  in 
nursing.  Commencing  with  rigidity  of  the  masseters,  the  disease  gradually 
extends  to  the  other  voluntary  muscles,  and  in  the  course  of  a  few  hours  the 
muscles  of  the  limbs  as  well  as  of  the  trunk  are  involved.  Persistent  mus- 
cular contraction,  which  is  the  pathognomonic  feature  of  infantile  tetanus,  is 
developed  not  fully  in  the  beginning,  but  by  degrees  in  each  affected  muscle, 
so  that  it  is  not  till  after  the  lapse  of  several  hours,  perhaps  even  a  day,  that 
the  greatest  amount  of  rigidity  is  attained.  Therefore  in  the  commence- 
ment of  the  disease  the  limbs  can  be  flexed  and  the  jaw  pressed  open 
more  readily  than  at  a  subsequent  stage,  though  with  manifest  pain  to 
the  infant. 

During  the  period  of  maximum  rigidity  the  jaws  are  fixed  almost  immov- 
ably, often  with  a  little  interspace  between  them,  against  which  the  tongue 
presses  and  in  which  frothy  saliva  collects.  The  head  is  thrown  backward 
and  held  in  a  fixed  position  by  the  stiff"ness  of  the  cervical  muscles.  The  fore- 
arms are  flexed ;  the  thumbs  are  thrown  across  the  palms  of  the  hands,  and 
are  firmly  clenched  by  the  fingers ;  the  thighs  are  drawn  toward  the  trunk ; 
the  great  toes  are  adducted  and  the  other  toes  flexed.  Occasionally  opisthot- 
onos results  from  the  extreme  contraction  of  the  dorsal  and  posterior  cervical 
muscles.  The  infant  can  sometimes  be  raised  without  any  yielding  of  the 
muscles  by  the  one  band  under  the  occiput  and  the  other  under  the  heels. 

The  rigidity  is  liable  to  variation  in  its  intensity  even  after  the  full  devel- 
opment of  the  disease.  If  the  infant  be  quiet,  especially  if  asleep,  the  mus- 
cles are  partially  relaxed  to  such  an  extent  sometimes,  in  the  first  stages  of 
the  complaint,  that  the  features  have  a  placid  and  natural  expression,  though 
only  for  a  short  time.  Frequent  exacerbations  occur  in  the  muscular  con- 
traction, sometimes  without  any  apparent  cause,  and  sometimes  produced  by 
anything  which  excites  or  disturbs  the  child.  Attempts  to  open  the  lips  or 
jaws  or  eyelids  or  to  bend  the  limbs,  blowing  on  the  face,  or  even  crawling 
of  a  fly  upon  it,  occasion  the  paroxysms. 

During  the  paroxysm  the  eyelids  are  forcibly  compressed,  as  well  as  the 
lips,  which  are  either  drawn  in  or  are  pouting ;  the  forehead  and  cheeks  are 
thrown  into  wrinkles  and  the  physiognomy  is  indicative  of  great  suff'ering. 
The  unnatural  positions  of  the  trunk  and  limbs  which  result  from  muscular 
contraction  are  increased  for  the  moment ;  the  head  is  more  forcibly  thrown  back 
and  the  limbs  more  strongly  flexed.  The  muscular  movements  which  occur 
during  the  paroxysms  are  sometimes  described  as  clonic  spasms.  There  is 
indeed  occasionally  some  quivering  of  the  limbs,  and  yet,  as  I  have  on  difl"er- 
ent  occasions  noticed,  so  far  from  the  muscular  action  being  a  clonic  spasm, 
it  is  clearly  tonic  and  is  intensified  during  the  paroxysm.  In  fatal  cases  the 
paroxysms  occur  more  and  more  frequently  until  the  period  of  collapse. 

The  crying  of  the  child  aff'ected  by  tetanus  is  never  loud,  however  great 
the   suflFering.     It  is   variously  described   by  writers   as   "  whimpering "   or 


PROONOSTS.  171 

"  whining."  It  is  of  this  suppressed  character  in  consequence  of  the  rigid 
state  of  the  respiratory   muscles  and  their  imperfect  movement. 

During  the  exacerbation  respiration  is  suspended,  or  so  imperfect  and  the 
circulation  so  retarded  that  the  surface  becomes  of  a  deep-red.  almost  livid, 
color.  Sometimes  epistaxis  occurs,  affording  partial  relief  to  the  congestion, 
and  sometimes,  though  less  frequently,  the  blood  forces  itself  from  the  con- 
gested liver  along  the  umbilical  vein  and  escapes  from  the  umbilicus.  The 
intense  passive  congestion  consequent  on  the  tetanic  spasm  is  general  through- 
out the  system,  but  extravasation  of  blood  appears  to  be  more  common  around 
the  brain  and  spinal  cord  than  elsewhere. 

The  frequency  of  the  pulse  and  respiration  varies  in  different  cases  and 
at  different  stages  of  the  same  case.  They  are  often  somewhat  accelerated, 
but  at  other  times  are  natural,   or  are  even   slower  than  in  health. 

While  the  appetite  of  the  infant,  to  appearance,  is  not  diminished,  the 
pain  which  it  experiences  in  nursing  is  such  that  alimentation  is  necessarily 
deficient.  It  can  be  fed  with  a  spoon  for  a  time  after  it  ceases  to  take  food 
in  the  natural  way,  but  artificial  feeding  soon  fails.  The  milk  placed  in  its 
mouth  is  in  great  part  pressed  back  through  the  violence  of  the  spasm  which 
is  induced  by  the  attempt  to  feed  it. 

In  consequence  of  imperfect  nutrition  the  infant  rapidly  wastes  away. 
There  is  no  other  disease,  except  the  diarrhoeal  affections,  in  which  the  ema- 
ciation is  so  rapid.  In  a  case  related  by  Dr.  W.  B.  Lindsay'  the  record  states 
that  '■•  the  infant  was  fat  three  days  before,  but  was  now  emaciated."  Rom- 
berg, who  saw  tetanus  neonatorum  in  European  hospitals,  and  Robert  H. 
Chinn'-  of  Texas,  both  speak  of  the  rapid  emaciation.  The  trunk  and  extrem- 
ities lose  their  fulness  and  the  features  become  pinched.  Several  observers 
have  noticed  the  appearance  of  miliaria  in  this  reduced  state  of  system, 
especially  around  the  shoulders,  and  sometimes  a  decidedly  icteric  hue 
appears   on    the   skin. 

The  condition  of  the  intestines  is  not  uniform.  They  may  be  relaxed, 
particularly  if  the  disease  be  due  to  some  irritation  in  them ;  in  other  cases 
the  stools  are  natural  or  constipated. 

It  is  often  difficult  to  ascertain  the  state  of  the  eyes,  since  attempts  to 
open  the  eyelids  bring  on  spasms  and  cause  firm  compression  of  the  lids 
against  each  other.  According  to  Sir  Henry  Holland,  one  of  the  first  symp- 
toms which  occurred  in  cases  on  the  island  of  Heimacy  was  strabismus,  with 
rolling  of  the  eyes.  But  this  statement  must  be  received  with  caution,  since 
these  cases  were  not  seen  by  any  physician  and  the  information  was  obtained 
from  the  parents  and  priests.  If  true,  the  proximate  cause  of  the  disease  in 
Heimacy  would  seem  to  be  located  in  the  cerebro-spinal  axis.  Contraction 
of  the  pupils  commonly  occurs  in  the  stage  of  collapse. 

Mode  op  Death. — Death  in  infantile  tetanus  may  occur  from  apnoea  in 
the  paroxysms,  from  extreme  congestion  of  the  cerebral  vessels,  or  apoplexy ; 
and,  lastly,  it  may  occur  from  exhaustion.  The  last  mode  is  probably  the 
most  frequent. 

Prognosis. — All  writers  till  recently  agree  that  tetanus  of  the  infant 
rarely  terminates  favorably.  Cullen  attributes  the  ignorance  of  physicians 
in  regard  to  this  disease  to  the  fact  that  it  is  so  little  amenable  to  treatment 
that  they  are  not  usually  summoned  to  attend  those  affected  with  it.  In  the 
island  of  Heimacy,  of  185  cases  occurring  during  a  series  of  years  about  the 
commencement  of  the  present  eentur}^,  not  one  survived ;  and  in  the  same 
locality,  at  Westmannoe,  a  small  islet,  64  per  cent,  of  all  the  infants  born 
died  of  trismus  (report  of  Dr.  Schleisner).  Similar  statements  in  regard  to 
the  mortality  of  tetanus  infantum  are  given  by  physicians  in  the  Southern 

1  N.  0.  Med.  Jour.,  Sept.,  1846.  ^  N.  0.  Med.  and  Surg.  Jour.,  Sept.,  1854. 


172  TETANUS  NEONATORUM. 

States.  Dr.  H,  0.  Wooten^  of  Alabama  says  that  he  has  "  never  seen  a 
decided  case  of  tetanus  nascentium  that  did  not  prove  fatal,  ....  and  that 
it  is  very  generally  deemed  useless  to  call  in  medical  aid  after  the  initiatory 
symptoms  are  well  declared."  Mr.  Maxwell,^  speaking  in  reference  to  the 
West  Indies,  says :  "  From  observations  which  I  have  made  for  a  series  of 
years,  ....  I  found  that  the  depopulating  influence  of  trismus  nascentium 
was  not  less  than  25  per  cent.  It  scarcely  has  a  parallel  within  the  bills  of 
mortality."  Dr.  D.  B.  Nailer^  says  :  "  About  two-thirds  of  the  deaths  among 
the  negro  children  are  from  this  disease,  and  so  uniformly  fatal  is  it  that  a 
physician  is  never  sent  for." 

Yet  death  does  not  always  result :  eight  of  the  forty  cases  in  my  collection 
recovered ;  but  a  correct  opinion  cannot  be  formed  from  this  of  the  actual 
ratio  of  favorable  to  unfavorable  cases,  since  favorable  cases  are  much  more 
likely  to  be  published.  In  the  history  of  these  8  cases  two  interesting  facts 
are  noticed,  which  when  present  may  serve  as  a  ground  for  hope  of  a  success- 
ful termination.  These  were,  the  age  at  which  the  disease  began  and  the 
fluctuation  of  the  symptoms.  With  two  exceptions,  the  infants  who  recov- 
ered were  about  a  week  old  when  the  initiatory  symptoms  appeared,  and  there 
were  fluctuations  in  the  gravity  of  the  symptoms ;  whereas  fatal  cases  ordi- 
narily grow  progressively  worse.  Yet  in  favorable  cases  the  symptoms  are 
never  so  severe  as  they  become  in  a  few  hours  in  those  who  succumb. 

Duration  in  Fatal  Cases. — Of  18  cases  observed  by  Finckh  in  the 
Stuttgart  Hospital,  15  died  in  two  days,  2  in  five  days,  and  1  in  seven  days. 
During  the  epidemic  in  the  Stockholm  hospitals  in  1834,  where  42  cases  were 
treated,  the  disease  seldom  lasted  more  than  two  days.  Romberg  says :  "  It 
generally  lasts  from  two  to  four  days,  but  its  duration  is  at  times  limited  at 
from  eight  to  twenty-four  hours,  and  occasionally,  though  rarely,  it  extends 
from  five  to  nine  days." 

In  31  fatal  cases  in  my  collection,  in  which  the  duration  is  mentioned — 

1  lived 3  hours. 

11  others  lived 1  dav  or  less. 

12  lived 2  days. 

4  lived 3  days. 

3  lived 4  days. 

Both  Underwood,  who  published  a  treatise  on  diseases  of  children  in 
1789,  and  Dr.  Elsasser  at  a  more  recent  date,  recorded  fatal  cases  which  were 
unusually  protracted.  The  one  described  by  Underwood  was  treated  in  the 
British  Lying-in  Hospital,  and,  although  all  the  others  treated  in  this  institu- 
tion died  by  the  third  day,  this  lived  six  weeks ;  but  it  is  suggested  by  the 
author  that  death  was  due  in  part  to  some  other  afi"ection.  The  child  treated 
by  Elsasser  lived  thirty-one  days. 

Duration  in  Favorable  Cases. — In  the  8  favorable  cases  in  my  col- 
lection the  duration  of  the  disease,  reckoned  from  the  time  when  the  infant 
ceased  nursing  till  it  began  again,  was  as  follows :  In  1  case,  two  days ;  in 
1,  a  few  days  ;  in  1,  fourteen  days;  in  2,  fifteen  days;  in  1,  twenty-eight 
days  ;  in  1,  twenty-one  days  ;  and  in  the  remaining  case,  about  five  weeks. 

Diagnosis. — To  one  who  has  seen  this  disease  in  the  new-born  or  is 
familiar  with  its  symptoms  diagnosis  is  easy.  The  symptoms  which  possess 
diagnostic  value  are  more  manifest  and  reliable  than  in  most  other  infantile 
maladies.  Permanent  rigidity  of  the  voluntary  muscles,  with  temporary 
exacerbations,  such  as  have  been  described  above,  which  are  induced  by  any 

'  N.  0.  Med.  Jour.,  May,  1846. 

■■*  Jamaica  Phys.  Jour.,  copied  into  the  London  Lancet,  April  11,  1835. 

3  N.  0.  Med.' Jour.,  Nov.,  1846. 


TREATMENT.  173 

cause  which  disturbs  the  infant — as  attempts  to  open  the  mouth  or  eyelids — 
is  pathognomonic. 

Preventive  Treatment. — While  tetanus  neonatorum,  if  fully  developed, 
is  ordinarily  fatal  in  spite  .of  any  remedial  measures  heretofore  used,  there  is 
no  doubt  of  the  efficacy  and  value  of  preventive  measures  when  properly 
employed.  This  was  shown  by  the  great  reduction  in  mortality  in  the  Dub- 
lin Lying-in  Hospital  through  the  thorough  ventilation  introduced  by  L)r. 
Clarke.  Dr.  Meriwether'  of  Montgomery,  Ala.,  says:  "When  the  disease 
appears  endemically  on  a  plantation  it  may  be  arrested  by  having  the  negro 
houses  whitewa.shed  with  lime  inside  and  out ;  by  raising  the  floors  above  the 
ground;  by  removing  all  filth  from  under  and  about  the  houses;  by  par- 
ticular attention  to  cleanliness  in  the  bedding  and  clothing  of  the  mother ; 
and  in  the  dressing  of  the  child,  so  as  to  prevent  any  of  the  matter  from  the 
umbilicus  lying  long  in  contact  with  the  skin.  Many  physicians,  especially 
in  the  Southern  States,  speak  confidently  of  care  in  dressing  the  cord  and 
attention  to  the  umbilicus  as  a  means  of  prevention.  Grafton'-  says  that  he 
has  "  never  known  the  disease  to  occur  in  any  child  whose  navel  had  the  tur- 
pentine dressing."  He  uses  turpentine  as  follows  :  "  At  the  first  time  a  few 
drops  of  undiluted  turpentine  are  applied  immediately  to  the  umbilicus  around 
the  cord,  and  it  is  anointed  at  every  succeeding  dressing,  the  turpentine  being 
diluted  one-half  or  two-thirds  with  olive  oil,  lard,  or  fresh  butter."  This  use 
of  turpentine  has  also  been  recommended  by  other  practitioners  in  warm 
regions. 

Dr.  John  Furlonge  ^  of  St.  John's,  Antigua,  believes  that  no  case  would 
occur  with  the  following  treatment :  "  The  cord,  when  divided,  should  be 
wrapped  in  clean  linen.  Every  night  for  two  weeks  one  or  two  drops  of 
tinct.  opii  and  spts.  vini,  equal  parts,  should  be  given,  and  castor  oil,  with  a 
little  magnesia,  every  morning.  The  child  must  be  washed  in  tepid  water 
every  morning  and  the  funis  dressed."  If  this  treatment  be  attended  by  the 
success  which  is  claimed  for  it  by  Dr.  Furlonge,  so  great  care  in  dressing  the 
cord  is  certainly  well  repaid  in  localities,  as  at  Antigua,  where  a  large  pro- 
portion  of  the  infants  die  of  tetanus. 

Some  experienced  observers  go  so  far  as  to  assert  that  it  is  possible  to 
ward  off  tetanus  neonatorum  after  the  occurrence  of  premonitory  symptoms. 
Dr.  Dowell  *  says  :  "  Some  with  slight  twitchings  of  the  muscles  have  recov- 
ered without  any  trouble  by  being  put  into  a  mustard-bath,  washed  clean,  and 
put  in  a  clean  and  well-ventilated  cabin." 

Treatment. — In  considering  the  effect  of  medicinal  agents  which  have 
been  employed  in  the  treatment  of  infantile  tetanus,  the  great  difficulty  which 
the  child  experiences  in  swallowing  should  be  borne  in  mind.  Without  care 
a  considerable  part  of  the  dose  is  lost  by  the  spasm  of  the  muscles  of  degluti- 
tion, which  ordinarily  occurs  when  the  spoon  is  placed  in  the  mouth,  so  that, 
unless  special  attention  be  given  to  this  matter,  it  is  uncertain  whether  the 
prescribed  dose  is  fully  administered. 

The  treatment  employed  by  different  physicians  has  been  very  diverse. 
Antiphlogistic  remedies  were  prescribed  by  Finckh,  but  every  case  so  treated 
was  fatal.  He  states  that  whenever  blood  was  abstracted,  even  in  small  quan- 
tities, the  symptoms  were  aggravated.  The  same  result  has  followed  depletory 
measures  in  the  practice  of  other  physicians. 

The  internal  remedies  which  have  been  most  frequently  prescribed  are 
opiates  and  antispasmodics.     Furlonge  in  a  favorable  case  gave  laudanum  in 

'  Ainer.  Jour,  of  Med.  ScL,  April,  1854. 
2  N.  0.  Med.  and  Surg.  Jour.,  July,  18-53. 
^  Edin.  Med.  and  Sure/.  Jour.,  Jan.,  1830. 
*  Amer.  Jour,  of  the  Med.  Sei.,  January,  1863, 


174  TETANUS  NEONATORUM. 

doses  of  one  drop  every  three  hours  alternately  with  two  grains  of  Dover's 
powder.  Woodworth  also  gave  one-drop  doses  of  laudanum  ;  Eberle,  one- 
sixth  of  a  drop  hourly.  The  opiate  has  generally  been  given  in  combination 
with  an  antispasmodic.  The  Dover's  powder  given  every  three  hours  by 
Furlonge  was  combined  with  five  grains  of  sulphate  of  zinc.  The  hourly 
doses  of  laudanum  by  Eberle  were  combined  with  six  drops  of  tincture  of 
asafoetida. 

When  angesthetics  began  to  be  employed  in  the  treatment  of  diseases,  it 
was  believed  that  they  would  be  especially  useful  in  cases  of  tetanus.  Accord- 
ingly, chloroform  has  been  used  in  tetanus  in  the  infant,  with  the  effect  of 
controlling  the  spasm  during  the  time  of  its  use,  but  without  curing  the  dis- 
ease. In  Case  7  in  our  first  table  it  was  employed  several  times,  but  appar- 
ently without  delaying  the  fatal  result.  The  editor  of  the  A^ew  Orleans 
Medical  and  Surgical  Journal  states,  in  the  May  issue  of  that  periodical  for 
1853,  that  he  has  used  chloroform  in  tetanus  neonatorum,  with  the  effect,  he 
believes,  of  prolonging  life.  Anaesthetics  certainly  relieve  the  suffering  of 
the  infant,  and  on  this  account,  even  if  they  do  not  prolong  life,  their  judi- 
cious employment  seems  proper. 

The  remedy  which,  in  my  opinion,  is  far  preferable  to  all  others  is  hydrate 
of  chloral.  Since  the  introduction  of  this  agent  into  therapeutics  it  has  been 
employed  by  several  physicians  in  the  treatment  of  this  disease  with  so  good 
a  result  that  it  will  probably  supersede  all  other  medicines  for  this  purpose. 
Dr.  Widerhofer  ^  of  Vienna  states  that  he  has  saved  six  out  of  ten  or  twelve 
by  the  use  of  chloral.  He  prescribes  it  in  doses  of  one  to  two  grains  by  the 
mouth,  or,  if  there  be  great  difficulty  in  swallowing,  two  or  four  grains  by  the 
rectum.  Dr.  F.  Auchenthales '^  relates  a  case  in  which  he  gave  even  six- 
grain  doses,  and  in  nine  days  the  disease  had  entirely  disappeared.  I  have 
recently  employed  hydrate  of  chloral  in  a  case  of  tetanus,  giving  it  in  half- 
grain  doses  every  two  hours,  except  when  there  was  profound  sleep.  The 
disease  was  fully  developed  and  the  symptoms  severe  when  I  was  called.  I 
did  not  believe  that  the  infant  with  the  old  remedies  would  live  more  than 
two  days,  but  by  the  chloral  life  was  prolonged  nearly  one  week.  Moreover,. 
by  the  use  of  chloral  the  suffering  of  the  infant  is  greatly  diminished.  The 
frequent  inhalation  of  sulphuric  ether  also  aids  materially  in  controlling  the 
spasms. 

The  administration  of  alcoholic  stimulants  is  required  at  short  intervals- 
on  account  of  the  rapid  emaciation  and  great  prostration. 

Local  treatment  directed  to  the  umbilicus  in  those  cases  in  which  there 
is  evidence  of  inflammation  of  the  umbilicus  or  umbilical  vessels  should  not 
be  neglected.  The  application  of  an  emollient  poultice  to  the  umbilicus  has- 
been  followed  by  apparent  improvement,  if  we  may  believe  the  statement  of 
some  physicians  who  have  made  use  of  this  treatment.  Dr.  Meriwether  of 
Alabama  says  if  there  be  no  improvement  from  the  medicine  which  he  orders 
he  applies  a  blister,  larger  than  a  dollar,  to  the  umbilicus,  and  with  this  treat- 
ment the  child  generally  improves — a  remarkable  statement,  since  so  few 
improve  at  all. 

A  warm  foot-bath,  repeated  at  intervals  of  a  few  hours,  and  stimulating: 
embrocations  along  the  spine,  are  proper  adjuvants  to  the  treatment. 

Sclerema  Neonatorum. 

This  is  a  rare  disease,  and  most  of  the  cases  which  have  been  observed" 
have  occurred  in  foundling  asylums  or  maternity  wards.  It  is  characterized 
by  induration  or  rigidity  of  the  skin  and  subcutaneous  tissue  over  a  greater  or 

'  London  Lancet,  March  18,  1871.  ^  Jahr.f.  Kindt rheil.,  N.  S.,  iv. 


SCLEREMA  NEONATORUM.  175 

less  extent  of  the  system.  The  sensation  communicated  to  the  finger  pressed 
upon  the  affected  surface  is  not  unlike  that  produced  by  the  cadaver.  Those 
having  the  disease  are  feeble,  poorly  nourished,  and  a  considerable  proportion 
are  prematurely  born.     Thejr  temperature  is  below  normal. 

Sclerema  of  the  newly-born  was  first  described  by  Underwood  in  the 
eighteenth  century,  and  f^jllowing  him,  in  1781,  Andry  applied  this  term  to 
oedema  occurring  in  the  first  days  after  birth,  and  which  should  not  be  con- 
founded with  sclerema.  Sclerema  neonatorum  occurs  in  emaciated  or  atro- 
phic infants,  but  the  skin  over  the  affected  part,  instead  of  lying  in  wrinkles 
or  folds,  as  is  usual  in  a  state  of  great  emaciation  or  atrophy,  becomes 
smooth  and  is  firmly  adherent  to  the  subjacent  parts,  from  which  it  cannot 
be  raised.  The  induration  usually  first  appears  in  the  lower  extremities,  and 
it  passes  upward  along  the  hips  and  lumbar  region,  and  it  may  occur  not  only 
upon  the  trunk  and  upper  extremities,  but  even  upon  the  face.  The  limbs 
are  extended  and  immobile,  and  the  soft  parts,  firm  and  re.sisting,  do  not  pit 
on  pressure.  The  skin  has  a  dusky-yellow  color  and  is  perhaps  slightly 
cyanotic.  The  respiration  is  feeble  and  slow.  The  rigidity  when  extensive 
resembles  that  in  tetanus.  Nursing  from  the  breast  is  imperfectly  performed, 
and  when  the  muscles  of  the  face  and  lips  are  involved  is  impos.sible.  The 
causes  of  sclerema  appear  to  be  prematurity,  atrophy  or  poor  nutrition,  and 
great  heart  failure. 

This  disease,  so  long  as  the  patient  is  able  to  take  nutriment,  may  con- 
tinue for  weeks  before  the  fatal  ending,  with  a  constant  abnormally  low  tem- 
perature. 

Parrot  made  post-mortem  examinations,  and  found  hardening  and  atrophy 
of  the  skin  and  rete  Malpighii,  the  cells  pertaining  to  which  being  indistinct 
and  forming  a  firm  mass.  In  the  adipose  tissue  underlying  the  skin  the  fat 
had  disappeared  to  a  considerable  degree,  the  fat-cells  being  atrophied,  but 
having  distinct  nuclei.  The  fibres  of  the  connective  tissue  were  apparently 
increased  in  number  and  thickness.  The  blood-vessels,  particularly  in  the 
papillae,  were  shrunken  or  narrowed  to  such  an  extent  that  their  lumina  were 
not  visible.  Henoch  made  a  post-mortem  examination  of  the  brain  and  spi- 
nal cord  in  two  cases  which  had  lain  for  weeks  in  his  ward  in  a  rigid  state, 
and  found  them  normal. 

A  clear  idea  of  the  symptoms  and  anatomical  characters  of  sclerema  can 
be  obtained  by  the  narration  of  a  typical  case  that  occurred  in  the  New  York 
Foundling  Asylum.  Dr.  W.  P.  Northrup,  the  curator,  gave  a  full  and 
graphic  description  of  this  case  at  the  first  session  of  the  American  Paediatric 
Society :  The  patient,  a  female,  was  brought  to  the  asylum  as  a  foundling  at 
the  age  of  five  days.  It  was  jaundiced,  had  sprue,  and  a  rectal  temperature 
of  962°  F.  The  efforts  to  increase  its  temperature  were  unavailing,  and  two 
days  later  it  was  carefully  examined.  Its  face  was  cold  and  rigid,  and  the 
coldness  and  rigidity  had  extended  over  not  only  the  features,  but  the  scalp, 
shoulders,  arms,  hands,  hips,  thighs,  legs,  and  feet.  The  extremities  were  so 
stiff  that  pressure  upon  them  or  attempts  to  move  them  communicated  the 
sensation  of  a  cadaver  or  half-frozen  tissue.  Its  eyes  were  closed ;  its  sur- 
face had  a  dirty,  yellowish-brown  color.  When  handled  it  uttered  a  feeble 
whimpering  cry,  but  was  otherwise  motionless  and  quiet ;  no  pulse  ;  rectal 
temperature  below  the  lowest  figure  on  the  thermometer ;  respiration  feeble 
and  shallow.     Death  occurred  two  days  later,  at  the  age  of  nine  days. 

At  the  autopsy  the  sclerema  was  found  to  be  less  in  the  abdominal  walls 
than  elsewhere.  On  incising  the  hardened  tissues  no  blood  or  serum  escaped 
from  the  cut  surface.  The  lungs  had  been  fully  inflated,  no  collapse  being 
present,  and  they  contained  dark  hemorrhagic  points  or  spots.  Nothing 
unusual    was   observed    in    the    skull,   brain,   heart,   and   great   vessels,   the 


176  TETANUS  NEONATORUM. 

stomach,  intestines,  liver,  and  kidneys,  except  the  urates  in  the  tubuli 
uriniferae.  The  hemorrhagic  extravasations  in  the  lungs  were  found  to  con- 
sist of  fresh  blood  in  the  alveoli  and  connective  tissue.  Dr.  Northrup  made 
microscopic  examinations  of  the  skin  and  subcutaneous  tissues,  and  found 
that  they  took  injections  well,  showing  a  normal  vascular  network.  The 
microscopic  slides  have  been  examined  by  expert  microscopists  and  derma- 
tologists, and  they  can  discover  nothing  abnormal  that  throws  light  on  the 
cause  or  pathology  of  the  sclerema. 

Sclerema  bears  considerable  resemblance  to  oedema  of  the  new-born.  In 
oedema  the  temperature  is  low  and  the  oedematous  tissues  may  present  con- 
siderable firmness,  but  the  surface  usually  pits  on  pressure,  unlike  that  in 
sclerema.  Of  the  diiferent  opinions  expressed  by  observers  in  reference  to 
the  cause  and  pathology  of  sclerema,  that  expressed  by  Ludwig  Langer  in 
1881  (  Wiener  Sitzungsherichtj  1881)  is  the  most  plausible.  It  is  as  follows  : 
In  the  adult  oleic  acid  is  the  chief  constituent  of  the  adipose  tissue,  but  in 
the  newly-born  the  fat  contains  a  large  proportion  of  palmatin  and  stearin, 
which  solidify  when  the  heat  of  the  body  undergoes  a  moderate  reduction 
below  the  normal. 

Infants  having  sclerema  after  lingering  for  days  or  weeks  die  in  a  state  of 
extreme  weakness.  I  am  not  aware  that  recovery  has  occurred  in  any  case 
of  genuine  sclerema  of  the  new-born.  Still,  it  is  proper  to  increase  the  tem- 
perature by  warm  applications  to  the  body  and  limbs  and  to  endeavor  to 
improve  the  nutrition  in  every  possible  way.  Perhaps  a  more  abundant 
breast-milk  or  breast-milk  of  a  better  quality  can  be  obtained,  and  a  few 
drops  of  Tokay  or  other  good  wine  or  of  brandy  may  be  given  every  sec- 
ond hour. 

CEdema  Neonatorum. 

In  this  disease  thickening  of  the  integument  occurs  and  the  subcutaneous 
connective  tissue  is  infiltrated  with  serum.  The  oedema  in  most  cases  is  at 
first  in  the  legs,  from  which  it  extends  along  the  thighs  to  the  genitals.  It 
may  extend  over  the  trunk,  upper  extremities,  and  cheeks,  but  in  some  cases 
it  appears  only  in  the  hands  and  feet,  producing  tumefaction  of  the  palms  of 
the  one  and  soles  of  the  other.  If  the  amount  of  serous  infiltration  be  great, 
the  tissues  may  be  firm  and  resisting,  communicating  to  the  touch  a  sensation 
similar  to  that  in  sclerema ;  but  when  the  infiltration  is  less  in  degree  the  tis- 
sues are  soft  and  doughy.  The  skin  has  a  dusky  or  yellowish  color,  and 
sometimes,  when  much  distended,  it  has  a  shiny  appearance.  In  cases  of 
great  oedema  the  movement  of  the  afiiected  part  is  diminished,  but  not  to  the 
same  extent  as  in  sclerema.  As  in  sclerema,  the  temperature  is  below  the 
normal. 

In  fatal  cases  the  adipose  tissue  is  found  of  a  brownish,  yellowish,  or 
reddish-yellow  color,  from  which  a  yellowish  serum  exudes.  CEdema  of  the 
newly-born  does  not  appear  to  result  from  the  same  cause  in  all  instances. 
Occurring  in  feeble,  ill-nourished  infants,  it  apparently  results,  in  most  in- 
stances, from  extreme  heart-weakness.  The  feeble  circulation  leads  to  venous 
congestion  and  consequent  serous  transudation.  Pulmonary  atelectasis,  occur- 
ring as  it  usually  does  in  ill-nourished  and  feeble  infants,  is  also  an  occasional 
factor  in  producing  venous  stasis  and  transudation  of  serum.  Elsasser  has 
shown  that  occasionally  in  the  newly-born  the  oedema  results  from  nephritis, 
as  it  frequently  does  in  the  adult.  Henoch  relates  the  case  of  an  infant  of 
four  weeks  who  had  '-marked  oedema  of  face  and  limbs,"  with  serous  effu- 
sion in  the  pleural,  pericardial,  and  peritoneal  cavities,  and  compression  of  the 
left  lower  lobe,  resulting  from  parenchymatous  nephritis.     Another  occasional 


PEMPHIGUS  NEONATORUM.  177 

cause  of  the  ccdema  is  erysipelas.  This  cause  is  revealed  by  the  dark-red 
color  of  the  skin  characteristic  of  erysipelatous  inflammation. 

llecently  Prof.  Dumas  in  an  elaborate  paper  on  oedema  of  the  new-born 
arrives  at  the  following  conclusions:  "1.  (Edema  of  the  new-born  is  only 
one  of  the  symptoms  of  a  phlegmasia  alba  dolens  which  is  developed  during 
the  first  days  after  birth.  2.  Its  causes  are  of  the  same  nature  as  in  the 
adult,  and  may  be  divided  into  predisposing  and  determining  varieties.  Among 
the  latter,  the  principal  one  consists  in  the  incomplete  establishment  of  res- 
piration or  in  the  pathological  or  other  causes  which  this  function  encounters. 
3.  The  symptoms  of  phlegmasia  in  the  new-born  are  the  same  as  in  the  adult, 
excepting  certain  modifications  with  respect  to  the  special  physiology  of  the 
first  days  following  birth.  4.  The  pathological  anatomy  is  also  about  the 
same,  but  the  venous  thrombosis  in  the  new-born  is  more  frequently  located 
in  the  inferior  vena  cava  than  it  is  in  the  same  disease  in  the  adult."  It  does 
not  seem  improbable  that  Prof.  Dumas's  explanation  is  applicable  to  a  consid- 
erable proportion  of  cases,  the  formation  of  clots  in  the  veins  producing  such 
obstruction  and  venous  congestion  that  serum  transudes  as  a  consequence. 
Dunias  recommends,  in  order  to  prevent  this  disease,  "  suitable  care  to  effect 
respiration  in  the  new-born  at  the  moment  of  birth,  and  not  too  hasty  liga- 
tion of  the  cord." 

(Edema,  like  sclerema,  is  ordinarily  fatal,  but  occasionally,  as  when  it 
results  from  erysipelas,  recovery  is  possible.  The  treatment  should  be  largely 
hygienic  and  dietetic.  An  abundant  supply  of  good  breast-milk  should  be 
obtained,  or  if  this  be  impossible  peptonized  cow's  milk.  As  in  sclerema, 
artificial  warmth  and  moderate  alcoholic  stimulation  are  required. 

Pemphigus  Neonatorum. 

Pemphigus  occurs  in  two  distinct  forms  in  the  newly-born,  which  may  be 
properly  designated  i^empliigus  simplex  and  pemphigus  cachecticus. 

Pemphigus  Simplex  commonly  occurs  between  the  ages  of  two  and 
twelve  days.  The  vesicles,  which  vary  in  size  from  that  of  a  pea  to  a  hazel- 
nut, appear  in  some  cases  nearly  simultaneously,  but  in  other  instances  in 
successive  crops.  When  fully  developed,  they  ordinarily  have  a  transparent 
yellowish  color,  and  they  may  appear  upon  almost  any  part  of  the  surface 
except  the  palms  of  the  hands  and  soles  of  the  feet.  When  the  eruption  is 
nearly  general  upon  the  surface,  as  it  occasionally  is,  one  or  two  blebs  may 
even  appear  upon  these  parts,  but  as  a  rule  in  pemphigus  simplex  the  palms 
of  the  hands  and  soles  of  the  feet  are  not  affected. 

In  investigating  the  causes  of  this  form  of  pemphigus  we  are  struck  with 
the  fact  that  in  a  considerable  proportion  of  the  recorded  cases  those  affected 
with  it  appear  to  be  otherwise  in  perfect  health.  Occasionally  in  maternity 
hospitals  it  occurs  as  an  epidemic.  Thus,  Ahlfeld  observed  twenty-five  cases 
during  two  months  in  an  institution  in  Leipzig.  The  mothers  of  these  infants 
were  apparently  healthy,  and  the  pemphigus  commenced  in  all  between  the 
second  and  fourteenth  days  after  birth.  The  palmar  surfaces  of  the  hands 
and  plantar  surfaces  of  the  feet  were  not  affected  in  any  of  these  cases,  though 
vesicles  appeared  on  the  fingers  in  some  of  them.  Ahlfeld,  from  these 
observations,  believed  that  the  disease  was  infectious  or  of  a  miasmatic  nature. 
Koch  states  that  thirty-one  cases  occurred  in  the  practice  of  a  certain  mid- 
wife, while  in  the  practice  of  other  midwives  no  case  occurred.  Weyl  of 
Berlin,  aware  of  facts  like  the  above,  states  that  the  disease  is  undoubtedly 
contagious.  Bohn,  on  the  other  hand,  regards  cutaneous  irritants  as  a  cause, 
and  he  states  that  the  repeated  occurrence  of  pemphigus  in  the  practice  of 
a  certain  midwife  was  traced  to  the  fact  that  she  habitually  used  water  too 
12 


178  TETANUS  NEONATORUM. 

hot  in  bathing  the  infants.  But  there  is  now  a  sufficient  number  of  observa- 
tions to  render  highly  probable,  if  they  do  not  demonstrate,  the  contagious 
nature  of  pemphigus  in  certain  cases.  Roeser  always  found  micrococci  in 
the  serum  of  the  vesicles.  Gibier  found  chain  bacteria,  single  bacteria,  and 
also  bacteria  in  zoogloea  in  the  vesicles.  Scharlau  met  the  disease  in  different 
members  of  a  family,  and  succeeded  in  inoculating  himself  from  the  vesicular 
contents.  We  may  conclude,  therefore,  that  pemphigus  of  the  newly-born 
is  probably  in  certain  cases  microbic  and  inoculable,  though  the  microbe 
which  causes  the  disease  has  not  been  fully  identified.  But  in  some  instances 
it  is  not  improbable  that  the  disease  is  produced  by  causes  not  microbic,  as 
from  cutaneous  irritants.  Further  investigations  in  regard  to  the  etiology 
of  pemphigus  simplex  are  required  before  positive  statements  can  be  made. 

Pemphigus  simplex  is  usually  attended  by  little  constitutional  disturb- 
ance, but  sometimes,  it  is  said,  a  slight  fever  attends  the  eruption  of  the 
vesicles.  The  skin  adjacent  to  the  vesicles  may  have  the  normal  or  a  slightly 
congested  or  vascular  appearance.  The  vesicular  contents  escape  in  a  few 
days  by  rupture  of  the  vesicle,  or  disappear  by  absorption,  and  the  detached 
cuticle  forms  a  thin  scale  which  is  soon  thrown  off,  and  in  a  few  days  replaced 
by  a  new  growth  of  cuticle. 

Peraphigus  Cachecticus. — This  form  of  pemphigus  occurs  in'  infants 
who  have  a  profound  cachexia,  and  this  cachexia  is  in  a  large  proportion  of 
cases  due  to  inherited  syphilis.  Unlike  pemphigus  simplex,  it  attacks  by 
preference  the  palms  of  the  hands  and  soles  of  the  feet.  It  also  occurs  upon 
thin  portions  of  the  skin,  as  the  groin,  axilla,  and  neck.  The  surface  upon 
which  the  vesicles  are  situated  presents  a  reddish  or  livid  appearance,  and  the 
vesicles  are  only  partially  filled.  The  exuded  liquid  is  not  so  clear  as  in 
pemphigus  simplex,  and  it  is  often  turbid  or  even  bloody.  The  vesicles  or 
remains  of  vesicles  are  sometimes  observed  at  birth,  and  are  then  believed  to 
have  a  syphilitic  origin.  When  the  cause  is  syphilis  other  manifestations  of 
this  disease  may  be  also  present. 

Pemphigus  cachecticus  may  be  prolonged  several  weeks,  if  the  patient  live, 
by  the  occurrence  of  new  vesicles.  It  is  important,  as  regards  the  selection 
of  remedies,  to  bear  in  mind  the  fact  that  the  profound  dyscrasia  which 
underlies  and  gives  rise  to  an  attack  of  pemphigus  cachecticus  may  occur 
from  other  causes  than  syphilis,  as  perhaps  struma.  The  evils  which  attend 
a  family  subjected  to  a  life  of  poverty  in  a  great  city,  as  overwork,  scanty 
and  poor  diet,  overcrowding,  and  foul  air,  may  be  the  cause  of  the  dyscrasia 
in  the  infant  born  under  such  circumstances,  even  when  the  parents  are 
actuated  by  the  best  motives  and  endeavor  to  lead  a  correct  life. 

Anatomy. — The  vesicles  occur  in  the  epidermis  between  the  layers  of 
the  stratum  granulosum  and  stratum  lucidum  (Weyl).  The  contents  of  the 
vesicles  consist  largely  of  serum,  but  sometimes  also  of  other  substances,  as 
pus-cells,  epithelial  cells,  etc. 

Treatment. — This  is  simple,  consisting  of  cleanliness,  the  use  of  abun- 
dant pure  breast-milk,  and  frequent  dusting  the  surface  with  a  powder  consist- 
ing of  bismuth  and  lycopodium.  In  the  cachectic  form  of  pemphigus,  espe- 
cially if  the  vesicles  have  an  unhealthy  appearance,  they  should  be  broken, 
and  their  surface  may  be  dusted  with  a  powder  of  one  part  of  iodoform  and 
ten  of  bismuth.  In  syphilitic  cases  Henoch  recommends  the  addition  of  1 
gramme  (15  grains)  of  corrosive  sublimate  to  the  bath  employed.  The  use 
of  a  few  drops  of  Tokay  wine  or  other  alcoholic  stimulant  at  each  nursing  is 
also  required  in  the  cachectic  cases. 


PART  III. 
CONSTITUTIONAL    DISEASES. 


SECTION   I. 

DIATHETIC    DISEASES. 


CHAPTER    I 
EACHITIS. 


Rachitis,  or  rickets,  is  regarded  as  a  constitutional  disease,  though  the 
most  prominent  symptoms  and  lesions  which  characterize  it  pertain  chiefly  to 
the  osseous  system.  It  occurs  in  the  first  years  of  life,  and  therefore  during 
the  period  of  most  active  growth  of  the  skeleton.  It  is  manifested  by  an 
abnormal  nutrition  and  changed  physiological  action  of  the  bone-producing 
tissues — namely,  the  epiphyseal  cartilage  and  the  periosteum — and  by  the 
arrest,  more  or  less  complete,  of  the  deposition  of  lime-salts  in  these 
tissues. 

Frequency  of  Rachitis. 

Rachitis  is  a  common  result  of  faulty  diet  and  of  antihygienic  conditions, 
and  is  therefore  frequent  among  the  poor  of  cities,  and  especially  in  families 
who  dwell  in  crowded  tenement-houses.  It  has  heretofore  been  prevalent  in 
the  city  infantile  asylums,  but  of  late  years,  as  regards  at  least  the  city  of 
New  York,  it  is  much  less  common,  in  consequence  of  the  greater  attention 
now  given  to  sanitary  requirements  in  the  management  of  these  institutions. 
Mild  cases  of  rickets  are  often  overlooked,  since  physicians  may  not  be  sum- 
moned to  attend  them,  while,  even  if  they  be  summoned,  many  who  have  not 
given  particular  attention  to  this  disease  are  apt  to  err  in  diagnosis  and  to 
refer  the  symptoms  to  some  other  than  the  true  cause.  Commencing  grad- 
ually and  insidiously,  rachitis  not  infrequently  continues  for  months,  even  in 
its  typical  form,  before  a  correct  diagnosis  is  made.  In  the  absence  of  deform- 
ity, which  is  a  late  symptom,  the  fretfulness,  tenderness  of  surface,  and  per- 
spirations receive  a  wrong  explanation.  Practitioners  who  have  heretofore 
given  little  attention  to  this  malady,  and  who  believe  it  to  be  rare,  if  they 


180  BACHITIS. 

are  instructed  in  reference  to  its  characteristic  signs,  and  look  for  them  in 
their  visits  among  the  city  poor,  are  surprised  at  the  number  of  cases  which 
they  meet.  A  few  years  since  in  the  New  York  Infant  Asylum  my  atten- 
tion was  directed  to  a  rachitic  child  whose  head  had  so  changed  from  the 
normal  shape  that  the  nurses,  as  well  as  the  physician,  had  remarked  the  dif- 
ference. Prompted  by  the  occurrence  of  this  case,  which  had  gradually 
developed  under  my  eyes,  I  made  a  careful  examination  of  all  the  infants, 
and  discovered,  what  I  had  not  previously  suspected,  that  about  one  in  nine 
had  become  rachitic.  In  most  of  the  infants  the  disease  was  mild,  but  with 
symptoms  so  characteristic  that  it  was  readily  recognized.  By  effecting  cer- 
tain improvements  in  the  diet,  among  which  was  the  daily  allowance  of  beef 
tea  to  the  older  infants,  rachitis,  unless  of  a  mild  type,  has  since  been  rare  in 
this  institution. 

The  late  Dr.  John  S.  Parry  of  Philadelphia  stated  that  at  least  28  per 
cent,  of  all  the  children  between  the  ages  of  one  month  and  five  years  who 
came  under  his  observation  in  the  Philadelphia  Hospital  during  the  three 
years  preceding  the  publication  of  his  paper,  in  1872,  were  rachitic.  This 
is  certainly  a  larger  proportion  of  those  who  present  indubitably  rachitic 
symptoms  than  occurs  in  any  of  the  three  New  York  institutions  for  chil- 
dren with  which  I  have  an  official  connection.  In  the  New  York  Foundling 
Asylum,  with  its  sixteen  hundred  inmates,  and  in  the  Bureau  for  the  Belief 
of  the  Out-door  Poor,  where  over  eight  thousand  children  are  annually 
treated,  rachitis  is  certainly  less  frequent  than  is  indicated  by  the  statistics 
of  Dr.  Parry.  In  Europe,  from  the  testimony  of  many  observers,  both  con- 
tinental and  British,  rickets  is  very  common  among  the  families  who  seek 
medical  advice  in  the  institutions  of  charity.  Bitter  von  Bittershain  finds 
that  39  per  cent,  of  all  the  children  who  are  brought  to  the  Prague  Medical 
"  Poliklinik "  are  rachitic,  and  Prof.  Henoch  states  that  the  proportion  is 
equally  large  in  the  families  of  Berlin  who  are  in  similar  reduced  circum- 
stances. According  to  Dr.  Gee,  whose  statement  was,  however,  made  as  far 
back  as  1867-68,  of  the  patients  under  the  age  of  two  years  in  the  London 
Hospital  for  Sick  Children,  30.3  per  cent,  are  rachitic.  Both  Dr.  Hiller  and 
Sir  William  Jenner  not  only  allude  to  the  frequency  of  rachitis,  but  state 
that  it  is  the  cause  of  many  deaths  in  London  families.  Chalybaeus  states 
that  of  nearly  three  thousand  children  in  Dresden  brought  to  him  for  vac- 
cination, 8.4  per  cent,  exhibited  signs  of  rachitis.  In  an  interesting  com- 
munication read  at  the  meeting  of  the  Ninth  International  Medical  Congress 
in  1887,  Dr.  Moncorvo  of  Brazil  stated  that  45  per  cent,  of  the  sick  children 
treated  by  him  in  Bio  Janeiro  had  rachitis.  In  New  York  City  rachitis  is 
very  common  in  the  families  of  Italian  immigrants.  According  to  my 
observations  in  the  Bureau  for  the  Belief  of  the  Out-door  Poor,  a  majority 
of  the  most  pronounced  cases,  attended  with  great  enlargement  of  the  joints 
and  marked  curvatures,  come  from  the  Italian  tenement-houses. 

But  rachitis  does  not  occur  exclusively  among  the  poor.  Children  of 
well-to-do  families  are  also  liable  to  it,  provided  that  the  conditions  soon  to 
be  enumerated  are  present.  Ignorance  or  disregard  of  the  hygienic  require- 
ments of  young  children,  and  especially  the  use  of  improper  diet,  leads  to 
the  development  of  rachitis  in  wealthy  as  well  as  in  destitute  families.  Merei, 
in  his  treatise  on  the  Disorders  of  Infantile  Development  (London,  1855).  states 
that  in  Manchester,  where  his  observations  were  made,  one  child  in  every 
five  in  families  in  comfortable  circumstances  present  rachitic  symptoms  :  and 
he  believes  that  this  cannot  be  much  above  the  real  proportion  in  "  the  whole 
of  the  wealthy  classes." 

Bachitis,  in  its  milder  form,  is  not  uncommon  in  affluent  families  in  this 
country,  the  cause  of  the  delayed  dentition,  the  fretfulness,  and  perspiration 


AGE  AT  WHICH  RACHITIS  OCCURS. 


181 


not  being  suspected  in  many  instances,  as  I  have  had  opportunities  to  observe. 
Often  family  physicians  are  not  consulted  in  reference  to  such  symptoms,  and 
when  they  are  called  in  so  little  attention  has  rachitis  received  on  the  part  of 
many  practitioners  that  they  ai'e  very  apt  to  overlook  the  true  pathological 
state  which  is  present.  Still,  admitting  the  fact  that  many  cases  are  not 
diagnosticated,  I  repeat  that,  though  rachitis  is  not  uncommon  on  this  side 
of  the  Atlantic,  its  percentage  of  frequency  falls  below  that  observed  in 
European  cities — a  fact  which  may  be  due  to  less  crowding  in  their  domiciles 
and  to  a  more  liberal  and  better  supply  of  food  among  the  families  of  the 
poor  in  this  country. 


Fig.  10. 


Age  at  which  Rachitis  Occurs. 

Rachitis  is,  with  few  exceptions,  a  disease  of  infancy,  commencing  prior 
to  the  age  of  two  and  a  half  years.  Now  and  then  it,  or  a  state  closely 
resembling  it,  occurs  in  the  foetus,  causing  deformities 
such  as  are  present  in  typical  cases.  In  the  Kinder- 
spital  Museum  at  Prague  is  a  specimen  showing  this, 
and  described  by  Ritter.  Hink  and  Winkler  also 
describe  such  cases,  and  Virchow  alludes  to  a  specimen 
in  the  Wurzbui'g  Museum  which  exhibits  such  deform- 
ities as  characterize  rachitis.  Bednar  even  regards 
foetal  rachitis  as  not  uncommon  (Hillier,  Parry).  In 
the  Wood  Museum  of  Bellevue  Hospital  is  a  skeleton 
which  is  probably  similar  to  those  in  the  Prague  and 
Wurzburg  Museums.  It  shows  in  a  striking  manner 
the  deformities  of  this  congenital  disease.  The  case 
occurred  in  my  practice,  and  the  dissection  was  made 
by  Prof.  Francis  Delafield.  The  infant,  born  at  term, 
died  a  few  hours  after  birth  from  atelectasis,  appa- 
rently produced  by  the  contracted  state  of  the  thoracic 
walls.  The  parents  were  hard-working  English  people 
whose  mode  of  life  and  surroundings  were  such  as  are 
known  to  conduce  to  rachitis.  They  were  free  from 
syphilitic  taint.  The  accompanying  woodcut  (Fig.  10) 
represents   this    skeleton. 

The  following  remarkable  case  of  supposed  foetal 
rachitis  was  related  to  me  by  Heitzmann,  whose  inter- 
esting  experiments    will   be   presently   detailed  : 


Skeleton  of  a  Rachitic 
Infant  which  died  a  few 
hours  after  birth. 


Case  1. — A  woman  who  had  frequently  inhaled  the  vapor  of  lactic  acid  each 
day  for  many  months,  as  she  was  employed  to  feed  animals  with  this  agent,  gave 
birth  to  an  infant  at  term  which  died  immediatelj'^  after  it  Avas  born.  It  exhib- 
ited the  signs  of  congenital  rachitis  in  a  high  degree.  The  skull-bones  were 
completely  absent ;  in  the  cartilages  of  the  bones  of  the  extremities  and  in  those 
of  the  ribs  there  were  scanty  depositions  of  lime-salts.  The  death  of  the  child 
was  evidently  due  to  the  absence  of  the  skull-bones,  inasmuch  as  the  pressure 
of  the  womb  during  delivery  had  caused  cerebral  hemorrhage.  All  the  organs 
of  the  chest  and  abdomen  were  found  in  full  development  and  healthy. 

We  will  see  hereafter  that  the  theory  which  attributes  rachitis,  in  certain 
instances,  to  a  chemical  irritant  is  substantiated  by  experiment,  and  that  it 
has  already  been  shown  that  two  such  agents,  phosphorus  and  lactic  acid, 
may  cause  this  disease.  Now,  as  the  irritating  action  of  phosphorus  on  the 
osseous  system  occurs  when  it  is  inhaled  in  the  form  of  vapor  as  well  as  when 
received  in  the  ingesta,  so  lactic  acid,  if  the  above  case  be  rightly  interpreted, 


182  RACHITIS. 

produces  its  special  effect  upon  the  bone-producing  tissues  when  inhaled  as 
decidedly  as  when  received  in  the  ingesta  or  generated  in  the  system.  These 
remarks  seem  necessary  for  an  understanding  of  this  unusual  case,  although 
they  anticipate  what  will  be  said  under  the  head  of  Etiology.  In  the  New 
York  Journal  of  Obstetrics  for  November,  1870,  Prof.  Abraham  Jacobi  also 
published  the  description  of  a  case  of  congenital  rachitic  craniotabes.  Whether 
or  not  we  accept  as  genuine  all  the  reported  cases  of  foetal  rachitis,  there  can 
be  little  doubt,  from  the  number  of  observations  already  made  and  carefully 
recorded  and  from  the  opinion  of  high  authorities  like  Virchow,  that  such 
cases  do  occur. 

Recently  Schwarz  examined  five  hundred  newly-born  infants  in  the  obstet- 
ric clinic  in  Vienna,  and  he  states  that  only  19.4  per  cent,  were  entirely  free 
from  signs  of  rachitis.  This  remarkable  statement  we  hesitate  to  accept, 
thinking  that  there  may  have  been  some  error  in  the  observation.^ 

Enlargement  of  the  costochondral  articulations,  known  as  the  "  rachitic 
rosary,"  which  is  one  of  the  earliest  and  most  reliable  signs  of  rickets,  has 
been  observed,  though  rarely,  in  infants  only  a  few  weeks  old.  Dr.  Parry 
saw  it  as  early  as  the  sixth  week  after  birth,^  and  Dr.  Gree  at  the  third  or 
fourth  week.^  This  should  not,  however,  be  regarded  as  a  sign  of  rachitis, 
unless  the  enlargement  be  so  great  that  it  can  be  readily  appreciated  by 
examination  through  the  integument  or  by  sight,  for  in  young  children,  with 
the  bones  in  the  process  of  normal  development,  these  joints  usually  have  a 
diameter  a  little  larger  than  that  of  the  ribs.  Rachitis,  with  few  exceptions, 
begins  within  the  first  eighteen  months  of  life.  Though  first  detected  and 
diagnosticated  at  a  later  date,  it  will  ordinarily  be  ascertained,  on  inquiry, 
that  its  symptoms  had  an  earlier  beginning.  Still,  according  to  certain 
observers,  it  may  have  a  considerably  later  commencement.  Glisson,  Portal, 
and  Tripier  state  that  they  have  seen  it  commence  in  children  who  were  well 
on  toward  the  age  of  puberty.  Sir  William  Jenner  states  that  he  has  seen 
children  of  seven  and  eight  years  who  were  only  beginning  to  suffer  from 
rachitis.* 

The  following  are  the  aggregate  statistics  of  Bruennische,  Von  Rittershain, 
and  Ritsche,  relating  to  the  age  at  which  rachitis  occurs : 

No.  of  Cases. 

During  the  first  half  year 99 

"       second  half  of  first  vear 259 

"            "       year  .    ,    .    . " 342 

"       third  year 134 

"       fourth  year 31 

"       fifth  year  •    •    • 17 

Between  the  fifth  and  ninth  years 21 

Aggregate *    ■ 903 


Causes  of  Rachitis. 

Inheritance. — In  some  infants  there  is  an  undoubted  hereditary  pre- 
disposition to  rachitis.  Feeble  digestion  and  defective  assimilation  in  the 
infant — which  are,  as  we  shall  see,  important  factors  in  producing  the  rachitic 
state — are  often  traceable  to  disease  or  cachexia  of  one  or  both  parents.  The 
offspring  of  a  tubercular,  syphilitic,  or  otherwise  enfeebled  parent  is  more 
likely  to  become  rachitic  than  those  of  healthy  and  robust  ancestry  ;  and  it 
appears  that  disease  of  the  mother  is  more  likely  to  entail  a  rachitic  predis- 

I  Annual  of  Med.  Sd.,  1889. 

^  American  Journal  of  the  Medical  Sciences,  January,  1872. 

'  St.  Bartholomew's  Hospital  Reports,  vol.  iv.  *•  Lancet,  December  11,  1880. 


CAUSES  OF  RACHITIS.  183 

position  than  that  of  the  father.  Among  the  parental  causes  may  be  men- 
tioned poverty,  hardships,  and  defective  nutrition  of  either  parent,  age  of  the 
father,  and  exhausting  discharges  of  the  mother,  such  as  purulent,  hemor- 
rhoidal, or   uterine  fluxes.  ' 

Food. — Of  the  exciting  causes,  the  most  common  is  the  use  of  food  not 
sufficiently  nutritive,  or,  if  nutritious,  not  suited  to  the  age  and  digestive 
powers  of  the  child.  Thin  and  poor  breast-milk  and  artificial  food  of  poor 
quality  or  not  suitable  for  the  stage  of  growth  and  development  are  common 
causes  of  rickets.  Those  children  who  have  been  prematurely  weaned,  and 
who  have  been  given  a  food  which  is  not  a  proper  substitute  for  the  natural 
aliment,  and  those  too  long  wet-nursed  and  not  allowed  the  additional  nutri- 
ment which  they  require,  are  especially  liable  to  this  disease.  Those  whose 
digestive  power  is  feeble  from  whatever  cause  are  more  liable  to  become  rachitic 
than  those  who,  in  a  state  of  robust  health,  have  a  hearty  digestion.  Hence 
we  meet  with  rickets  as  a  sequel  of  various  protracted  and  exhausting 
maladies  during  infancy. 

It  might  be  supposed,  from  the  nature  of  rachitis,  that  the  use  of  food 
deficient  in  phosphoric  acid  and  lime  is  the  common  cau.se  of  rachitis ;  but 
facts  show  that  this  is  not  the  correct  view  of  its  etiology  as  it  commonly 
occurs,  although  in  its  treatment  these  agents  are  of  undoubted  value.  The 
disturbed  and  altered  nutrition  of  the  osteoplastic  tissues — namely,  of  the 
epiphyseal  cartilage  and  the  periosteum — is  the  important  factor  in  producing 
the  rachitic  bone  disease,  and  this  may  occur  although  the  ingesta  contain  a 
sufficient  amount  of  phosphoric  acid  and  lime.  Deficiency  of  these  substances 
probabl}'  tends  to  diminish  the  amount  of  lime-deposition,  but  it  is  not  the 
essential  element  in  the  causation  of  the  malady.  This  is  to  be  found  in  the 
unhealthy  condition  and  action  of  the  cartilage  and  periosteum,  or  rather  in 
the  agencies,  now  partly  ascertained,  which  produce  the  abnormal  state  and 
altered  nutrition  of  these  tissues. 

Cheadle  believes  that  the  chief  cause  of  rachitis  is  bad  feeding.  Hand- 
fed  infants,  he  says,  are  especially  liable  to  it,  particularly  if  their  diet  be 
farinaceous.  W.  H.  Peters  reports  a  case  caused,  he  thinks,  by  feeding  with 
undiluted  cow's  milk.  The  child,  eight  months  old,  was  ordered  milk  and 
lime-water,  equal  parts,  and  in  three  months,  the  signs  of  rachitis  had  dis- 
appeared.^ 

The  important  fact  has  been  ascertained  by  experiments  on  young  animals 
that  rachitis  can  be  produced,  as  I  have  already  stated,  by  at  least  two  chem- 
ical agents,  which  may  be  admitted  into  the  system  in  the  ingesta,  and  which 
exert  an  especially  irritating  action  on  the  osteoplastic  tissues.  Senator  states, 
in  Ziemssen's  EncyclopxcUa^  that  "  Wegner  ....  has  recently  brought  experi- 
mental evidence  to  show  that  true  rickets  may  be  artificially  produced  by  the 
continued  administration  of  very  minute  doses  of  phosphorus,  ....  together 
with  a  simultaneous  withdrawal  of  lime  from  the  food."'  The  fact  being 
established  that  it  is  possible  to  produce  rickets  by  certain  deleterious  prin- 
ciples in  the  ingesta  opens  an  interesting  field  for  experimental  inquiry. 
Since  improper  feeding  and  indigestion  are  known  to  sustain  a  causative 
relation  to  rachitis,  experiments  have  been  made  to  ascertain  whether  some 
chemical  agent,  developed  in  the  system  during  the  digestive  process  or  intro- 
duced with  the  food,  may  not  cause  rachitis  as  it  ordinarily  occurs  in  the 
infant.  Among  the  foremost  in  that  line  of  experiment  has  been  Dr.  Heitz- 
mann,  a  resident  of  Vienna  when  his  observations  were  made,  but  now  of 
New  York. 

In  young  children  acids,  especially  the  lactic,  are  commonly  produced., 
and  often  in  large  quantities,  as  the  result  of  improper  feeding,  of  indigestion, 

^  Annual  of  the  Unirer.  Med.  Sci.,  1889. 


184  RACHITIS. 

and  of  intestinal  catarrh.  The  acidity  of  the  infant's  stools  under  such  con- 
ditions of  ill-health  is  well  known.  What  more  natural,  then,  than  the  sup- 
position or  belief  that  this  acid,  thus  generated,  sustains  the  same  causative 
relation  to  rickets  as  phosphorus  in  the  experiments  which  have  been  made 
with  that  agent.  But  the  acid  which  is  produced  so  abundantly  in  disturbed 
states  of  the  digestive  apparatus  in  the  infant,  believed  to  be  chiefly  the 
lactic,  must,  in  order  to  reach  the  bones  and  influence  their  nutrition,  pass 
through  the  blood,  which  is  always  alkaline.  This  difficulty  in  the  way  of 
the  theory  that  lactic  acid  is  the  irritating  agent  is  removed  by  physiologists, 
who  tell  us  that  among  the  organic  acids  the  existence  of  lactic  acid  in  healthy 
blood  is  not  entirely  beyond  doubt,  but  that  it  has  been  found  in  the  latter 
under  abnormal  conditions.^  Lactic  acid  has  also  been  found,  after  having 
made  the  circuit  of  the  system,  in  the  excretion  from  the  kidneys. 

Heitzmann,  in  order  to  ascertain  whether  this  acid  sustained  a  causal 
relation  to  rickets,  made  a  series  of  experiments  which  have  passed  into  the 
literature  of  this  disease,  and  he  has  kindly  furnished  me  with  their  details, 
as  follows : 

"  Marchand,  Ragsky,  Lehman,  Simon,  and  others  have  found  free  lactic 
acid  in  the  urine  of  persons  sufi"ering  from  rickets  and  osteomalacia.  C. 
Schmidt  discovered  lactic  acid  in  the  liquid  of  malacic  shaft-bones  which 
were  transformed  into  globular  cysts.  Encouraged  by  these  chemical 
researches,  I  undertook  a  series  of  experiments  on  the  action  of  lactic  acid, 
administered  both  by  the  mouth  and  by  subcutaneous  injection,  upon  the 
bones  of  living  animals ;  which  experiments  were  begun  in  April,  1872,  and 
continued  until  the  end  of  October,  1873.  The  experiments  were  made  upon 
five  dogs,  seven  cats,  two  rabbits,  and  one  squirrel.  On  dogs  and  cats  under 
one  year  of  age  the  lactic  acid,  given  either  by  mouth  or  injection,  in  com- 
bination with  restricted  administration  of  calcareous  food,  produced  swelling 
of  the  epiphyses  of  the  shaft-bones  and  the  anterior  ends  of  the  ribs  at  their 
attachments  to  the  costal  cartilages.  This  result  was  plain  in  the  second 
week  after  the  beginning  of  the  lactic-acid  treatment.  Up  to  the  fourth  and 
fifth  weeks  the  swelling  of  the  epiphyses  and  of  the  ends  of  the  ribs  kept 
increasing,  and  then  was  accompanied  by  curvatures  of  the  bones  of  the 
extremities.  As  accompanying  symptoms  I  noticed  catarrhal  inflammation  of 
the  conjunctiva,  of  the  mucosa  of  the  bronchi,  the  stomach,  and  the  intestines, 
with  emaciation  and  convulsive  movements  of  the  extremities.  The  micro- 
scopic examination  of  the  epiphyses  gave  an  image  fully  identical  with  that  of 
the  epiphyses  of  rickety  children.  LTpon  continuing  the  administration  of  the 
lactic  acid,  the  swelling  of  the  epiphyses  of  the  shaft-bones  gradually  increased, 
and  so  did  the  curvatures  of  the  same  bones.  After  four  or  five  months  of 
lactic-acid  treatment,  under  often-repeated  catarrhal  inflammations  of  the 
above-named  mucous  layers,  the  shaft-bones  became  soft  to  such  a  degree 
that  they  could  be  bent  like  the  branches  of  a  willow  tree.  After  from  four 
to  eleven  months  of  the  same  treatment  the  microscopic  examination  of  the 
bones  gave  a  result  corresponding  with  that  obtained  from  the  bones  of 
women  who  have  died  with  osteomalacia. 

"  On  the  three  herbivorous  animals  no  swelling  of  the  epiphyses  was 
noticeable.  One  rabbit  died  three  months  and  the  other  five  months  after 
the  commencement  of  administration  of  the  lactic  acid,  but  with  symptoms 
of  inanition.  No  marked  evidences  of  rachitis  or  malacia  were  traceable  in 
the  bones  of  these  animals.  The  squirrel,  on  the  contrary,  which  died  after 
thirteen  months  of  treatment  with  lactic  acid,  gave  all  the  features  of  osteo- 
malacia. 

"  My  experiments  give  the  resiilt  that  hy  continuous  administration  of  lactic 

^  Heinrich  Frey  of  Zurich. 


CAUSES  OF  RACHITIS.  185 

acid,  at  first  rickets,  (utd  afterward  osteom(dacia,  can  he  artificiaUy  produced  in. 
Jlesh-caters  ;  whUe  in  herhivorous  animals  odi'omalacia  sets  in  luitliont  jJrecediny 
symptoms  of  rickets.  Through  these  experiments  I  have  proved  the  identity 
in  nature  of  these  tvro  diseases,  the  differences  in  their  course  being  due  to 
the  difference  in  the  age  at  which  the  solution  of  the  lime-salts  is  established. 
....  Rickets  can  be  produced  on  dogs  and  cats  only  under  the  age  of  ten 
or  twelve  months.  Mr.  Hess  fed  with  lactic  acid  a  dog  of  the  age  of  one  and 
a  half  years,  and  failed  to  produce  rickets.  This  result  is  in  full  agreement 
with  my  experiments.  I  maintain  that  lactic  acid,  though  not  free  in  the 
blood,  if  in  contact  with  the  tissues  producing  bone  or  with  fully-developed 
bone,  owing  to  its  great  affinity  for  lime  either  prevents  the  formation  of 
bone  (rickets)  or  dissolves  bone  already  made  (osteomalacia)." 

On  the  other  hand,  rachitis  sometimes  occurs  in  infants  who  present  no 
history  of  indigestion  or  of  intestinal  catarrh,  and  in  whom  there  is  no  ground 
for  the  belief  that  lactic  or  any  other  acid  is  produced  in  undue  or  injurious 
quantity.  In  a  considerable  proportion  of  such  cases  inquiry  elicits  the  fact 
of  antihygienic  conditions,  but  there  is  no  evidence  of  imperfect  digestion  or 
of  gastro-intestinal  catarrh,  such  as  produces  lactic  acid.  In  the  cases  occur- 
ring in  the  New  York  Infant  Asylum,  alluded  to  above,  some  of  the  children 
had  manifest  gastro-intestinal  derangement ;  but  others,  who  were  wet-nursed, 
gave  no  evidence  of  faulty  digestion,  though  the  nutriment  which  they 
received  was  probably  insufficient ;  for,  as  already  stated,  by  providing  a 
more  liberal  diet,  by  allowing  among  other  articles  the  juice  of  meat,  rachitis 
became  much  less  frequent,  and  is  seldom  observed  at  present  among  the 
infants  of  that  institution,  unless  in  a  vei'y  mild  form. 

Virchow  and  others  have  suggested  that  the  prime  factor  in  causing 
rachitis  is  the  use  of  a  diet  that  is  deficient  in  calcareous  salts,  and  we  have 
seen  that  in  the  interesting  experiments  of  Dr.  Heitzmann  the  administra- 
tion of  calcareous  food  to  the  animals  was  restricted.  Still,  as  Niemeyer  has 
well  said,  deprivation  or  restricted  use  of  the  chalky  salts  cannot  possibly 
cause  the  most  important  histological  change  in  rachitis — namely,  the  prolif- 
eration of  the  epiphyseal  cartilages  and  periosteum — and  we  must  look  for 
some  other  factor  in  the  causation. 

Pathology  furnishes  many  examples  of  chronic  disease  attended  by  pro- 
liferation of  tissue,  the  causes  of  which  are  not  uniform.  Cirrhosis,  with  its 
proliferation  of  hepatic  connective  tissue,  which,  as  we  shall  see,  presents  a 
similitude  in  some  respects  to  rachitis,  is  sometimes  undoubtedly  produced 
by  the  irritating  action  of  a  chemical  agent — to  wit,  alcohol ;  but  all  phy- 
sicians know  that  there  are  many  ciri'hotic  patients  who  refrain  entirely  from 
the  use  of  alcohol  in  any  form.  In  like  manner,  it  seems  to  me  that  if  we 
admit,  as  we  must  in  the  light  of  experiments,  that  certain  chemical  agents, 
notably  phosphorus  and  lactic  acid,  introduced  into  the  system  or  produced 
in  it,  cause  rachitis  by  their  irritating  action,  there  are  other  typical  cases  in 
which  there  is  no  reason  to  suspect  the  operation  of  such  agents.  We  must 
therefore  remain  in  the  belief  that  rachitis,  like  many  other  pathological  pro- 
cesses, does  not  result  from  a  fixed  and  uniform  cause,  but  from  conditions 
which  vary  to  a  certain  extent  in  different  patients.  Kassowitz  believes  that 
the  osseous  changes  which  occur  in  rachitis  result  from  inflammation,  which 
occurs  from  different  causes.  Comley  believes  that  the  cause  of  rachitis  is  a 
chemical  change  in  the  blood  which  occurs  from  digestive  disorders.  Cheadle 
believes  that  all  other  causes  are  subsidiary  to  bad  feeding.  Bottle-fed  infants, 
especially  those  whose  diet  is  mainly  farinaceous,  he  says,  are  especially  liable 
to  rachitis.^  Gallois,  Fournier,  and  Broca  regard  rickets  as  "  the  expression 
of  a  constitutional  degeneracy,  of  which   the   causes  are  multiple."      The 

^  London  Lancet,  August,  1888. 


186  RACHITIS. 

proximate   cause,  chemical   or   other,  Gallois  thinks  will  be   more    clearly 
ascertained.^ 

Anatomical  GnARACTEits  of  Rachitis. 

For  convenience  of  description  the  course  of  rachitis  is  divided  into 
three  periods :  (1)  That  of  proliferation  and  altered  nutrition  of  cartilage 
and  periosteum ;  (2)  That  of  curvature  and  deformity ;  (3)  That  of  recon- 
struction. 

Anatomical  Characters  in  the  Stage  of  Proliferation  and  Altered 
Nutrition. — Ossification  of  a  long  bone  occurs  from  the  epiphyseal  cartilages 
and  from  the  periosteal  or  fibrous  membrane  which  surrounds,  nourishes,  and 
protects  the  bone.  Growth  in  length  is  from  the  former,  in  thickness  from 
the  latter.  As  regards  the  flat  bone,  while  growth  in  thickness  occurs  from 
the  periosteum,  that  in  breadth  is  from  the  cartilage  of  its  border,  which  cor- 
responds with  the  epiphyseal  cartilage  of  the  long  bone. 

Cartilaginous  Changes. — If  we  examine  the  epiphyseal  cartilage  of 
a  long  bone  during  normal  ossification,  we  observe  first,  beginning  at  the 
distal  end,  a  white  zone  consisting  of  a  hyaline  matrix,  in  which  are  the 
usual  cartilage-cells.  This  constitutes  most  of  the  cartilage.  Underneath 
this,  and  nearer  the  bone,  is  the  zone  of  proliferafion^  the  cartilage  in  which 
is  softer  and  more  yieldittg  than  that  of  the  distal  zone,  in  consequence  of 
cell-formation  and  absorption  of  the  matrix  to  make  way  for  cell-groups. 
Each  cartilage-cell  in  the  proliferating  zone  has  divided  into  two  cells,  and 
each  of  these  cells  into  two  other  cells,  and  the  division  has  been  repeated,  so 
that  eight  cells  instead  of  one  are  observed,  surrounded  by  a  common  capsule. 
The  capsule  becomes  distended  by  the  cell-multiplication  and  by  the  swelling 
of  each  cell,  the  size  of  which  is  considerably  greater  than  that  of  the 
parent  cell.  Near  the  bone — namely,  along  the  extremity  of  the  diaphysis — 
the  cell-groups,  enclosed  in  their  capsules,  nearly  touch  each  other,  the 
matrix  having  for  the  most  part  been  absorbed.  The  end  of  the  diaph- 
ysis is  covered  with  a  layer  of  these  cell-groups  about  to  undergo  ossifica- 
tion, with  almost  no  intervening  matrix.  The  proliferating  zone  has  very 
little  depth.  It  appears  to  the  naked  eye  as  a  very  thin,  scarcely  per- 
ceptible, layer  of  a  reddish-gray  color  upon  the  end  of  the  shaft.  It  is  so 
shallow  that  it  does  not  perceptibly  increase  the  thickness  of  the  car- 
tilage. 

In  rachitis  the  state  of  affairs  is  different.  The  zone  of  proliferation, 
instead  of  being  confined  to  a  single,  or  at  most  a  double,  layer  of  cell-groups, 
consists  of  many  layers  involving  nearly  the  whole  epiphyseal  cartilage. 
The  cells,  still  enclosed  in  their  distended  capsules,  undergo  a  more  fre- 
quent division  than  in  health,  so  that  instead  of  groups  of  eight  cells,  as  in 
the  normal  state,  each  group  consists  of  from  thirty  to  forty  cells.  There- 
fore, in  rachitis  the  proliferating  cartilaginous  zone  is  a  broad  cushion,  very 
soft,  of  a  grayish  translucent  appearance,  causing  the  characteristic  swelling.- 
observed  around  the  joint.  Over  the  distal  end  of  the  proliferating  carti- 
lage there  may  still  be  a  layer  or  zone,  though  perhaps  of  little  depth,  of 
normal  cartilage,  like  that  in  health. 

Osseous  Changes. — While  this  occurs  the  ossifying  process  is  also 
arrested.  We  indeed  perceive  an  effort  in  the  direction  of  bone-formation. 
The  Haversian  canals,  surrounded  by  capillary  loops,  extend  from  the  bone 
into  the  proliferating  zone  of  cartilage.  Their  extension  is  effected  by 
absorption  of  the  matrix  and  appropriation  of  cell-groups  which  lie  in  their 
way.     The  cells  in  these  groups  as  they  enter  the  Haversian  system  become 

^  Annual  of  the  Univer.  Med.  Sci.,  1889. 


ANATOMICAL  CHARACTERS  OF  RACHITIS. 


187 


much  smaller  by  a  rapid  segmentation,  forming  medullary  cells.  We  also  find, 
as  further  evidence  of  the  attempt  at  bone  formation,  granules  and  masses 
scattered  through  the  cartilage,  and  here  and  there  spicula3  and  nodules  of 
true  bone  springing  up  from  the  bony  substratum  of  the  shaft.  Home  of 
the  canals  extend  far  into  the  cartilage,  nearly,  indeed,  to  its  free  surface, 
but  most  of  them  terminate  in  its  lowest  portion.  The  growth  of  bone  in 
thickness  occurs  from  the  under  surface  of  the  periosteum.  In  health  a  soft. 
Avascular,  germinal  tissue  springs  from  the  periosteal  surface,  and  rapidly 
receives  lime-salts  and  is  transformed  into  bone.  This  general  tissue,  con- 
sisting largely  of  capillaries  arising  from  the  fibrous  tissue  of  the  periosteum, 
is  a  very  thin  substratum,  barely  visible,  transient,  and  constantly  changing, 
from  its  conversion  into  bone. 

In  rachitis  this  vascular  subperiosteal  tissue,  not  undergoing  or  undergoing 
slowly  and  imperfectly  the  osseous  transformation,  and  at  the  same  time 
increasing  more  rapidly  than  in  health,  under  the  irritating  infiuence  of  the 
rachitic  disease  becomes  a  thick  layer.  Its  color  and  appearance  are  like 
spleen  pulp,  so  that  the  older  observers  supposed  there  was  a  hemorrhagic 
extravasation  between  the  periosteum  and  the  bone.  Thei'e  is,  however,  no 
extravasation  of  blood,  unless  it  accidentally  occur  from  the  numerous  delicate 
capillaries.  The  resemblance  to  extravasated  blood  or  spleen  pulp  is  due  to 
the  abundant  growth  of  large  and  thin-walled  capillaries  from  the  under  sur- 
face of  the  periosteum,  as  shown  by  the  microscope.  The  vascular  outgrowth 
is,  for  the  most  part,  quite  uniform  over  the  diaphyses  of  the  long  bones, 
while  upon  the  cranial  bones  its  thickness  is  much  greater  in  one  locality 
than  in  another.  The  attempt  at  ossification  also  appears  in  this  tissue. 
Lime-salts  are  scantily  and  loosely  deposited  through  it,  forming  osteo- 
phytes— vascular  and  fragile — rather  than  true  bone. 

The  question  naturally  arises.  How  does  rachitis  afiect  bone  which  is 
already  formed  when  the  rachitic  state  begins?  Virchow's  answer  is  the 
following :  "  Rachitis  has  ....  by  more  accurate  investigation  been  shown 
to  consist,  not  in  a  process  of  softening  in  the  old  bone,  as  it  had  previously 
been  considered  to  be,  but  in  a  non-solidification  of  the  fresh  layers  as  they 
form  :  the  old  layers  being  consumed  by  the  normally  progressive  formation 
of  medullary  cavities,  and  the  new  remaining  soft,  the  bone  becomes  brittle."^ 
It  seems,  however,  from  the  experiments  of  Heitzmann,  that  this  opinion 
should  be  modified,  at  least  as  regards  rachitis  produced  by  lactic  acid. 
Moreover,  in  rachitic  craniotabes  occurring  in  infancy  there  is  certainly  bone- 
absorption,  for  portions  of  the  occipital  and  parietal  bones  are  absorbed  to ' 
cause  the  soft  spaces.  We  must  therefore  believe  that  there  is  in  rachitis 
more  or  less  absorption  of  lime-salts  in  the  bone,  in  addition  to  that  required 
in  the  normal  growth  of  medullary  cavities  and  canals  for  vessels. 

In  healthy  bone  the  earthy  salts  are  in  excess  of  organic  matter  nearly 
in  the  proportion  of  two  to  one ;  but  in  rachitis  the  proportion  is  reversed, 
the  organic  matter  being  much  in  excess.  The  following  table  gives  analyses 
of  rachitic  bones  by  Marchand,  Davy,  Boettger,  and  Friedleben  : 


Femur. 

Radius. 

Vertebra. 

Inorganic 

Organic. 

Inorganic. 

Organic. 

Inorganic. 

Organic. 

Case  I 

Case  II.    .    .    . 
Case  III.  .    .    . 
Case  IV.  .    .    . 

20.60 
37.80 
20.89 
52.85 

79.40 

62.20  (conval.) 

79.11 

47.15 

21.24 
20.00 

78.76 
80.00 

18.68 
32.29 

81.32 
67.71 

^  Cellular  Pathology,  Chance's  translation,  Lecture  xix. 


188  RACHITIS. 

As  might  be  expected,  the  relative  proportion  of  organic  and  inorganic 
matter  varies  greatly  in  different  cases  and  at  different  stages  of  the  same 
ease.  In  severe  rachitis  many  bones  are  affected.  It  is  stated  that  there  is 
no  bone  in  the  entire  skeleton  that  may  not  suffer,  but  in  mild  cases  only  a 
few  are  involved,  at  least  to  such  an  extent  as  to  produce  structural  changes 
appreciable  to  touch  or  sight. 

Pathology  op  Rachitis. 

In  this  connection  it  is  proper  to  consider  the  pathology  of  rachitis. 
What  is  its  nature?  Niemeyer,  in  my  opinion,  expresses  the  correct  view 
when  he  says,  "  It  seems  to  me  that  the  most  probable  hypothesis  regarding 
the  cause  of  rachitis  is  that  which  refers  it  to  inflammation  of  the  epiphyseal 
cartilages  and  periosteum."  The  increased  vascularity  of  the  periosteum, 
the  proliferation  of  periosteum  and  cartilage,  the  tenderness  and  pain  on 
motion,  and  the  febrile  movement  in  acute  forms  of  the  disease,  indicate 
inflammation  rather  than  any  other  recognized  pathological  state.  The 
rachitic  inflammation,  as  it  affects  the  osseous  system,  appears  to  be  of  a 
chronic  or  subacute  character,  presenting  an  analogy  with  certain  other  well- 
known  inflammations,  such  as  cirrhosis  and  certain  forms  of  chronic  nephritis, 
in  which  proliferation  of  connective  tissue  and  sclerosis  occur.  The  eburna- 
tion  rather  than  normal  ossification  which  terminates  the  rachitic  process  may 
properly  be  considered  an  osteosclerosis.  Conformably  with  the  theory  of 
the  inflammatory  nature  of  rachitis,  the  periosteum  is  found  infiltrated  and 
thickened,  and  of  a  reddish  hue  from  hypersemia  and  from  the  presence  of 
the  newly-formed  capillaries  underneath,  which  have  been  described  above  as 
forming  a  layer  of  considerable  thickness  known  as  the  "  germinal  vascular 
tissue."  Moreover,  as  in  inflammation,  some  secretion  along  with  the  vascu- 
lar growth  occurs  over  the  bone  from  the  under  surface  of  the  periosteum. 
The  various  interspaces  in  long,  short,  and  flat  bones,  the  diploe,  cancelli,  and 
interlamellar  openings,  contain  a  substance  similar  to  that  exuded  under  the 
periosteum.     It  appears  to  be  an  inflammatory  exudation. 

Anatomical  Characters  in  the  Stage  of  Deformity. — Rachitic  bone, 
when  the  disease  has  continued  for  some  time  and  is  still  in  its  active  period, 
presents  a  bluish  or  dusky-red  appearance,  from  its  increased  vascularity. 
After  a  variable  time,  weeks  or  months  according  to  the  severity  of  the 
disease,  deformities  begin  to  appear. 

Spiegelberg's  description  of  the  appearance  of  the  rachitic  foetus  cor- 
responds for  the  most  part  with  what  I  observed  in  the  one  whose  skeleton 
is  represented  in  Fig.  10.  According  to  this  writer,  the  body  and  limbs  are 
plump,  the  latter  short  and  curved ;  the  abdomen  large  and  prominent ;  and 
the  head  sometimes  hydrocephalic.  The  skin  is  thick  and  loose,  and  the  adi- 
pose tissue  well  developed  ;  the  liver  large  ;  the  epiphyses  swollen  and  soft ; 
the  short  and  curved  diaphyses  sometimes  broken.  The  rotundity  of  the 
thorax  is  preserved,  and  the  sternum  is  not  carried  forward,  since  there  has 
been  no  respiration ;  the  ribs,  in  softness  and  liability  to  fracture,  correspond 
with  the  long  bones  of  the  extremities.  The  sternum,  most  of  all  the  bones, 
shows  the  delay  in  ossification  ;  the  clavicle  is  among  those  least  affected. 
The  cranium  may  be  represented  by  a  membranous  bag  with  plaques  of 
bone,  or  the  cranial  bones  may  be  formed  and  in  shape,  but  thickened  and 
softened ;  the  sacral  promontory  is  pressed  forward  and  downward ;  the  sa- 
cral vertebrae  flattened ;  the  ilia  flattened  and  widened ;  and  the  pubic  arch 
increased. 

It  is  interesting  to  compare  these  deformities  with  those  in  the  child,  since 
they  occur  under  conditions  so  very  different.     Rachitic  bone  seldom  retains 


PATHOLOGY  OF  RACHITIS.  189 

its  normal  form  or  shape  ;  its  projecting  points  are  rounded,  and  as  soon  as 
it  softens  it  begins  to  yield  to  pressure  exerted  upon  it.  Hence  the  curva- 
tures so  common  and  characteristic.  The  portion  of  a  long  bone  which  is 
formed  after  rachitis  commences  contains  so  little  earthy  matter  that  it  bends 
readily  in  its  fresh  state,  either  by  muscular  action  or  by  the  weight  of  the 
trunk,  "in  the  manner,"  says  Vogel,  "  of  a  quill  or  willow  stick."  The  inte- 
rior of  the  bone,  which  was  formed  before  rachitis  began,  and  which  contains 
nearly  or  quite  the  normal  proportion  of  lime,  is  likely  to  break  instead  of 
bending,  but,  as  it  is  surrounded  on  all  sides  by  the  soft  tissue,  the  fragments 
are  not  displaced,  and  probably  do  not  crepitate.  So  scanty  is  the  calcareous 
deposition  in  typical  cases  that,  says  Trousseau,  "  the  bones  ....  can  be 
cut  with  a  knife  with  as  much  ease  as  a  carrot  or  other  soft  root,"  and  the 
dried  specimen  weighs  but  one-sixth  to  one-eighth  as  much  as  normal  bone. 
One  writer  states  that  the  dried  rachitic  bone  is  sometimes  so  porous,  from 
the  small  amount  of  lime  which  it  contains,  that  it  is  possible  to  respire 
through  it  as  through  a  sponge. 

In  ordinary  cases  the  bones  which  exhibit  most  strikingly  the  rachitic 
change,  and  which,  therefore,  should  be  carefully  examined  in  making  the 
diagnosis,  are  the  cranial  bones,  the  ribs,  and  the  radius — the  sternal  ends  of 
the  ribs  and  the  lower  end  of  the  radius.  It  is  seldom  that  these  bones  do 
not  give  evidence  of  the  disease  if  it  be  present,  and  in  greater  degree  than 
other  bones.  They  are  the  first  to  be  aflFected  to  an  extent  that  is  appre- 
ciable to  the  observer. 

Changes  in  the  Cranial  Bones. — In  these  bones  interesting  and 
important  alterations  occur.  Their  edges,  which  correspond  with  the  epi- 
physeal cartilages,  undergo  proliferation  and  become  thickened  like  the  latter. 
This  thickening  and  the  delayed  union  of  the  sutures  produce  grooves  which 
can  be  traced  by  the  fingers  between  the  bones,  and  which  are  sometimes 
appreciable  to  the  sight.  Rachitis  causes  some  enlargement  of  the  cranium, 
but  the  enlargement  seems  greater  than  it  really  is  on  account  of  the  retarded 
growth  of  the  facial  bones.  In  a  discussion  on  rachitis  in  the  London  Patho- 
logical Society,  reported  in  the  Lancet,'^  it  was  stated  that  in  17  rachitic  chil- 
dren, with  an  average  of  4.72  years,  the  average  circumference  of  the  head 
was  21.22  inches,  while  in  the  same  number  who  were  non-rachitic  and  with, 
an  average  of  6.05  years,  the  average  circumference  was  19.95  inches. 

The  retarded  ossification  is  manifested  not  only  in  the  open  sutures,  but 
also  in  the  large  size  and  patency  of  the  fonfcuteU,  which  are  not  closed  till 
long  after  the  usual  time.  The  anterior  fontanel  should  be  closed  between 
the  fifteenth  and  twentieth  months,  but  in  the  rachitic  it  remains  membra- 
nous till  after  the  second  year,  even  into  the  third  or  fourth  year.  Since 
examination  of  the  anterior  fontanel  is  important  in  determining  whether 
or  not  rachitis  be  present,  it  should  be  borne  in  mind  that  in  the  normal  state 
this  space  increases  in  size  till  the  seventh  month,  when  it  is  at  its  maximum, 
and  that  after  the  ninth  month  it  becomes  progressively  smaller. 

The  shape  of  the  rachitic  head  varies.  In  general,  instead  of  its  normal 
rounded  form,  it  approaches  a  square  shape.  Another  type  is  sometimes 
observed  in  which  there  is  no  marked  angularity,  but  in  which  the  antero- 
posterior diameter  is  enlarged.  In  the  square  head  the  forehead  projects  and 
both  the  frontal  and  parietal  protuberances  are  unusually  prominent.  The 
sutures  are  depressed  to  a  certain  extent,  as  has  already  been  mentioned,  and 
the  anterior,  lateral,  superior,  and  posterior  surfaces  of  the  cranium  are  more 
flattened  than  in  health.  The  lambdoidal  suture,  which  should  close  by  the 
fourth  month,  and  the  sagittal,  which  should  close  by  the  end  of  the  first  year, 
have  made  little  progress  toward  union  when  the  second  year  begins.     The 

^  Lancet,  1880,  vol.  ii.  p.  1017. 


190  RACHITIS. 

undue  prominence  of  the  frontal  and  parietal  bosses  takes  its  origin  from  the 
exaggerated  proliferation  of  the  periosteal  or  fibrous  covering  of  the  bones. 

Craniotabes. 

Thinning  of  the  cranial  bones  in  places  so  that  the  brain  lacks  proper  pro- 
tection has  long  been  noticed  in  the  examination  of  rachitic  heads,  but  the 
injury  that  results  to  the  infant  was  overlooked  till  pointed  out  by  Dr.  Elsas- 
ser.  Craniotabes  occurs  for  the  most  part  in  patients  under  the  age  of  one 
year,  and  a  large  proportion  are  under  eight  months.  Its  occurrence  in  the 
foetus,  as  shown  by  a  case  published  in  the  New  York  Obstetrical  Journal  in 
1870  and  by  Heitzmann's  case,  has  already  been  alluded  to.  The  factors  in 
producing  this  thinning  are  rachitic  softening  of  the  bones  and  pressure — pres- 
sure of  the  brain  from  within  and  of  the  pillow  from  without.  Consequently, 
the  portions  of  the  cranial  arch  in  which  the  thinning  occurs  are  the  posterior 
and  lateral,  the  occipital  bone  and  the  posterior  half  of  the  parietal.  If  the 
infant  lie  chiefly  on  one  side  in  its  crib,  on  this  side  the  craniotabes  occurs, 
while  those  portions  of  the  cranium  which  are  not  pressed  upon,  as  the  frontal 
bone,  exhibit  no  thinning.  The  soft  spots  are  yielding  when  pressed  upon, 
and  in  the  cadaver  they  are  seen  to  be  translucent  when  held  to  the  light. 
The  amount  of  absorption  varies  greatly  according  to  the  degree  of  rachitic 
softening  and  the  amount  and  continuance  of  the  pressure.  There  may  be 
in  some  instances  simple  depressions,  like  erosions  in  the  bone,  with  a  contin- 
uous but  thin  bony  layer  remaining  ;  but  in  other  cases,  such  as  have  been 
particularly  examined  and  studied  by  physicians,  the  bone-absorption  is  com- 
plete over  areas  of  greater  or  less  extent,  so  that  the  pericranium  and  dura 
mater  are  in  contact.  In  examining  a  child  for  craniotabes  it  should  be  borne 
in  mind  that  the  margins  of  the  bones,  even  when  there  is  no  thinning,  but 
thickening  from  the  cartilaginous  proliferation,  are  flexible  in  the  rachitic. 
The  pressure  must  be  made  in  a  direction  from  the  sutures,  to  ascertain 
whether  craniotabes  has  occurred.  The  pressure  should  at  first  be  made 
lightly  and  cautiously  with  the  fingers,  for  if  there  be  total  absence  of  bone, 
unless  of  very  little  extent,  deep  and  forcible  pressure  might  injure  the  brain^ 
for  so  soft  and  delicate  an  organ,  covered  only  by  the  scalp  and  dura  mater, 
"  badly  tolerates  pressure.  If  the  first  examination  detect  no  soft  place,  the 
fingers  may  be  pressed  more  firmly  against  the  scalp,  when,  if  the  bone  be 
much  thinned,  so  that  there  is  only  a  small  layer  of  the  lime-salts  underneath,, 
it  will  be  found  to  yield.  The  sensation  communicated  to  the  fingers  when 
there  is  an  open  space  in  the  cranium  and  the  dura  mater  and  scalp  are  in 
contact  has  been  likened  to  that  experienced  when  pressing  upon  a  fully-dis- 
tended bladder.  At  a  meeting  of  the  London  Pathological  Society,  reported 
in  the  Lancet  for  November  20,  1880,  Dr.  Lees  presented  statistics  to  show 
that  craniotabes  was  one  of  the  lesions  of  inherited  syphilis ;  but  whether  it 
may  result  from  syphilis  or  not,  the  evidence  that  there  is  a  cranial  softening 
which  is  strictly  rachitic  appears  from  repeated  observations  to  be  sufficient. 

Symptoms  op  Craniotabes. — As  craniotabes  gives  rise  to  peculiar  symp- 
toms quite  distinct  from  those  of  the  general  rachitic  disease,  they  may  be 
properly  considered  in  this  connection.  Craniotabes  usually  occurs  during 
the  first  year  of  infancy,  and  most  frequently  prior  to  the  tenth  month.  The 
brain  at  this  age  is  soft  and  yielding,  since  it  contains  a  large  percentage  of 
water.  Unless  handled  with  care  at  an  autopsy  it  is  readily  lacerated,  and 
moderate  pressure  upon  it  is  seen  to  disturb  and  move  it  a  considerable  dis- 
tance from  the  point  of  contact.  It  assists  to  a  proper  understanding  of  the 
symptoms  of  craniotabes  to  recall  to  mind  the  fact,  well  known  to  surgeons, 
that  slight  depression  of  even  a  small  portion  of  the  skull  usually  produces 


CRANIOTABES.  191 

grave  symptoms.  It  is  not  surprising,  therefore,  that  craniotabes,  when 
there  is  a  space  of  considerable  size  in  the  cranial  arch  destitute  of  bone, 
is  attended  by  symptoms  due  to  the  mechanical  effect  of  external  pressure 
whenever  a  substance  less  yielding  than  the  brain  comes  in  contact  with  the 
unprotected  part. 

Since  pressure  from  the  pillow  without  and  from  the  brain  within  is 
believed  to  be  the  cause  of  the  absorption,  the  craniotabes  must  obviously 
occur  in  the  posterior  and  postero-lateral  portions  of  the  cranium.  Cor- 
responding with  this  explanation  of  the  causation,  the  thinning  actually 
occurs  in  the  occipital  and  posterior  portions  of  the  parietal  bones,  while  the 
anterior  halves  of  the  parietal  bones  and  the  frontal  bones  are  even  thicker 
than  normal,  from  the  cartilaginous  and  periosteal  proliferation  occurring 
along  the  sutures  and  on  the  surface  of  these  bones,  as  already  described. 
It  is  well  known  that  long-continued  pressure  produces  absorption  of  cal- 
careous matter  even  more  readily  than  of  soft  tissues,  as  is  shown  in  the 
absorption  of  a  tooth  of  the  first  set  by  the  growth  of  the  dental  pulp  of  the 
second  set.  In  the  normal  growth  of  the  skull  constant  absorption  of  the 
under  surface  of  the  cranial  bones  is  going  on  to  make  room  for  the  enlarg- 
ing brain,  and  when  no  calcareous  deposition  occurs  upon  the  external  sur- 
face to  compensate  for  the  loss  within,  we  might  expect  even  a  greater  amount 
of  craniotabes  than  ordinarily  occurs. 

Every  rachitic  infant  is  fretful,  but  one  with  craniotabes  is  especially  so 
if  the  open  spaces  be  of  considerable  size.  If  it  lie  upon  the  pillow  in  its 
accustomed  manner,  as  is  most  natural  for  it,  the  unprotected  portion  of  the 
brain  may  be  so  pressed  upon  by  the  weight  of  the  head  that  it  feels  uncom- 
fortable. It  does  not  have  quiet  sleep,  probably  because  the  cerebral  circula- 
tion and  functions  are  in  a  measure  disturbed ;  it  is  apt  to  awaken  readily 
and  often,  and  frets  till  it  is  taken  in  the  nurse's  arms.  Sometimes  it  instinct- 
ively seeks  a  position  on  the  edge  of  the  pill(3w  with  the  face  downward,  and 
it  becomes  more  quiet  when  resting  over  the  nurse's  shoulder  with  the  face 
backward.  But  if  fretfulness,  disturbed  sleep,  and  the  necessity  of  closer 
attention  on  the  part  of  the  mother  and  nurse  were  the  only  ill-effects  of 
craniotabes,  it  would  possess  much  less  pathological  significance  than  pertains 
to  it.  Pressure  upon  so  delicate  and  important  an  organ  as  the  brain  involves 
risks  and  produces  serious  symptoms  in  proportion  to  its  degree.  Even  a 
slight  injury  of  the  skull  which  produces  depression,  though  it  may  be  of 
trifling  amount,  will  cause  serious  forms  of  nervous  disorder.  So  craniotabes 
is  believed  to  sustain  a  causative  relation  in  certain  cases  to  one  of  the  most 
dangerous  of  the  neuroses — namely,  laryngismus  stridulus,  an  affection  which 
is  also  designated  "  internal  convulsions,"  "  spasm  of  the  glottis,"  and  "  Kopp's 
asthma,"  although  Kopp  was  not  the  first  to  describe  and  recognize  the  mal- 
ady. The  etiology  of  this  neurosis  has  not  been  fully  elucidated.  It  is  cer- 
tain that  a  large  proportion  of  those  who  suffer  from  it  are  rachitic,  and  that 
it  is  more  common  and  severe  where  rachitis  is  prevalent,  as  in  England,  than 
where  it  is  rare,  as  in  the  rural  districts  of  America.  It  is  not  often  the 
cause  of  death  in  this  country,  and  the  fatal  cases  that  do  occur  are  only  seen 
in  cities,  whereas  in  parts  of  Europe  where  rachitis  is  much  more  common 
than  with  us  it  causes  many  deaths. 

Certain  infants  when  in  a  state  of  excitement  have  what  are  termed 
*■  holding-breath  spells."  The  face  is  flushed  and  breathing  ceases  for  some 
seconds,  after  which  respiration  returns  and  is  normal.  These  attacks  are 
unimportant,  but  they  appear  to  be  the  same  in  nature  with  the  more  severe 
and  dangerous  seizures  of  laryngismus  stridulus.  They  have  no  pathological 
significance,  excepting  as  they  show  the  same  neuropathic  state  as  that  in 
laryngismus,  and  as  they  may  be  precursors  of  this  disease.     Laryngismus 


192 


RACHITIS. 


stridulus,  or  glottic  spasm,  is  usually  preceded  by  more  or  less  impairment  of 
the  general  health,  and  often  by  fretfulness,  which  is  characteristic  of  the 
rachitic  state ;  but  the  attack  occurs  suddenly,  without  premonition,  and  is 
of  short  duration.  It  begins  with  an  arrest  of  respiration,  a  true  apnoea,  as 
if  from  paralysis  of  the  respiratory  centre  in  the  medulla.  The  lips  may  be 
livid  ;  a  pallor  spreads  over  the  face  ;  sometimes  more  or  less  rigidity  of  the 
limbs  occurs,  with  carpo-pedal  contractions  ;  and  after  a  few  seconds,  a  quarter, 
or  half  minute  a  long  and  deep  but  difficult  inspiration  through  the  narrow 
chink  of  the  glottis  follows,  accompanied  in  many  patients  by  a  whistling  or 
crowing  sound,  and  the  attack  ends  with  perhaps  a  momentary  look  of 
bewilderment  or  dread  on  the  child's  face.  Now,  this  disease,  like  eclampsia, 
does  not  have  a  uniform  causation.  In  certain  cases  it  appears  to  be  a  reflex 
phenomenon  due  to  an  irritant  in  some  part  of  the  system,  as  in  the  intestines  ; 
but  many  observations  have  established  the  fact  that  rachitis  also  sustains 
a  causal  relation  to  it.  A  large  proportion  of  the  infants  aff"ected  with 
laryngismus  exhibit  unmistakable  rachitic  signs,  and  in  the  opinion  of  many 
experienced  observers  the  exposed  state  of  the  brain  affords  explanation  of 
the  fact  that  so  many  of  the  rachitic  have  this  neurosis.  Still,  from  observa- 
tions which  I  have  made,  and  from  those  of  other  observers,  like  Senator,  it 

Fig.  11. 


Head  of  a  Rachitic  Child  in  the  New  York  Infant  Asylum. 

is  certain  that  laryngismus  stridulus  is  common  in  the  rachitic  who  do 
not  have  craniotabes,  so  that  there  must  be  a  causal  relation  in  rachitis  to 
laryngismus  independently  of  the  cranial  softening.  The  accompanying 
woodcut  represents  the  rachitic  head  of  a  child  in  the  New  York  Infant 
Asylum.     This  patient  had  also  attacks  of  laryngismus  stridulus. 

Changes  in  the  Vertebra,  etc. — The  short  bones  which  participate  in 
the  rachitic  disease  become  softer  and  mor?  yielding,  and  their  cancelli  are 
filled  with  a  reddish  pulpy  substance.  In  many  rachitic  cases  the  vertebrae 
are  but  slightly  involved,  so  that  no  deformity  of  the  spinal  column  results ; 
but  occasionally,  when  many  bones  are  affected,  the  vertebrae  and  interver- 
tebral cartilages  soften  and  spinal  curvatures  result.  The  curvatures  are  due 
to  the  weight  of  the  shoulders  and  head  on  the  spinal  column.  They  are, 
with  some  deviations,  an  exaggeration  of  those  present  in  the  normal  state. 


CRANIOTABES. 


193 


Fig.  12. 


Rachitic  curvatures  of  tlie  sjiiiiu  are  theretore  mainly  antero-posterior  with 
some  lateral  deflections.  Where  there  is  much  curvature  the  vertebrae 
become  wedge-sha{)ed,  narrowed  upon  the  concavity,  and  thickened  upon  the 
convexity.  The  intervertebral  cartilages  are  also  more  or  less  changed  by 
the  pressure,  being  thinned  where  the  vertebnc  approximate  to  each  other  on 
the  concave  aspect  of  the  curvature,  and  of  normal  tliickne.ss  or  thicker  than 
normal  upon  the  convexity.  The  accompanying  woodcut  exhibits  the  nature 
and  appearance  of  rachitic  spinal  curvature  in  the  adult.  Rachitis,  having 
occurred  at  the  usual  age,  resulted  in  the  perma- 
nent deformity  here  illustrated.  In  extreme  cases, 
fortunately  rare,  the  functions  of  important  organs 
may  be  seriously  impaired  by  the  curvature  and 
conse(|uent  compression,  as  in  Pott's  disease.  Thus, 
according  to  Miller,  the  aorta  has  been  so  doubled 
upon  itself  as  to  diminish  materially  the  flow  of 
blood  to  the  lower  extremities  and  sensibly  impair 
their  nutrition.  The  eff"ect  of  so  great  curvature 
upon  the  functions  of  the  heart  and  lungs  must 
obviously  be  detrimental. 

At  first  the  spinal  curvatures  disappear  when 
the  child  reclines  or  is  lifted  by  the  axillse,  so  as 
to  raise  the  head  and  shoulders  from  the  spine,  but 
when  the  deformity  has  continued  so  long  that  the 
vertebrae  and  cartilages  have  become  wedge-shaped, 
it  remains  for  life,  or  can  only  be  rectified  slowly 
and  with  difficulty  by  mechanical  appliances.  As 
seen  in  the  woodcut,  the  common  curvature  in  the 
dorsal  region  is  backward  (Jci/phosis),  while  to  com- 
pensate the  patient  instinctively  carries  the  neck 
forward,  with  the  head  thrown  back,  causing  cer- 
vical lordosis,  a  similar  anterior  curvature  being 
common  in  the  lumbar  region.  Lateral  curvature 
(^scoliosis')  may  or  may  not  be  present,  even  when 
there  is  considerable  antero-posterior  flexure.  Sco- 
liosis is  sometimes  produced  by  the  nurse  in  carry- 
ing the  infant  habitually  over  one  arm. 

Changes  in  the  Maxilla. — Fleischmann  has  investigated  the  changes 
which  rachitis  produces  in  the  maxillary  bones.  Stunted  growth  of  the  facial 
bones  generally  has  long  been  known,  and  has  been  remarked  upon  by  various 
writers  ;  but  according  to  Fleischmann  other  interesting  changes  occur  in  the 
jaw-bones  which  aff'ect  the  direction  and  position  of  the  teeth.  According  to 
this  author,  the  arched  shape  of  the  lower  jaw  becomes  polygonal,  and  the 
direction  of  the  alveolar  process  also  changes,  so  that  it  inclines  inward. 
This  deviation  in  the  arch  and  in  the  alveolar  process,  which  begins  in  the 
region  of  the  canine  teeth,  necessarily  causes  shortening  of  the  lower  jaw. 
Commencing  soon  after,  a  change  is  observed  in  the  upper  jaw-bone  from  the 
zygomatic  arch  forward,  so  as  to  cause  lengthening  of  this  bone,  changing 
here  also  the  shape  of  the  arch  and  the  position  of  the  teeth.  The  lateral 
incisors,  instead  of  being  in  front,  have  a  lateral  position,  and  the  incisors  and 
molars  diverge,  so  that  when  the  jaws  are  closed  they  overlap  the  correspond- 
ing teeth  of  the  lower  jaw  in  front  and  upon  the  sides — a  condition  the  oppo- 
site of  that  seen  in  the  jaws  of  old  people.  Fleischmann  attributes  these 
changes  in  the  lower  jaw  to  the  action  of  the  masseter  and  mylo-hyoid  mus- 
cles, and  perhaps  the  genio-glossus,  and  to  pressure  of  the  lip,  the  deficiency 
of  earthy  salts  in  the  bone  rendering  it  more  easily  acted  on  by  the  muscles. 
13 


Rachitic  Spinal  Curvature 
in  an  Adult.  (From  a  speci- 
men in  the  Wood  Museum, 
Bellevue  Hospital.) 


194 


RACHITIS. 


The  change  in  the  upper  jaw-bone  he  attributes  to  lateral  pressure  of  the 
zygomatic  arches. 

Changes  in  the  Ribs. — The  ribs  are  early  affected  in  rachitis.  The 
swelling  of  their  anterior  ends,  where  they  unite  with  costal  cartilages,  pro- 
ducing the  "  rachitic  rosary,"  has  been  already  alluded  to  as  one  of  the  first 
and  most  conspicuous  signs  of  rachitis.  The  costochondral  articulations  are 
enlarged  in  all  directions,  appearing  as  nodules  under  the  skin.  If  an  oppor- 
tunity occur  of  inspecting,  at  an  autopsy,  the  pleural  surface,  the  nodular 
prominences  are  seen  to  be  even  greater  and  more  distinct  there  than  under 
the  skin. 

The  deformity  of  the  thorax  consequent  upon  softening  of  the  ribs  is 
interesting.     Commencing  with  the  spine,  the  ribs  extend  nearly  directly 


Fig.  13. 


Rachitic  Child  with  characteristic  Deformity  of  Head,  Ribs,  and  Radius. 
New  York  Foundling  Asylum.) 


(From  a  patient  in  the 


outward ;  at  the  union  of  the  dorsal  and  lateral  regions,  they  make  a  short 
curve  forward,  and  then  turn  inward,  also  with  a  short  curve  toward  the 
sternum  (Fig.  14).  This  abrupt  bending  of  the  ribs — which,  in  their  soft- 
ened state,  has  been  caused  by  atmospheric  pressure  during  respiration — pro- 
duces a  depression  in  the  thoracic  wall  at  about  the  point  where  the  ribs  and 
their  cartilages  unite.  A  groove  extends  on  the  antero-lateral  surface  of  the 
thorax  from  the  second  or  third  rib  downward  and  a  little  outward.  Some- 
times the  bottom  of  the  groove  is  occupied  by  the  costochondral  joints ;  in 
other  cases  these  joints  are  a  little  to  one  side  of  the  deepest  part  of  the 
groove.  The  transverse  diameter,  therefore,  of  the  anterior  half  of  the 
thorax  is  much  less  than  in  health.  This  necessarily  diminishes  the  lateral 
expansion  of  the  lung  in  inspiration  and  causes  unusual  prominence  in  the 
sternum.  Hence  the  expressions  "  pigeon-breasted,"  "  resemblance  to  the 
prow  of  a  ship,"  etc.,  applied  to  this  deformity.  The  presence  of  the  heart 
renders  the  groove  more  shallow  on  the  left  side,  at  the  fourth  and  fifth  ribs, 
than  on  the  opposite  side,  since  this  organ  affords  partial  support  to  the  chest- 
wall.  On  the  other  hand,  the  right  groove  is  not  as  long  as  the  left,  as  the 
lower  ribs  on  this  side  are  partially  supported  by  the  liver.  On  both  sides, 
however,  the  lower  part  of  the  thorax,  that  below  the  seventh,  eighth,  or 
ninth  ribs,  widens,  being  pressed  outward  and  supported  by  the  abdominal 


CBANIOTABES. 


195 


viscera.  There  is,  therefore,  in  addition  to  the  longitudinal  groove,  an 
antero-posterior  depression,  sometimes  also  spoken  of  as  a  furrow  or  groove, 
on  either  side,  lying  between  the  sixth  and  ninth  ribs. 

The  ribs  with  their  attached  muscles  are  important  agents  in  respiration, 
but  the  soft  and  yielding  nature  of  the  ribs  in  the  rachitic  retards,  and  to  a 


Fig. 


Deformity  of  Chest  and  Rachitis. 

great  extent  prevents,  the  lateral  expansion  of  the  thorax  which  is  necessary 
for  normal  and  full  inspiration.  The  action  of  the  respiratory  muscles,  and 
the  pressure  from  within  of  the  air  descending  along  the  air-passages,  is  not 
sufficient  to  overcome  fully  the  external  atmospheric  pressure  in  the  absence 
of  proper  resiliency  of  the  ribs.  Consequently,  with  each  inspiration  we 
observe  more  or  less  sinking  in  of  the  thorax  on  either  side,  just  as  when  a 
moderate  obstruction  to  the  entrance  of  air  exists  in  the  larynx  or  trachea. 
As  the  ribs  become  firmer  from  the  deposit  of  lime-salts,  respiration  is  more 
regular  and  normal. 

Changes  in  Bones  of  Upper  Extremity. — Although  swelling  of  the 
lower  end  of  the  radius  (see  Fig.  13)  is  one  of  the  earliest  signs  of  rachitis, 
the  bones  of  the  upper  extremities  are  less  frequently  curved  and  distorted 
than  those  of  the  lower  extremities.  The  clavicle  sometimes  softens  and 
bends,  producing  two  curvatures — one  backward,  near  the  scapula,  and 
another  of  larger  size  nearer  the  sternum,  directed  forward  and  a  little  upward. 
Careful  examination  shows,  in  some  rachitic  patients,  thickening  of  the  margins 
of  the  scapula,  like  that  of  the  cranial  bones.  The  humenis  is  occasionally 
bent,  and  usually  at  the  point  of  insertion  of  the  deltoid,  in  consequence  of 
the  powerful  action  of  this  muscle  in  raising  and  supporting  the  arm.  The 
radius  and  ulna  are  bent  outward  and  twisted.  The  deformity  is  attributed 
by  Sir  William  Jenner  to  the  fact  that  rickety  children  support  themselves, 
while  in  the  sitting  posture,  upon  the  palms  of  the  hands  pressed  upon  the 


196 


RACHITIS. 


floor  or  couch.  Supporting  the  weight  of  the  body  in  this  way  not  only,  in 
his  opinion,  causes  bending  of  the  ulna  and  radius,  but  also  aids  in  producing 
the  deformities  of  the  humerus  and  clavicle. 

Changes  in  Bones  of  Pelvis. — The  deformities  of  the  pelvic  bones 
resulting  from  rachitic  softening  are,  in  the  female  infant,  the  most  important 
of  any  which  the  skeleton  undergoes.     They  are  produced  by  pressure  from 


Fig.  15. 


Fig.  16. 


Fig.  17. 


Rachitic  Deformities  of  the  Pelvis.    (From  specimens  in  the  Wood  Museum. 


above  of  the  abdominal  organs,  serving  to  widen  the  brim  of  the  pelvis,  and 
also  by  pressure  of  the  spinal  column,  sustaining  the  weight  of  the  trunk, 
shoulders,  and  head,  pressing  forward  the  promontory  of  the  sacrum  in  the 
sitting  posture,  and  thus  diminishing  the  antero-posterior  diameter  of  the 
pelvic  brim.  There  is,  moreover,  twofold  pressure  from  below — that  caused 
by  the  heads  of  the  thigh-bones  in  standing,  and  that  exercised  by  the 
tuberosities  of  the  ischia  in  sitting.  Both  these  forms  of  pressure  have  a 
tendency  to  narrow  the  outlet  of  the  pelvis.  Hence  the  marriage  of  the 
female  who  has  been  rachitic  in  infancy  may  involve  serious  consequences. 
Many  of  the  tedious  instrumental  labors  in  the  families  of  the  city  poor, 
which  severely  tax  the  patience  and  endurance  of  young  practitioners,  are 
attributable  to  rickets  in  early  life. 

Changes  in  Bones  of  Lower  Extremities. — The  curvature  of  the 
femur  is  usually  forward  or  forward  and  outward.  The  neck  of  the  femur 
sometimes  bends  by  the  weight  of  the  body  or  by  use  of  the  legs,  so  that  the 
angle  which  it  forms  with  the  shaft  is  changed.    The  annexed  woodcuts  show 


Fig.  18. 


Fig.  19. 


Rachitic  Deformities  of  the  Femur.    (Wood  Museum.) 


the  rachitic  bend  of  this  bone  in  an  adult  years  after  rachitis  had  ceased  and 
when  the  bone  had  become  consolidated  by  the  new  deposition  of  lime-salts. 
The  curvature  of  the  tibia  and  Jibiila  varies.  In  those  under  the  age  of 
one  year  it  is  frequently  outward,  so  that  the  knees  are  separated  from  each 
other.  In  those  old  enough  to  stand  the  weight  of  the  body  usually  deter- 
mines also  a  forward  bending  of  these  bones.     In  one  case  in  my  practice  an 


CRANIOTABKS. 


197 


anterior  curvature  so  abrupt  that  an  angle  of  about  70°  was  formed  existed 
about  four  inches  above  each  ankle.  This  patient,  though  old  enough  to  walk, 
almost  constantly  sat  during  the  day  with  the  feet  extended  beyond  the  sofa, 
so  that  the  edge  of  the  latter  corresponded  with  the  concavity  of  the  legs. 
It  seemed  to  me  that  the  weight  of  the  feet  must  have  been  a  factor  in  caus- 
ing these  curvatures,  especially  as  the  case  was  one  of  very  marked  rachitic 
softening  of  different  bones.  Still,  tibial  and  fibular  bending  at  this  point 
has  been  noticed  by  different  observers,  who  have  attributed  it  to  the  weight 
of  the  body  in  walking.  Various  other  curvatures  besides  those  mentioned 
occur  in  the  bones  of  the  lower  extremities,  the  direction  in  which  the  limbs 
bend  being  determined  by  the  particular  circumstances  of  the  case. 

In  mild  cases  of  rickets  most  of  the  deformities  described  above  are  lack- 
ing, but  in  typical  cases  certain  of  them  stand  out  prominently,  so  as  to  be 
readily  detected  by  one  familiar  with  the  disease.  In  all  such  cases  the 
diagnosis  is  easy  beyond  that  of  most  other  maladies,  for  the  changes  which 
occur  are  not  only  conspicuous  but  pathognomonic. 

Rachitis  produces  another  important  effect  on  the  skeleton.  Its  growth 
is  stunted,  not  only  during  the  rachitic  period,  but  subsequently,  so  that  those 
who  have  been  rachitic  in  childhood,  unless  very  mildly,  have  less  than  the 
average  stature  in  adult  life.  The  stunted  growth  is  apparent,  though  ample 
allowance  be  made  for  curvatures.  The  arrest  of  development  is  greater  in 
some  bones  than  in  others.  It  is  greatest  in  the  bones  of  the  face,  pelvis, 
and  lower  extremities.     Stunted  growth  of  the  pelvic  bones  of  the  female 


Fig.  20. 


Fig.  21. 


Rachitic  Deformities  of  the  Femur,  Tibia,  and  Fibula.    (Wood  Museum.) 

infant,  conjoined  with  the  deformities  alluded  to  above,  may  seriously  affect 
her  subsequent  life,  and  a  rachitic  pelvis  in  the  female,  exhibiting  both 
stunted  growth  and  deformity,  constitutes  a  valid  reason  for  avoiding  mar- 


198  RACHITIS. 

riage.  As  a  rule,  the  older  the  child  is  when  rachitis  begins  the  less  is  the 
skeleton  affected,  and  the  less,  consequently,  is  the  deformity. 

Effect  of  Rachitis  on  Dentition. — As  might  be  expected  from  the 
nature  of  rachitis,  dentition  is  delayed.  If  the  disease  show  itself  before 
any  tooth  has  appeared,  the  first  teeth — to  wit,  the  lower  central  incisors — 
will  probably  not  appear  before  the  ninth  or  tenth  month,  or  even  later.  Sir 
Wm.  Jenner  considers  the  non-appearance  of  a  tooth  by  the  ninth  month, 
with  few  exceptions,  a  sign  of  rachitis.  Teeth  which  appear  during  the 
rachitic  state  are  frail,  deficient  in  enamel,  and  crumble  readily.  They 
become  carious,  rot,  and  break  before  the  usual  time.  If  certain  teeth  have 
appeared  when  rachitis  begins,  several  months  elapse  before  others  cut  the 
gum.  It  is  even  said  that  a  child  who  has  rachitis  severely  may  never 
have  a  tooth,  may  remain  toothless  for  life,  but  I  have  never  observed 
such  a  case.  Ordinarily,  when  the  rachitic  state  ceases  and  the  health 
is  fully  restored,  dentition  goes  on  as  before.  The  arrest  of  teething,  so 
easily  observed,  has  long  been  considered  one  of  the  most  reliable  diag- 
nostic signs.  The  physician  cannot  justly  pronounce  on  the  nature  of  the 
disease  in  a  case  of  suspected  rachitis  unless  he  first  carefully  inspects  the 
gums. 

Changes  in  the  Soft  Tissues. — Although  the  conspicuous  lesions  of 
rickets  pertain  to  the  skeleton,  the  soft  tissues  are  also  more  or  less  implicated. 
The  ligaments  become  relaxed  and  flabby,  giving  unusual  mobility  to  the 
joints  and  unsteadiness  to  the  movements.  The  fibrous  bands  which  unite 
the  vertebrae,  as  well  as  the  ligaments  of  the  extremities,  participate  in  the 
relaxation.  In  certain  patients  the  muscles  throughout  the  system — partly, 
perhaps,  in  consequence  of  the  gastro-intestinal  disturbance,  indigestion,  and 
malnutrition  ;  partly,  perhaps,  for  want  of  use  (for  the  rachitic  are  usually 
quiet) — become  shrunken  and  flabby.  The  sj^leen  is  frequently  enlarged,  as 
ascertained  by  palpation  and  percussion.  Hitter  von  Rittershain  found  this 
organ  decidedly  enlarged  in  10  out  of  35  cases  which  he  examined  after 
death.  The  enlargement  is  the  result  of  cellular  proliferation,  common  in 
diseases  which  are  attended  by  dyscrasia.  The  liver  in  many  patients  under- 
goes no  perceptible  change,  except  that  it  may  be  pushed  a  little  downward. 
It  is  occasionally  found  enlarged  from  fatty  infiltration,  but  no  special  sig- 
nificance attaches  to  this,  for  fatty  liver  is  common  in  various  forms  of 
disease  attended  by  innutrition  and  wasting.  It  is  common  in  tuberculosis 
and  in  protracted  intestinal  catarrh,  and  its  pathological  significance  appears 
to  be  the  same  in  these  various  diseases.  Tlaere  can  be  little  doubt  that  Sir 
Wm.  Jenner  errs  when  he  states  that  albuminoid  infiltration  of  the  liver  is 
common  in  rachitis.  Parry,  Glee,  Dickinson,  and  Senator  agree  that  it  is 
rare,  and  that  if  it  does  occur  it  is  by  coincidence. 

In  a  discussion  on  rachitis  in  the  London  Pathological  Society,  Dr.  Dick- 
inson^ spoke  of  enlargement  of  the  spleen,  liver,  and  lymphatic  glands 
which  he  had  observed  in  rachitic  cases.  According  to  him,  the  spleen 
undergoes  the  greatest  enlargement,  the  lymphatic  glands  the  least,  and  of 
the  latter,  "  the  mesenteric  glands  show  the  most  decided  swelling."  The 
spleen  in  some  patients  has  been  so  large  that  it  occupied  the  greater  part 
of  the  left  half  of  the  abdominal  cavity,  but  a  less  degree  of  enlargement  is 
the  rule.  The  liver  frequently  extends  one  or  two  inches  below  the  ribs.  Its 
enlargement,  Dr.  Dickinson  adds,  is  not  amyloid.  "  There  is  no  new  growth  or 
deposit,  only  an  irregular  development  of  the  proper  tissues  of  the  organs."  He 
believes  that  both  the  corpuscular  .and  interstitial  elements  are  increased  in 
the  liver,  spleen,  and  lymphatic  glands.  But  other  members  of  the  society 
had  observed  this  enlargement  only  in  occasional  cases,  and  they  considered  it 
^  Lancet,  December  11,  1880. 


CRANIOTABES.  199 

due  rather  to  the  state  of  health  which  caused  rachitis  than  to  rachitis  itself. 
Dr.  C.  Hilton  Fagge  stated  that  he  had  failed  to  find  swelling  of  the  liver, 
spleen,  or  lymphatic  glands  in  a  large  majority  of  cases.'  An  undue  devel- 
opment of  the  lymphatic  glands  from  hyperplasia  is  very  common  in  chil- 
dren in  various  states  of  ill-health,  and  the  mesenteric  glands  are  especially 
liable  to  become  enlarged  from  this  cause  in  protracted  cases  of  intestinal 
catarrh  or  irritation. 

The  abdomen  is  j^i'otuheranf  from  various  causes.  The  lateral  depression 
of  the  thoracic  walls  causes  the  liver  and  spleen  to  descend  a  little  lower  in 
the  abdominal  cavity  than  natural.  The  enlargement  of  the  liver  and 
spleen,  the  feeble  tonicity  of  the  intestinal  muscular  fibres,  and  consequent 
distension  of  the  intestines  with  gas,  and  the  rachitic  shortening  of  the 
spinal  column,  which  causes  approximation  of  the  ribs  and  pelvis,  necessarily 
produce  abdominal  protuberance. 

The  ki(liiei/x  themselves  are  not  diseased  in  rickets,  but  there  is  an  exag- 
gerated discharge  of  phosphates  in  the  urine,  and,  as  stated  above,  lactic  acid 
and  free  phosphoric  acid  have  been  found  in  this  excretion.  The  urine  is 
commonly  pale  ;  its  urea  and  uric  acid  are  diminished ;  and  it  sometimes  con- 
tains a  sediment  of  oxalate  of  lime. 

The  brain  is  usually  well  developed  and  appears  healthy,  with  the  normal 
proportion  of  white  and  gray  substance.  In  one  case  the  weight  of  this  organ 
was  ascertained  by  Dr.  Gee  to  be  fifty-nine  ounces,  and  in  another  forty-two 
and  a  half  ounces.  In  both  brains  the  proportion  of  white  and  gray  sub- 
stances, and  their  color  and  consistence,  seemed  normal. 

Anatomical  Characters  of  the  Third  Stage,  or  that  of  Recon- 
struction.— This  stage  will  be  better  understood  if  we  recollect  what  has 
occurred  during  the  first  and  second  stages.  The  vascular  periosteum  is 
drawn  tightly  over  convexities,  the  pressure  upon  which  diminishes  the 
hyperaemia  and  the  amount  of  exudation  underneath.  Over  the  concavities 
the  periosteum  is  loose ;  it  is  hyperaemic,  with  abundant  new  capillaries,  the 
interspace  between  it  and  the  bone  being  filled  with  the  gelatiniform  sub- 
stance already  described.  The  reparative  process  goes  forward  more  rapidly, 
and  the  deposition  of  lime-salts  is  more  abundant  upon  the  concave  surfaces, 
where  there  have  been  free  exudation  and  no  compression  of  the  capillaries, 
than  elsewhere.  The  lime-salts  are  deposited  from  the  blood.  Consequently, 
from  the  increased  capillary  circulation  and  hyperaemic  state  of  the  perios- 
teum produced  by  rachitis  the  chalky  matter  is  rapidly  efi'used  wherever  there 
is  an  open  space  under  the  periosteum  and  where  the  capillaries  are  in  a  state 
of  engorgement.  Hence  the  reconstructed  bone  is  thicker  and  firmer  upon 
the  concave  aspect  of  the  long  bones  than  elsewhere,  and  thinnest  upon  the 
convex  aspect,  where  the  periosteum  is  more  tense  and  its  capillaries  more  or 
less  compressed. 

It  is  a  question  whether  true  ossification  occurs  at  first  during  the  repar- 
ative stage.  The  deposition  of  chalky  matter  is  designated  by  some  writers 
as  a  petrifaction  rather  than  a  true  bone-formation.  Trousseau  likens  it  to 
the  formation  of  callus  after  a  fracture.  It  certainly  produces  a  substance 
more  compact  than  ordinary  bone.  The  term  "  eburnation  "  has  been  applied 
to  this  new  osseous  formation,  and  I  have  designated  it  "  osteo-sclerosis." 
Some  years  since  I  examined  microscopically  an  adult  bone  which  exhibited 
the  rachitic  curvature  in  a  marked  degree,  and  was  very  hard.  It  contained 
the  elements  of  true  bone,  but  it  may  have  been  produced  after  the  rachitis 
had  ceased  and  in  the  subsequent  growth. 

Recovery  fi'om  rickets  is  gradual.  Little  by  little  the  cartilaginous  and 
periosteal  proliferation  ceases,  the  hypertemia  abates,  and  the  bone-producing 

'  Lancet,  November  20,  1880. 


200  RACHITIS. 

tissues  return  to  their  normal  state.     Certain  of  the  deformities  are  perma- 
nent, but  others  disappear  in  the  further  growth  of  the  skeleton. 

Symptoms  of  Rachitis. 

Preceding  and  accompanying  rachitis,  symptoms  may  be  present  which 
are  due  to  indigestion  and  intestinal  catarrh,  such  as  flatulence,  unhealthy 
stools,  and  poor  or  capricious  appetite.  When  rachitis  begins  the  infant 
becomes  fretful ;  its  sleep  is  frequently  restless  and  disturbed,  and  it  awakens 
often.  It  repels  attempts  to  amuse  it,  and  is  apparently  annoyed  by  them. 
Nurse  and  mother  speak  of  it  as  a  cross  child.  It  perspires  freely  from  the 
head  and  neck  both  when  awake  and  when  asleep,  while  the  extremities  and 
trunk  are  dry.  Its  pillow  is  wet  with  perspiration  during  sleep,  and  sweat- 
drops  may  be  seen  upon  forehead  and  face.  If  the  surface  be  dry  a  little 
excitement  or  elevation  of  temperature  causes  the  perspiration  to  appear. 
The  rachitic  child  does  not  well  tolerate  the  bed-clothes,  and  attempts  to  throw 
them  off  from  its  limbs,  even  in  cool  weather,  lying  exposed  and  causing 
considerable  annoyance  to  the  nurse,  who  strives  to  prevent  its  taking  cold. 
Sometimes  miliaria,  due  to  the  moist  state  of  the  skin,  appear  upon  the  face 
and  neck.  The  subcutaneous  veins  which  return  blood  from  the  head  are 
large,  and  the  jugular  veins  full. 

Another  symptom  is  soon  observed — to  wit,  tenderness  over  a  consider- 
able part  of  the  surface,  perhaps  largely  due  to  the  morbid  state  of  the  peri- 
osteum over  so  many  bones,  though  it  is  also  experienced  when  pressure  is 
made  upon  the  soft  parts  of  the  abdomen.  The  tenderness  is  probably,  in 
part,  the  cause  of  the  fretful  disposition.  The  little  patient  appears  to 
dread  to  be  touched ;  its  flesh  is  sore ;  it  repels  attempts  to  amuse  it,  and 
wishes  to  be  quiet.  Dandling  it  upon  the  arms,  swinging  it,  or  even  walking 
with  it,  which  delights  the  healthy  child  and  elicits  a  smile  of  satisfaction, 
only  adds  to  its  discomfort.  It  is  most  at  ease  when  left  alone  upon  a  soft 
cot  or  pillow,  or,  if  it  have  craniotabes,  when  quietly  held  over  the  shoulder. 
Languor,  disinclination  to  use  the  limbs  or  to  play,  moderate  thirst,  with  other 
symptoms  referable  to  the  digestive  apparatus  which  are  present  in  many  cases 
and  which  have  already  been  described,  are  soon  followed  by  changes  in  the 
skeleton  which  are  perceptible  to  the  sight  and  on  palpation.  The  pulse  and 
temperature,  in  a  large  proportion  of  the  ordinary  chronic  cases,  do  not  devi- 
ate from  the  healthy  state,  except  that  in  some  patients  there  is  a  slight 
febrile  movement  in  the  latter  part  of  the  day. 

Although  rachitis  is  ordinarily  a  chronic  disease,  insidious  in  its  com- 
mencement, gradual  and  progressive  in  its  development,  occupying  months, 
there  is  an  acute  form  which  is  attended  by  more  marked  febrile  movement 
and  tenderness,  and  in  which  the  articular  swelling  appears  more  quickly. 

A  hruit  de  soujjflet  of  greater  or  less  intensity,  synchronous  with  the  pulse, 
has  frequently  been  heard  in  rachitic  cases  by  applying  the  ear  over  the  ante- 
rior fontanel.  Drs.  Whitney  and  Fischer,  New  England  physicians,  first 
called  attention  to  this  murmur,  believing  it  to  be  a  sign  of  chronic  hydro- 
cephalus. MM.  Rilliet  and  Barthez  heard  it  in  cases  of  rachitis,  and  there- 
fore concluded  that  the  American  physicians  had  confounded  the  two  diseases. 
More  recent  observations  have  established  the  fact  that  this  hruit.  has  little 
diagnostic  value.  It  is  heard  whenever  there  is  sufficient  patency  of  the 
anterior  fontanel,  both  in  health  and  disease,  for  sound  is  conducted  better 
through  a  membrane  than  through  bone.  Dr.  Wirthgen  heard  the  hruit  in 
22  out  of  52  children,  of  whom  all  except  4  were  in  good  health.  I  have 
auscultated  the  anterior  fontanel  in  29  infants,  who  were  with  2  exceptions 
between  the  ages  of  three  and  thirty  months.     All  were  well  or  had  merely 


DIAGNOSIS  OF  RACHITIS.  201 

trivial  ailments  which  did  not  affect  the  cerebral  circulation.  In  most  of 
them  a  murmur  could  be  distinctly  heard  synchronous  with  the  respiratory 
act,  and  in  15  of  the  29  cases  no  other  sound  could  be  detected,  while  in  the 
remaining  14  a  hruit  could  be  detected  synchronous  with  the  pulse. 

Complications  and  Sequels  of  Rachitis. 

These  have  been  in  part  described  in  the  foregoing  pages,  but  there  are  cer- 
tain other  results  of  the  disease  to  which  it  is  proper  to  call  attention.  If  the 
deformity  in  the  thoracic  wall — namely,  the  lateral  depression  of  the  ribs  and 
anterior  projection  of  the  sternum — be  great,  we  would,  naturally  expect  that 
the  two  important  organs  underneath,  the  heart  and  lungs,  would  receive 
some  detriment.  Upon  the  surface  of  the  heart,  at  the  point  where  it  sup- 
ports the  softened  ribs,  a  white  patch  is  often  found,  due  to  thickening  of  the 
pericardium  and  proliferation  of  the  endothelial  cells,  just  as  thickening  of 
the  skin  in  the  palm  of  the  hand  occurs  from  friction  and  pressure  upon  that 
part.  It  is  probable  that  this  pressure  does  not  seriously  impair  the  function 
of  the  heart,  but  it  may  increase  the  weakness  of  its  movements  in  any 
asthenic  disease  which  may  occur  during  the  rachitic  period.  The  injury 
sustained  by  the  huu/s  is  greater  and  more  apparent.  If  the  ribs  be  flexible 
and  much  depressed,  full  inflation  of  the  lung  cannot  occur  in  those  parts 
where  the  depression  is  greatest.  Semi-collapse  of  certain  lobules  is  liable  to 
occur,  and  even  complete  collapse  of  the  thin  edges  of  the  lung.  The  stress 
of  respiration  falls  unequally  upon  different  parts  of  the  lung.  The  anterior 
portion,  which  ascends  with  the  sternum  as  that  is  propelled  forward,  is  more 
fully  dilated  than  the  lateral  and  posterior  parts,  and  hence  is  liable  to  become 
emphysematous.  If  in  this  state  of  the  thorax  and  lungs  severe  bronchitis 
or  broncho-pneumonia  arise,  the  state  is  one  of  great  peril.  The  mucus  and 
pus,  being  expectorated  with  difficulty,  clog  the  tubes  and  produce  dyspnoea. 
Full  inspiration  in  the  lateral  and  depending  portions  of  the  lung,  which  is 
required  in  order  to  expel  these  secretions,  not  occurring,  the  result  may  be 
unfavorable,  even  in  comparatively  mild  forms  of  inflammation.  Bronchitis 
and  broncho-pneumonia  are  the  causes  of  death  in  not  a  few  cases  of  severe 
rickets.  Certain  writers  state  that  chronic  hydrocephalus,  diarrhoea,  and 
eclampsia  may  complicate  rachitis.  I  have  not  seen  any  case  in  which 
rickets  seemed  to  sustain  a  causative  relation  to  either  hydrocephalus  or 
diarrhoea,  but  we  know  that  diarrhoea  frequently  precedes  and  accompanies 
rachitis,  and  its  relation  to  it  is  that  of  cause  rather  than  effect.  This  sub- 
ject has  been  sufficiently  treated  of  in  preceding  pages.  Rachitic  infants 
appear  to  be  more  liable  to  eclampsia  than  those  who  are  healthy.  This 
would  be  inferred  from  their  liability  to  laryngismus  stridulus. 

Diagnosis  of  Rachitis. 

Rachitis  in  many  instances  continues  a  considerable  time  before  its  nature 
is  suspected,  the  symptoms  to  which  it  gives  rise  being  overlooked  or  attrib- 
uted to  other  causes  than  the  true  one ;  and  yet  it  is  important  that  an  early 
diagnosis  be  made,  for  it  is  much  more  amenable  to  treatment  in  its  early 
than  in  its  later  stages.  The  deformities  which  mar  the  beauty,  and  to  a 
certain  extent  impair  the  activity  and  usefulness,  of  so  many  who  have  been 
rachitic  in  childhood  may  often  be  prevented  by  early  diagnosis  and  treat- 
ment. Many  with  this  disease  do  not  show  the  usual  signs  of  faulty  diges- 
tion and  innutrition,  especially  on  casual  inspection,  for  there  may  be  consid- 
erable adipose  development  and  rotundity  of  features  and  form  in  a  rachitic 
child ;  while,  on  the  other  hand,  there  are  numerous  instances  of  malnutri- 


202  RACHITIS. 

tion  and  wasting  without  rachitis.  Early  diagnosis  when  the  affection  is  of  a 
mild  type  is  necessarily  difficult,  but  a  watchful  and  painstaking  physician 
will  commonly  detect  the  disease  before  it  has  run  many  weeks  if  he  bear  in 
mind  its  frequency  and  carefully  examine  the  patient. 

If  called  to  a  suspected  case,  we  should  inquire  into  the  history,  and  par- 
ticularly whether  there  have  been  signs  of  intestinal  catarrh  or  innutrition. 
The  gums  should  be  inspected  to  ascertain  whether  there  is  backwardness  in 
dentition,  and  the  head  to  note  its  shape  and  size,  whether  it  is  elongated  or 
whether  it  approximates  the  square  shape,  with  broad  forehead  and  large  pro- 
tuberances. We  should  notice  also  the  state  of  the  fontanels  and  sutures, 
and  whether  softening  and  thinning  of  the  cranial  bones  be  present.  The 
costochondral  articulations  and  those  of  the  wrist  should  also  be  carefully 
examined  to  ascertain  if  there  is  any  enlargement,  and  the  shape  of  the 
thorax,  which  begins  to  exhibit  the  rachitic  deformity  at  an  early  stage  of  the 
disease,  should  likewise  be  noticed.  We  should  also  examine  the  child  in 
reference  to  other  less  prominent  signs,  such  as  spinal  curvature,  abdominal 
protuberance,  muscular  weakness,  and  relaxation  of  ligaments  (which  pro- 
duce feeble  and  unsteady  use  of  the  limbs),  perspirations  upon  the  head  and 
neck  from  slight  excitement  and  during  sleep,  fretfulness,  etc.  If  rachitis  be 
present,  certain  of  these  signs  will  be  observed. 

The  late  Dr.  Parry  called  attention  to  the  importance  of  making  a  differ- 
ential diagnosis  between  the  pseudo-paraplegia  of  rachitis  and  true  paraplegia, 
which  is  the  pi'ominent  symptom  of  acute  myelitis.  The  rachitic  child, 
from  muscular  weakness  and  ligamentous  relaxation,  and  from  the  soreness 
and  tenderness  common  in  this  condition,  may  seldom  use  his  legs — may  sit 
or  lie  quietly  at  the  age  when  healthy  children,  if  awake,  are  constantly  mov- 
ing their  limbs.  If  we  attempt  to  make  him  walk  or  stand,  his  legs  may  be 
so  limp  and  powerless  that  they  give  way  under  his  weight ;  but  this  is  a  dif- 
ferent state  from  paralysis.  In  paralysis  the  fault  is  in  the  nervous  system — 
usually  in  the  nervous  centres — whereas  in  rachitis  it  is  in  the  muscles  and 
ligaments.  The  rachitic  child  when  sitting  or  lying  down  readily  moves  his 
legs  if  his  feet  be  tickled  or  pinched,  while  the  paralyzed  limb  responds  to 
the  irritation  imperfectly.  In  acute  myelitis  the  loss  of  muscular  power 
is,  with  few  exceptions,  confined  to  the  muscles  of  the  lower  extremities  ;  but 
in  rachitis  the  muscular  feebleness  is  more  general,  being  noticeable  in  the 
arms  as  well  as  in  the  legs.  Great  relaxation  of  the  ligaments  is  in  most 
instances  due  to  rachitis.  It  is  especially  noticeable  in  the  ankle-  and  knee- 
joints,  and  is  a  diagnostic  sign  which  should  not  be  overlooked  in  the  exam- 
ination of  a  suspected  case  of  the  disease. 

Prognosis  of  Rachitis. 

The  prognosis  of  rickets  is  usually  favorable,  provided  that  no  serious 
complication  arises.  Rachitis  is  not  in  itself  fatal  under  ordinary  circum- 
stances. If  there  be  much  lateral  depression  and  narrowing  of  the  thorax, 
the  functions  of  the  heart  and  lungs  may  be  embarrassed,  and  if  the  patient 
have  a  severe  bronchial  catarrh  or  hroiicho-pneumonia ,  the  condition  becomes 
one  of  danger.  Rachitic  children  seem  to  be  especially  liable  to  catarrhal 
attacks  of  the  air-passages,  and  even  a  moderate  catarrh  with  a  deformed 
thorax  may  prevent  proper  decarbonization  of  the  blood  and  cause  lividity 
and  dyspnoea.  Therefore,  now  and  then  a  rachitic  child  succumbs  to  an 
attack  of  inflammation  of  the  respiratory  apparatus  which  would  not  have 
been  fatal  if  there  had  been  no  rachitic  deformity.  We  have  seen  that  in 
whatever  way  it  may  act  to  produce  this  form  of  spasm,  rachitis  is  a  cause  of 
laryngismus  stridulus.     Occasionally  spasm  of  the  glottis  is  fatal,  but  cases 


TREATMENT  OF  RACHITIS.  203 

with  such  a  teriiiiiiatioii   are  rare  in  America,  tliough  not  infrequent  in  some 
European  countries. 

Of  the  diseases  of  childhood  which  racliitic  children  tolerate  badly,  and 
which  may  prove  fatal  in  consequence  of  rachitic  bone-softening  and  deform- 
ity, pcrfiissis  should  be  mentioned.  If  this  be  severe  while  the  ribs  are  .soft 
and  yielding,  and  there  be  lateral  depression  of  the  thorax,  the  spasmodic 
cough  produces  great  suffering  and  involves  danger.  Lividity,  feeble  action 
of  the  heart,  pulmonary  and  cerebral  congestion,  and  eclampsia  may  occur. 
Measles,  if  it  be  attended  by  considerable  bronchitis,  and  especially  if  it  be 
complicated  by  broncho-pneumonia,  is  also  one  of  the  dangerous  intercurrent 
diseases.  The  gravity  of  these  inflammations  of  the  respiratory  apparatus  is 
usually  proportionate  to  the  degree  of  recession  of  the  ribs  during  inspiration. 
With  these  exceptions,  and  with  that  of  risk  to  the  married  female  who  has 
deformity  and  stunted  growth  of  the  pelvic  bones,  the  rachitic  are  not  liable 
to  any  ulterior  serious  consequences.  Minor  deformities  in  mild  cases  not 
infrecjuently  disappear  in  the  subsequent  growth  of  the  skeleton.  The  older 
the  child  is  when  rachitis  begins,  the  milder  is  ordinarily  the  form  of  the  dis- 
ease, and  the  more  speedy,  consequently,  the  recovery,  and  the  less  the 
deformity.  In  the  gravest  cases  the  disease  will  almost  always  be  found  to 
have  begun  under  the  age  of  one  year. 

Treatment  of  Rachitis. 

Since  rachitis  sometimes  develops  in  the  foetus,  it  is  important  in  order  to 
prevent  this  malady  that  the  parentage  be  healthy.  The  pregnant  woman 
should  lead  a  quiet  and  regular  life,  with  sufficient  exercise  to  produce 
healthy  digestion,  but  without  too  arduous  work,  and  with  regular  meals  and 
wholesome  diet.  By  the  observance  of  such  rales  foetal  rachitis  might  prob- 
ably in  most  instances  be  prevented.  Most  cases  of  rachitis,  however,  com- 
mence in  infancy,  so  that  by  proper  management  of  the  infant  we  may  hope 
to  prevent,  and  usually  can  prevent,  its  occurrence. 

The  correct  treatment  of  rachitis  is  apparent  when  we  consider  its  charac- 
ter and  the  nature  of  its  causes.  The  obvious  indication  is  to  restore  healthy 
nutrition.  This  requires  both  hygienic  and  therapeutic  measures.  The  apart- 
ment in  which  the  child  resides  should  be  dry,  airy,  and  plentifully  supplied 
with  light.  He  should  be  taken  daily  into  the  open  air  in  order  to  invigorate 
his  system,  but  in  such  a  way  as  not  to  increase  his  suffering  on  account  of 
his  general  tenderness.  Residence  in  the  country  is  far  preferable  to  that  in 
the  city,  because  of  the  better  hygienic  conditions  which  it  procures.  The 
purer  air,  the  better  diet,  and  consequently  the  more  robust  development, 
gained  by  rural  life  are  important  advantages,  to  obtain  which  is  abundantly 
worth  pecuniary  sacrifice  when  the  children  of  a  family  are  rachitic. 

The  diet  in  rachitis  should  receive  particular  attention,  since  indigestion 
and  gastro-intestinal  derangement  sustain  a  causal  relation  to  so  many 
cases.  Good  breast-milk  ought,  if  possible,  to  be  obtained  until  the  child  has 
reached  the  age  of  ten  months,  and  if  the  mother's  condition  be  such  that  she 
cannot  furnish  it,  a  wet-nurse  should,  if  practicable,  be  employed.  But  after 
the  age  of  six  months  additional  nutriment  is  required.  As  a  rule,  the  infant 
should  be  weaned  at  the  age  of  twelve  months,  but  longer  nursing  may  be 
best  under  certain  conditions,  as  the  presence  of  hot  weather,  an  abundant 
suppty  of  good  breast-milk,  and,  on  the  part  of  the  infant,  feeble  digestion 
and  easily-deranged  digestive  organs.  In  case  breast-milk  cannot  be  obtained, 
cow's  milk,  properly  diluted,  according  to  the  age,  with  water  or  with  a  fari- 
naceous solution,  is  the  best  substitute.  The  reader  is  referred  to  the  chapter 
relating  to  the  diet  of  infancy  for  full  particulars  relating  to  infant  feeding. 


204  RACHITIS. 

The  milk  should  be  sterilized  by  steaming  in  the  manner  mentioned  in  the 
chapter  on  artificial  feeding,  and  for  infants  with  feeble  digestion  it  may  be 
well  to  peptonize  the  milk.  A  properly-prepared  farinaceous  substance  mixed 
with  the  milk  has  not  only  nutritive  properties,  but  by  mechanically  sepa- 
rating the  particles  of  casein  it  tends  to  prevent  the  formation  of  curds  in  the 
stomach.  But  as  young  infants  digest  starch  with  difficulty,  it  is  well,  I 
think,  to  employ  a  flour,  as  barley,  wheat,  or  oatmeal,  in  which  the  starch  is 
to  a  great  extent  converted  into  dextrin  by  the  prolonged  action  of  heat  or 
into  grape-sugar  by  the  action  of  the  diastase  of  malt,  as  recommended  by 
Liebig.  This  flour,  made  into  a  gruel  and  mixed  with  sterilized  or  peptonized 
milk,  is  a  suitable  food  for  rachitic  infants. 

Meat  soups,  properly  prepared  according  to  the  age,  are  useful  additions 
to  the  diet.  I  have  elsewhere  stated  that  in  one  of  the  institutions  of  New 
York  rachitis  from  being  common  was  made  to  disappear  almost  entirely  by 
allowing  a  more  generous  diet,  a  part  of  which  was  the  daily  use  of  a  little 
beef  tea.  I  have  employed,  with  apparently  good  results,  beef  tea  prepared 
as  follows  :  Add  half  a  pound  of  finely-hashed  beef  to  one  pint  of  cold  water, 
mix  with  ten  drops  of  dilute  muriatic  acid,  allow  it  to  stand  cold  with  fre- 
quent stirring  half  an  hour,  then  place  it  upon  the  table  in  a  pail  or  large 
pan  of  boiling  water,  so  as  to  heat  it  without  coagulating  the  albumen.  In 
an  hour  it  is  ready  for  use.  The  peptonized  beef  of  the  shops  is  also  a 
useful  preparation. 

Medicines  which  improve  the  general  health  are  all  more  or  less  beneficial 
in  the  treatment  of  rachitis,  but  lime  and  cod-liver  oil  are  especially  indicated. 
The  following  formula  will  be  found  useful  in  most  cases : 

R.  Olei  morrhuse,  f.^iv; 

Aq.  calcis, 
Syr.  calcis  lactophosphatis,  da.  f  ^ij.     Misce. 

Of  this,  one  teaspoonful  should  be  given  four  or  five  times  daily  to  an 
infant  of  one  year.  This  combination  agrees  with  the  digestive  function,  and 
is  readily  taken  by  most  infants.  Cod-liver  oil,  while  it  improves  the  general 
nutrition,  is  especially  useful  in  rachitis. 

Care  should  be  taken  to  prevent  deformities  while  the  bones  are  soft  and 
yielding.  The  patient  should  not  be  encouraged  to  stand  or  use  the  limbs 
until  they  become  firmer.  He  should  lie  upon  an  even  and  soft  mattress  and 
should  be  taken  into  the  open  air  in  a  carriage.  A  uniform  support  of  body 
and  limbs  is  requisite  in  order  to  prevent  curvature. 

In  craniotabes  the  pillows  should  be  soft,  and  care  should  be  taken  that 
the  yielding  parts  of  the  cranium  should  not  be  unduly  pressed  upon.  The 
perspirations  may  be  relieved  by  sponging  with  vinegar  and  water.  The 
infant  should  be  regularly  bathed  in  water  a  little  cooler  than  the  body,  and 
rock  salt  may  be  added  to  the  bath.  The  proper  treatment  of  laryngismus 
stridulus,  which  so  frequently  complicates  rachitis,  is  described  in  our  remarks 
upon  that  disease.  Constipation,  common  in  the  rachitic,  should  be  treated 
by  simple  enemata,  except  so  far  as  it  can  be  relieved  by  change  in  the  diet. 
When  curvatures  are  unavoidable,  orthopaedic  treatment  will  subsequently 
be  required. 

Such  is  an  outline  of  the  treatment  which  rachitis  ordinarily  requires,  but 
other  medicinal  agents  may  be  found  useful  for  their  general  tonic  action  or 
by  supplying  lime-salts  to  the  system  ;  among  which  may  be  mentioned  the 
compound  syrup  of  the  phosphates,  the  citrate  of  iron  and  quinia,  wine  of 
iron,  the  various  preparations  of  cinchona,  columbo,  etc.  Flieschmann 
recommends   the  fluorine   compounds  in   order  to  increase   and  harden   the 


CA  USES.  205 

enamel  of  the  teeth,  employing  for  the  purpose  the  tooth  pastille  of  Ehrhardt 
or  Hunter,  which  contains  the  fluoride  of  potassium. 


CHAPTER    II. 

SCROFULA. 

The  term  scrofula  (scro/a,  a  pig,  from  the  resemblance  of  the  enlarged 
cervical  glands  of  a  scrofulous  individual  to  a  swine's  neck)  is  applied  to  a 
diathesis  which  is  characterized  by  increased  vulnerability  of  the  tissues. 
The  nutritive  pi'ocess  of  the  tissues  is  readily  disturbed  even  by  trifling  irri- 
tants or  agencies  in  those  who  have  this  diathesis,  and  therefore  the  scrofulous 
are  prone  to  inflammations  of  various  parts.  Inflammations,  which  can  prop- 
erly be  considered  as  dependent  upon  this  diathesis  or  as  occurring  under  its 
influence,  are  for  the  most  part  subacute  or  chronic,  and  they  difi"er  from 
ordinary  inflammations  in  the  fact  of  a  greater  cell-formation  and  greater 
liability  to  cheesy  degeneration  of  inflammatory  products,  so  that  return  to 
the  healthy  state  by  absorption  is  slow  or  impossible.  Moreover,  this  diathesis, 
while  it  gives  rise  to  certain  inflammations  which  do  not  occur  or  are  rare  in 
other  states  of  the  system,  and  which  all  physicians  at  once  recognize  as 
scrofulous,  often  modifies  those  common  inflammations  to  which  all  persons, 
whether  scrofulous  or  non-scrofulous,  are  liable,  as  coryza  and  bronchitis, 
rendering  them  more  protracted  and  less  amenable  to  ordinary  treatment. 

Scrofula  is  a  disease  chiefly  of  infancy  and  childhood.  Manhood,  espe- 
cially the  first  years  of  it,  is  not  entirely  exempt,  but  scrofulous  manifesta- 
tions after  the  age  of  twenty  years  are  feeble  and  infrequent,  disappearing 
entirely  as  the  individual  advances  toward  middle  life.  The  diathesis  is  most 
active  prior  to  the  age  of  ten  years. 

Causes. — Scrofula  is  congenital  or  acquired.  Parents  who  had  scrofulous 
symptoms  in  early  life  or  who  are  in  a  state  of  decided  cachexia,  as  from  can- 
cer, syphilis,  intermittent  fever,  or  tuberculosis,  are  likely  to  beget  scrofulous 
children.  Insufficient  nourishment  of  the  mother  during  a  considerable  part 
of  her  gestation,  and  advanced  age,  and  therefore  feebleness,  of  the  father, 
are  occasional  causes.  Near  blood-relationship  of  the  parents  is  also  a  recog- 
nized cause,  and  to  this  has  been  attributed  the  scrofula  of  royal  families. 
Children  whose  father  and  mother  are  first  cousins  are,  according  to  my 
observations,  likely  to  be  scrofulous. 

Again,  those  born  with  sound  constitutions  may  acquire  scrofula  through 
antihygienic  influences  in  the  first  years  of  life.  Among  the  poor  of  New 
York  we  often  observe  one  child  in  a  family  who  presents  scrofulous  symp- 
toms, while  the  rest  of  the  children  are  well,  and  in  many  cases  we  are  able 
to  trace  back  the  diathesis  to  some  depressing  cause  or  causes  which  were 
suflScient  to  eff'ect  the  peculiar  change  in  the  molecular  condition  of  the  tissues 
which  constitues  this  disease.  Obviously,  the  causes  of  acquired  scrofula  are 
quite  numerous.  In  the  infant  it  is  sometimes  produced  by  insufficiency  or  poor 
quality  of  the  breast-milk,  or  the  use  of  artificial  food  during  the  period  when 
breast-milk  is  required.  Too  protracted  nursing  at  the  breast  also,  especially 
if  artificial  food  be  almost  wholly  withheld,  may  cause  it ;  as  may  also,  in 
those  who  have  been  weaned,  the  continued  use  of  a  diet  which  is  deficient 
in  nutritive  properties. 

Residence  in  damp,  dark,  and  filthy  apartments  or  streets  may  also  pro- 


206  SCROFULA. 

duce  it.  Hence  one  reason  of  its  frequent  occurrence  among  the  city  poor. 
Residence  in  a  small,  crowded,  and  imperfectly  ventilated  apartment  has  been 
known  to  cause  it,  even  with  personal  cleanliness  and  a  diet  sufficiently 
nutritive. 

Scrofula  may  also  be  caused,  in  those  previously  robust  and  of  sound  con- 
stitution, by  disease  of  an  exhausting  nature.  The  eruptive  fevers,  as  small- 
pox, measles,  and  scarlet  fever,  if  severe,  occasionally  produce  this  result,  or 
they  render  active  the  diathesis,  which  had  hitherto  been  latent.  In  this  city, 
where  chronic  entero-colitis  of  infancy  is  common,  I  have  sometimes  been  able 
to  trace  the  diathesis  to  the  cachectic  state  and  the  impaired  nutrition  which 
it  causes. 

The  theory  has  recently  been  promulgated  that  scrofula  has  a  specific 
principle,  and  that  this  is  a  modified  form  of  the  tubercle  bacillus.  This 
theory  receives  some  support  from  the  fact  that  scrofulous  glands  sometimes 
contain  the  tubercular  bacillus,  and  scrofula  in  many  instances  precedes  tuber- 
culosis. Van  Merris  considers  the  scrofulous  inflammation  as  a  local  tubercu- 
losis, and  Grancher  describes  scrofula  as  a  local  curable  tuberculosis.  On  the 
other  hand,  Dr.  Jaeobi  regards  the  tubercle  bacillus  in  a  scrofulous  disease  as 
an  "  accidental  invasion,"  and  Lartigues  calls  attention  to  the  fact  that  the 
tubercle  bacillus  cannot  be  discovered  in  most  instances  in  the  lesions  of 
scrofula.  Alexander  also  states  that  wherever  we  can  trace  the  cause  of 
scrofula,  it  seems  to  be  distinct  from  any  probable  microbic  agency  (^Annual 
of  tlie  Uaiver.  Med.  Sci,  vol.  iv.,  1889).  Noeldechen  states  that  the  close 
relationship  of  tuberculosis  to  scrofula  arises  from  the  fact  that  scrofulous 
ailments  afibrd  the  most  favorable  soil  for  the  development  of  the  tubercle 
bacillus  (^Deutsche  med.  Zeit.,  1887).  Rabl  also  mentions  the  fact  that  the 
tubercle  bacillus  is  often  not  present  in  scrofulous  glands.  He  tabulates 
1000  cases  of  scrofula,  as  regards  their  causation,  as  follows :  79  had  scrofu- 
lous parents,  446  had  tuberculous  parents,  356  lived  in  damp  dwellings,  25 
were  subjected  to  other  bad  hygienic  surroundings,  69  could  be  ascribed  to 
acute  infectious  diseases,  14  to  vaccination,  7  to  decrepitude,  and  4  to  con- 
sanguinity of  parents  (  Wien.  med.  Zeit.,  1887). 

Scrofula,  as  we  have  seen,  results  from  a  variety  of  depressing  agencies 
afi'ecting  the  system  in  diff"erent  ways,  with  the  general  result  of  impairing  its 
vigor  and  lowering  its  tone.  The  theory  seems  improbable  that  these  many 
and  distinct  agencies  cause  the  phenomena  of  scrofula  through  the  action  of 
a  microbe  peculiar  to  this  disease. 

The  primary  scrofulous  ailments  by  which  the  diathesis  is  manifested 
occur  for  the  most  part  upon  one  of  the  free  surfaces — namely,  upon  some 
part  of  the  skin  or  mucous  membrane.  Certain  writers  attribute  this  to  the 
fact  that  these  parts  are  most  exposed  to  the  action  of  noxious  agencies.  The 
lymphatics  lying  in  the  inflamed  area  take  up  the  altered  lymph  and  carry  it 
to  the  adjacent  lymphatic  glands,  which  become  irritated  and  undergo  hyper- 
plasia, and  perhaps  ultimately  suppuration.  This  is,  in  a  large  proportion 
of  cases,  the  beginning  of  scrofulous  ailments.  Nevertheless,  in  not  a  few 
instances  the  first  manifestations  are  in  deep-seated  and  covered  parts,  as  when 
scrofulous  periostitis  or  osteitis  occurs  without  any  peripheral  lesion. 

Rabl  expresses  the  opinion  that  in  certain  cases  scrofula  results  from 
syphilis  in  the  parent  or  grandparent.  He  believes  that  syphilis  in  the  parent 
causes  scrofula  in  the  child  by  diminisbing  the  power  of  resistance  to  the 
causes  which  produce  the  latter  aff"ection.  He  thinks  that  in  this  manner 
parental  syphilis  gives  rise  in  some  children  to  symptoms  identical  with  those 
of  scrofula,  while  in  other  children  it  gives  rise  to  syphilitic  symptoms.  The 
author's  observations  in  this  particular  correspond  with  those  of  Rabl. 

Anatomical  Characters. — There  are  no  ascertained  anatomical  changes 


ANATOMICAL  CHARACTERS.  207 

in  the  blood  which  iiro  peculiar  to  scrofula.  As  long  as  the  appetite  and  gen- 
eral health  remain  good  and  the  local  affections  have  not  occurred,  the  com- 
position of  this  fluid  is,  so  far  as  known,  unaltered.  In  the  cachexia  which  is 
present  when  the  general  health  is  impaired  the  blood  becomes  impoverished, 
the  red  corpuscles  lose  a  portion  of  their  coloring  matter,  and  the  watery  ele- 
ment predominates. 

The  question  arises  whether  the  glandular  hyperplasia  of  scrofula  produces 
an  excess  of  white  corpuscles  in  the  blood.  Virchow  says :  "  During  the 
progress  of  an  attack  of  scrofula,  in  which,  if  the  disease  run  a  somewhat 
unfavorable  course,  the  glands  are  destroyed  by  ulceration  or  cheesy  thicken- 
ing, calcification,  etc.,  an  increased  introduction  of  corpuscles  into  the  blood 
can  only  take  place  as  long  as  the  irritated  gland  is  still,  in  some  degree, 
capable  of  performing  its  functions  or  still  continues  to  exist;  as  soon,  how- 
ever, as  the  glands  are  withered  or  destroyed  the  formation  of  lymph-cells 
likewise  ceases,  and  with  it  the  leucocytosis.  In  all  cases,  on  the  other  hand, 
in  which  a  more  acute  form  of  disturbance  prevails,  connected  with  inflam- 
matory tumefaction  of  the  gland,  an  increase  of  the  colorless  corpuscles 
always  takes  place  in  the  blood"  (^Cellnl.  Pathol.').  Although  the  glandular 
hyperplasia  occurring  in  scrofula  increases  the  number  of  white  corpuscles  in 
the  blood,  scrofula  cannot  be  regarded  as  sustaining  any  causal  relation  to 
that  great  and  constant  increase  of  white  corpuscles  which  characterizes  the 
disease  leukaemia ;  for  this  disease,  as  remarked  by  Niemeyer,  does  not  occur 
in  childhood,  when  the  scrofulous  diathesis  is  active,  but  in  manhood,  when  it 
has  ceased  to  exist  or  has  become  latent. 

Strumous  inflammations  of  the  cutaneous  and  mucous  surfaces,  which  we 
have  seen  are  the  initial  lesions  in  a  large  proportion  of  scrofulous  cases,  do 
not  present  any  peculiar  anatomical  elements.  Some  of  them  are  attended 
by  an  abundant  formation  of  cells  and  by  dense  infiltration  of  the  inflamed 
tissues ;  but  inflammations  which  do  not  depend  on  the  strumous  diathesis 
have  the  same  anatomical  elements.  The  most  marked  differences  between 
the  strumous  and  non-strumous  inflammations  are  found  in  their  origin, 
amount  of  cell-formation   and  inflammatory  exudate,  and  duration. 

The  swelling  of  the  lymphatic  glands  which  is  so  common  in  the  neigh- 
borhood of  scrofulous  inflammations,  and  is  produced  by  the  lodgment  in  the 
glands  of  irritating  or  noxious  products  of  the  inflammation  taken  up  by  the 
lymphatics  and  conveyed  to  the  glands,  is  due  to  hyperplasia  of  the  lymph- 
cells,  with  comparatively  little  or  no  increase  of  the  stroma.  Thus,  hyper- 
plasia of  the  cervical  glands  is  common,  resulting  from  eczema  of  the  scalp  or 
face,  or  from  otitis  or  any  of  the  forms  of  stomatitis;  and  so  pharyngitis  often 
gives  rise  to  hyperplasia  of  the  tonsils,  which  are  lymphatic  glands.  The 
scrofulous  nature  of  the  glandular  enlargement  is  apparent  from  the  fact  that 
it  continues  long  after  the  primary  inflammation  which  gave  rise  to  it  has 
abated.  Lymphatic  glands  sometimes  enlarge  in  those  who  are  not  scrofulous, 
but  the  tumefaction  is  commonly  less  in  degree,  and  in  most  instances  it  soon 
abates  when  the  exciting  cause  is  removed. 

The  glands  which  commonly  undergo  scrofulous  enlargement  are  the  cer- 
vical, inguinal,  bronchial,  and  mesenteric  ;  but  in  those  who  are  decidedly 
scrofulous  the  glands  in  the  vicinity  of  any  protracted  inflammation  are  very 
prone  to  hyperplasia.  Thus  I  have  seen  enlarged  and  cheesy  glands  in  the 
vicinity  of  scrofulous  osteitis  or  periostitis. 

Under  favorable  circumstances  the  glandular  enlargement  abates  after  a 
short  time  by  liquefaction  and  absorption  of  the  redundant  cells.  But  the 
products  of  hyperplastic  or  inflammatory  action  in  the  scrofulous  individual 
are  very  liable  to  undergo  cheesy  degeneration,  and  the  close  causal  rela- 
tion of  this  cheesy  substance  with  tubercles  is  now  admitted.     If  resolution 


208  SCROFULA. 

do  not  soon  occur  in  the  gland,  it  begins  to  undergo  cheesy  degeneration. 
It  becomes  firm  and  inelastic,  its  nutrient  vessels  narrowed  and  compressed, 
so  that  circulation  through  it  ceases,  and  its  cells,  losing  their  liquid  and 
vitality,  shrivel  away.  This  necrobiotic  process  appears  in  points  in  the 
gland  which  enlarge  and  unite,  till  finally  the  whole  gland  becomes  a  dead 
mass,  with  shrivelled  elements  of  a  whitish  appearance,  like  cheese,  the 
resemblance  to  which  has  suggested  the  name  by  which  the  degeneration 
is  known. 

In  certain  patients  cheesy  glands  act  as  an  irritant  like  inorganic  matter^ 
producing  suppurative  inflammation,  and  their  subsequent  history  is  that  of 
an  abscess.  Purulent  matter  mixed  with  the  cheesy  debris  escapes  by  ulcera- 
tion upon  the  nearest  surface,  and  scrofulous  ulcers  result  which  slowly  heal, 
leaving  permanent  cicatrices ;  calcification  of  a  cheesy  gland  occurs  in  excep- 
tional instances. 

The  cervical  lymphatic  glands  in  the  scrofulous  child,  having  under- 
gone hyperplasia  of  their  cellular  elements,  not  infrequently  continue  pain- 
less and  indolent  for  a  considerable  time,  producing,  according  to  their  size, 
an  unsightly  appearance  without  undergoing  cheesy  degeneration.  Finally, 
one  or  more  become  inflamed,  and  the  broken-down  gland  substance  softens 
and  is  expelled,  mixed  with  pus,  through  an  ulcerated  opening  in  the  skin. 

In  order  to  complete  the  description  of  the  anatomical  character  of  scrof- 
ula, it  would  be  necessary  to  describe  the  various  inflammations  to  which  the 
diathesis  gives  rise.  Those  which  are  most  common  and  important  occur  in 
the  skin,  mucous  membrane,  connective  tissue,  the  joints,  the  bones  with  their 
periosteal  covering,  and  the  eye  and  ear.  Eczema  and  coryza  are  also  very 
common  scrofulous  ailments.  Phlyctenular  keratitis  with  great  intolerance 
of  light,  otitis  externa,  causing  protracted  otorrhoea,  or  media  and  interna, 
causing  deep-seated  pain,  with  impairment  or  loss  of  hearing,  ofi"ensive  puru- 
lent discharge,  and,  in  the  gravest  cases,  caries  of  the  mastoid  cells  or  caries 
extending  along  the  petrous  portion  of  the  temporal  bone  even  to  the  brain, 
causing  meningitis  and  death,  are  not  uncommon  manifestations  of  scrofula, 
in  the  families  of  the  city  poor.  Strumous  cellulitis,  occurring  independently 
of  the  glandular  aficction  and  quickly  ending  in  suppuration,  is  also  common. 
The  term  cold  is  applied  to  the  abscess  when  the  local  symptoms  are  slight 
and  there  is  but  little  heat  of  the  parts.  In  young  children  the  common  seat 
of  these  abscesses  is  directly  under  the  skin,  so  that  if  subcutaneous  cellulitis 
running  into  an  abscess  occur  in  a  young  child,  he  probably  has  the  strumous 
diathesis. 

The  osseous  system  is  very  prone  to  inflammation  in  the  scrofulous. 
Periostitis,  osteitis,  and  arthritis,  rare  in  those  with  healthy  constitutions,, 
are  common  in  the  scrofulous,  in  whom  they  result  even  from  very  slight 
injuries,  and  sometimes  without  the  recollection  of  an  injury,  and  apparently 
from  the  direct  influence  of  the  diathesis.  These  inflammations  are  more 
common  in  the  lower  extremities  than  in  the  upper.  Periostitis  often  occurs 
in  scrofulous  children  without  osteitis,  when  its  usual  seat  is  upon  the  shafts 
of  the  long  bones,  and  it  also  accompanies  inflammations  of  the  bone,  as 
pleurisy  accompanies  pneumonia.  The  osseous  inflammations  of  strumous 
patients  are  of  two  kinds :  first,  the  destructive,  producing  caries  with  sup- 
puration or  necrosis  ;  and,  secondly,  the  so-called  funpous,  in  which  there  is 
proliferation  of  tissue,  as  in  white  swelling.  Often  both  these  processes 
coexist,  granulations  and  new  tissue  springing  up  while  the  carious  or 
necrotic   process  is   extending. 

Dactylitis  is  in  most  instances,  when  occurring  in  young  infants,  a  syph- 
ilitic afi"ection,  but  in  children  of  one  year  or  more,  in  whom  no  marked  syph- 
ilitic symptoms  have  previously  occurred,  it  originates  from  the  strumous 


SYMPTOMS. 


209 


— ,  aged  twenty  months,  was 
187G.     He  had  always  been 


cachexia,  as  in  the  following  case :  Charles  R — 
admitted  into  the  New  York  Infant  Asylum  in 

pallid  and  had  a  strumous  aspect.  A  physician  acquainted  with  his  parent- 
age states  positively  that  he  is  free  from  syphilitic  taint,  but  when  a  few 
months  old  he  had  a  mild  form  of  coryza,  which  gradually  abated  under  anti- 
strumous  treatment.     At  the  age  of  five  months  he  had  purpura  haemorrhagica 

Fig.  22. 


of  a  severe  form,  but  apparently  not  accompanied  by  hemorrhage^  from  any 
of  the  mucous  surfaces.  The  patches  of  extravasated  blood  were  quite 
numerous  and  large  over  the  trunk  and  limbs,  and  it  was  nearly  three 
months  before  they  entirely  disappeared.  A  few  months  subsequently  he 
began  to  have  offensive  otorrhoea  on  one  side,  which  did  not  entirely  cease. 
In  December,  1876,  at  the  age  of  eighteen  months,  well-marked  dactylitis 
was  first  observed,  involving  the  first  phalanx  of  the  left  middle  finger.  The 
swelling  was  somewhat  tender,  and  the  skin  which  covered  it  had  a  slightly 
reddish  or  pinkish  tinge,  indicating  the  inflammatory  nature  of  the  malady. 
Neither  joint  at  the  extremity  of  the  phalanx  was  involved,  so  that  the 
movements  were  unimpaired.  The  dactylitis  increased  somewhat  after  it 
was  first  discovered,  and  then  began  to  decline  under  treatment  with  cod- 
liver  oil  and  syrup  of  iodide  of  iron.  The  accompanying  woodcut  repre- 
sents the  outlines,  obtained  by  tracing  the  hand  of  the  infant  when  pressed 
on  paper. 

Symptoms. — The  scrofulous  diathesis  is  exhibited  by  certain  physical 
signs  which  are  present  in  infancy,  but  are  more  manifest  in  childhood.  In 
one  class  of  strumous  children  they  are  as  follows :  Form  tall  and  slender ; 
quickness  of  movement  and  perception  ;  intelligence  good ;  skin  thin  and 
semi-transparent,  through  which  the  superficial  veins  are  distinctly  seen ; 
features  delicate  ;  cheeks  habitually  pallid  or  florid,  and  flushed  by  slight 
excitement;  eyes  bright,  with  bluish  conjunctiva;  muscles  and  bones  slen- 
der in  proportion  to  their  length.  Those  children  who  present  these  pecu- 
liarities are  said  to  have  the  erethitic  form  of  the  diathesis. 


14 


210  SCROFULA. 

Others  have  what  has  been  designated  the  torpid  scrofulous  habit,  which 
is  characterized  by  softness  and  flabbiness  of  the  flesh,  distended  abdomen, 
large  head,  broad  face,  slow,  languid  movements,  and  an  over-production 
of  fat  in  the  subcutaneous  connective  tissue  in  certain  situations,  especially 
the  nose  and  upper  lip.  Though  typical  cases  can  be  readily  referred  to 
one  or  the  other  of  these  forms,  there  are  many  which  are  intermediate. 

One  of  the  earliest  of  the  scrofulous  manifestations  is  subcutaneous 
cellulitis,  alluded  to  above,  giving  rise  to  abscesses,  commonly  not  large, 
with  little  surrounding  induration,  little  pain,  tenderness,  and  heat,  and  slow 
in  discharging ;  in  a  word,  indolent.  The  most  frequent  seat  of  these 
abscesses  is  upon  the  extremities,  but  they  may  occur  upon  the  scalp  or 
elsewhere.  They  gradually  heal  when  the  pus  escapes,  their  site  being  indi- 
cated for  a  considerable  time  by  the  depression  and  reddish  discoloration 
of  the  skin.  Ordinarily,  these  abscesses  do  no  harm  apart  from  the  reduction 
of  the  general  health  which  they  effect,  but,  when  occurring  in  localities 
where  the  connective  tissue  lies  upon  the  periosteum,  as  upon  the  fingers, 
periostitis  may  result,  with  destruction  of  the  surface  of  the  bone.  Again, 
thrombi  may  occur  in  the  vessels  of  the  inflamed  part,  giving  rise  to  emboli, 
embolismal  pneumonia,  and  death.  Specimens  from  such  a  case  were  pre- 
sented by  me  to  the  New  York  Pathological  Society  in  1868. 

The  scrofulous  affections  of  the  skin  often  also  occur  at  an  early  age, 
even  befoi'e  dentition.  They  are  more  frequent  in  infancy  than  in  child- 
hood. The  most  common  are  eczema  and  impetigo,  and,  of  rare  occur- 
rence, ecthyma  and  lupus.  But  all  these  may  occur  in  those  who  are 
not  strumous  or  who  do  not  present  the  characteristics  of  the  strumous 
diathesis. 

Scrofulous  affections  of  the  mucous  surfaces  are  scarcely  less  frequent 
than  those  of  the  skin.  They  present  the  ordinary  features  of  mucous 
inflammations  of  a  subacute  and  chronic  character. 

Sometimes  they  occur  without  obvious  exciting  cause  ;  in  other  cases 
there  is  a  cause  of  this  kind,  such  as  exposure  to  cold ;  but  the  inflamma- 
tion, once  established,  continues  on  account  of  the  diathesis.  It  is  often 
doubtful  whether  inflammations  in  strumous  subjects  be  of  such  a  character 
that  it  is  proper  to  designate  them  strumous,  especially  if  they  occur  upon 
such  surfaces  as  are  frequently  the  seat  of  ordinary  inflammation.  If  the 
child  have  heretofore  presented  symptoms  of  scrofula,  if  the  inflammation 
be  subacute,  and  there  be  no  apparent  cause  to  originate  or  sustain  it  apart 
from  the  diathesis,  it  is  probably  of  a  strumous  character.  The  diagnosis 
is  rendered  more  certain  by  observing  the  effect  of  antistrumous  remedies. 
The  most  frequent  of  these  scrofulous  inflammations  of  mucous  surfaces 
are  coryza,  tracheo-bronchitis,  and  conjunctivitis.  More  rarely,  stomatitis, 
pharyngitis,  vaginitis,  and,  according  to  some,  entero-colitis,  are  of  a  stru- 
mous character.  Coryza  gives  rise  to  snufiling  respiration,  the  formation 
of  crusts  around  and  within  the  nares,  and  excoriation  of  the  upper  lip. 
The  tracheo-bronchitis  is  attended  by  thickening  of  the  mucous  membrane, 
increased  production  of  mucous  and  epithelial  cells,  and  a  loud  tracheal  rale 
accompanying  each  inspiration. 

Strumous  inflammation  of  the  mucous  membrane  of  the  trachea  and 
bronchial  tubes  is  not  a  very  infrequent  disease  in  this  city.  It  sometimes 
originates  in  a  simple  inflammation  from  cold  or  the  tracheo-bronchitis  of 
measles  or  pertussis,  and  it  may  continue,  with  its  rales,  cough,  and 
scanty  expectoration,  for  months,  unless  relieved  by  a  proper  course  of 
treatment. 

Among  the  most  common  of  the  strumous  affections  are  inflammation  of 
the   eyelid,   designated  psorophthalmia,  and    that   of   the   eye  itself.       The 


PROGNOSIS.  21 1 

former  is  characterized  by  redness  and  thickoninjz;  of  the  lids,  detachment  of 
the  eyelashes,  and  inflammation  and  altered  secretion  of  the  "  Meibomian 
glands  ;"  the  latter — to  wit,  strumous  ophthalmia — by  pain,  lachrymation, 
photophobia,  and  a  moderate  degree  of  hypertcniia  of  the  affected  organ. 
One  of  the  most  common  serious  results  of  strumous  conjunctivitis  and  kera- 
titis is  the  formation  of  phlyctenular  and  ulcers  on  the  margin  of  the  con- 
junctiva and  upon  the  cornea,  fed  by  newly-formed  vessels.  If  not  con- 
trolled by  proper  treatment  they  may  result  in  opacities  more  or  less  perma- 
nent, or  possibly,  worse   still,  in  perforation,  with  its  consequent  ill  effects. 

Inflammations  of  the  external  and  middle  ear  have  their  origin  very  gen- 
erally in  the  strumous  diathesis.  Occasionally  there  is  an  exciting  cause  of 
the  otitis,  as  an  injury  or  severe  constitutional  disease,  like  scarlet  fever. 
Protracted  otitis,  whether  external  or  internal,  and  especially  that  form  of 
it  which  leads  to  ulceration,  destruction  of  the  ossicles,  and  caries  of  the 
petrous  portion  of  the  temporal  bone,  it  is  proper  in  a  large  proportion  of 
cases  to  regard  and  treat  as  strumous. 

The  stubbornness  and  frequent  disastrous  consequences  of  scrofulous 
inflammation  of  the  bones  are  well  known.  Nearly  every  bone,  as  well  as  its 
periosteum,  is  liable  to  this  form  of  inflammation,  but  some  are  more  fre- 
quently affected  than  others.  Inflammation  of  the  bone  may  terminate  by 
resolution,  by  the  formation  of  an  abscess,  or  (and  frequently)  by  carious  or 
necrotic  destruction  of  the  bone  itself.  Necrosis  most  frequently  occurs  in 
the  shafts  of  the  long  bones  ;  caries  in  the  spongy  extremities  of  these  bones 
and  in  the  spongy  portions  of  the  short  bones.  If  ab.scesses  form,  the  pus 
may  finally  escape  from  the  system  by  a  tedious  ulcerative  process,  or, 
retained,  may  undergo  cheesy  degeneration.  Scrofulous  arthritis,  if  early 
detected  and  properly  treated,  may  resolve,  leaving  no  ill  effect ;  if  other- 
wise, suppuration,  ulceration,  cartilaginous  and  osseous,  and  ankylosis  often 
occur. 

Scrofulous  children  are  perhaps  no  more  liable  to  inflammation  of  the 
internal  organs  than  other  children,  but  the  inflammatory  products  are  more 
liable  to  cheesy  degeneration,  and  the  prognosis  is  therefore  less  favorable. 
The  most  frequent  of  these  inflammations  and  the  one  of  chief  interest  is 
pneumonia.  Catarrhal  pneumonia,  so  frequent  in  early  life,  whether  primary 
or  secondary,  in  connection  with  measles,  pertussis,  etc.,  is  a  disease  often 
involving  grave  consequences  in  those  who  are  decidedly  scrofulous,  since, 
instead  of  resolving,  the  affected  lung-tissue  presents  a  strong  tendency  to 
caseous  degeneration,  ending  in  tuberculosis  of  the  lungs  and  death.  I  have 
most  frequently  noticed  cheesy  pneumonia  during  extensive  epidemics  of 
measles  as  a  complication  or  sequel  of  this  disease.  It  may  occur  in  those 
who  are  not  scrofulous  if  the  vital  powers  be  greatly  reduced,  but  it  is  so 
much  more  common  in  the  scrofulous  that  some  recent  writers  have  desig- 
nated this  form  of  inflammation  by  the  term  of  scrofulous  instead  of  cheesy 
pneumonia.  From  the  fact,  however,  of  its  sometimes  occurring  in  the  non- 
scrofulous,  the  term  cheesy  or  caseous — especially,  too,  as  it  expresses  the 
anatomical  state — seems  more  appropriate. 

The  caseous  substance  which  results  from  degeneration  of  the  products 
of  scrofulous  inflammations  aff"ords  a  nidus  in  which  the  tubercle  bacillus 
frequently  obtains  lodgment  and  conditions  favorable  for  its  propagation. 
Hence  the  close  etiological  relations  of  scrofula  or  scrofulous  inflammations 
to  tuberculosis. 

Prognosis. — As  scrofula  may  be  acquired  through  antihygienic  influ- 
ences, so  it  may  disappear  or  become  latent  through  influences  of  an  opposite 
character.  Therefore  the  manifestations  of  scrofula  may  be  limited  to  a  brief 
period,  or  they  may  occur  at  intervals  through  the  whole  of  childhood  and 


212  SCROFULA. 

the  first  years  of  youth.  When  the  diathesis  is  inherited  and  fostered  by 
unfavorable  circumstances,  the  scrofulous  affections  appear  earliest,  are  most 
varied  and  severe,  and  continue  longest. 

In  most  cases,  with  proper  treatment,  the  prognosis  is  good,  but  the  dan- 
ger to  life  depends  on  the  nature  and  extent  of  the  scrofulous  inflammation. 
The  most  common  unfavorable  result  is  the  occurrence  of  pulmonary  or  gen- 
eral tuberculosis,  the  caseous  substance,  as  we  have  said,  affording  a  favorable 
nidus  for  the  development  and  propagation  of  the  tubercle  bacillus.  This  is 
the  usual  result  in  cheesy  pneumonia.  The  next  most  common  cause  of 
death,  either  directly  or  indirectly,  is  inflammation  of  the  osseous  system. 
Many  deaths  occur  from  inflammation  of  the  vertebrae  or  of  the  hip  or  knee- 
joint  when  it  has  been  allowed  to  continue  a  considerable  time  without  proper 
treatment.  Protracted  suppurative  inflammation  of  the  bones  is  liable  to 
produce  amyloid  degeneration  of  organs,  which  is  permanent  and  likely  to 
prove  fatal,  or  death  may  occur  from  exhaustion,  with  or  without  tubercu- 
losis. Among  the  city  poor  meningitis  is  not  very  uncommon,  consequent 
on  long-continued  otitis  media  and  caries  of  the  petrous  portion  of  the  tem- 
poral bone.  Permanent  impairment  of  sight  and  hearing  often  results  from 
neglected  strumous  ophthalmia  and  otitis. 

At  puberty  the  strumous  affections  gradually  become  less  frequent,  and 
they  finally  disappear  in  advancing  age.  Among  the  most  robust  adults  are 
some  who  in  early  life  presented  indubitable  symptoms  of  the  strumous 
diathesis. 

Treatment. — Prophylactic. — Measures  designed  to  prevent  scrofula  are 
impossible  without  the  co-operation  of  willing  and  intelligent  parents.  It  is 
obvious  that  the  prevention  of  congenital  scrofula  requires  the  treatment  of 
disease  or  impaired  health  in  the  parent.  If  parents  should  be  taught  or 
should  remember  that  good  health  in  themselves  is  the  necessary  condition  of 
the  inheritance  of  a  sound  constitution  in  the  child,  and  would  adopt  such 
therapeutic  and  regimenal  measures  as  would  procure  this,  the  number  of 
cases  of  inherited  scrofula  would  be  materially  reduced. 

As  the  first  years  of  life  are  very  important,  both  for  correcting  the 
diathesis  when  inherited  and  for  preventing  its  development  in  those  of  sound 
constitution,  care  should  be  taken  that  the  regimen  of  the  child  be  such  that 
it  does  not  cause  deterioration  of  the  general  health.  The  nursing  infant, 
if  the  mother  be  in  poor  health,  should  be  provided  with  a  healthy  wet-nurse, 
for  in  young  children  the  diathesis  may  be  acquired  solely  by  the  use  of  food 
that  is  scanty  or  of  poor  quality.  Those  old  enough  to  be  weaned  should 
have  plain  and  nutritious  diet,  with  a  proper  admixture  of  animal  food.  More 
or  less  outdoor  exercise  and  residence  in  a  salubrious  locality,  with  sufficient 
air  and  sunlight,  are  also  requisite. 

Curative. — Since  scrofula  originates  in  a  state  of  weakness  existing  in  the 
parent  in  the  congenital,  and  in  the  child  in  the  acquired,  form  of  the  disease, 
and  is  characterized  by  feeble  resistance  of  the  tissues  to  irritating  agents, 
the  inference  is  reasonable  that  all  tonics  have,  to  a  certain  extent,  an  anti- 
scrofulous  effect  upon  the  system.  The  ordinary  vegetable  tonics,  and  some- 
times the  ferruginous,  are  indeed  useful  in  the  treatment  of  scrofula. 
Employed  in  connection  with  proper  regimenal  measures,  they  are  sufficient, 
in  many  cases,  to  remove  the  diathesis  after  a  time  or  render  it  latent. 
Besides  these  medicinal  agents,  which  tend  to  correct  the  scrofulous  diathesis 
by  their  general  tonic  effect,  there  are  certain  others  which  experience  has 
shown  to  be  beneficial  in  the  treatment  of  scrofulous  affections,  and  which 
are  therefore  largely  used.  One  of  these  is  cod-liver  oil,  which  contains  iodine 
among  its  many  ingredients. 

Cod-liver  oil  is  useless  or  nearly  so  in  the  torpid  form  of  the  diathesis, 


TREATMENT.  213 

which  is  characterized  by  an  increased  deposit  of  fat  in  the  subcutaneous 
connective  tissue,  slow  circulation,  and  sluggish  muscular  movements.  On 
the  other  hand,  in  the  treatment  of  the  erethitic  form  it  possesses  real  value. 
Its  protracted  use  in  such  cases  does  so  modify  the  molecular  condition  of 
the  tissues  that  they  are  less  liable  to  inflammation,  and  the  diathesis  is  there- 
fore rendered  milder  or  removed.  From  one  to  three  teaspoonfuls,  according 
to  the  age,  should  be  given  three  times  daily.  While  we  frequently  expe- 
rience so  much  difficulty  in  administering  it  to  adults  affected  with  tubercu- 
losis, and  sometimes  find  it  necessary  to  discontinue  its  use  on  account  of  its 
nauseating  effect,  scrofulous  children  rarely  refuse  to  take  it,  and  it  does  not 
seem  to  diminish  their  appetite. 

Iodine  is  justly  celebrated  as  a  remedy  in  the  treatment  of  scrofulous  mal- 
adies, but  it  is  a  question  whether  it  has  not  been  overrated  as  a  remedy  for 
the  diathesis  itself.  Iodine  employed  internally  is  especially  serviceable  in 
glandular  hyperplasia  and  in  scrofulous  thickening  and  induration  of  the  con- 
nective tissue  and  periosteum.  In  general,  it  should  not  be  administered  to 
children  in  its  isolated  state,  on  account  of  its  irritating  properties,  but  one 
of  its  compounds  should  be  employed.  The  compounds  which  are  chiefly 
prescribed  in  the  treatment  of  scrofula  are  the  iodides  of  starch,  iron,  potas- 
sium, and  sodium.  If,  as  is  frequently  the  case,  the  patient  be  pallid  and  his 
appetite  poor,  the  iodide  of  iron  should  be  preferred ;  if  not  in  this  cachectic 
state  the  iodide  of  starch  may  be  used.  Pharmaceutists  prepare  syrups  of 
both  these  iodides,  so  that  they  can  be  readily  administered  to  the  youngest 
child.  The  iodide  of  starch  may  be  administered  by  dropping  from  one  to 
five  drops  of  the  officinal  tincture  of  iodine  on  a  little  powdered  starch  and 
giving  it  in  syrup.  These  iodides  are  preferable  to  the  iodides  of  potassium 
and  sodium  for  internal  administration  to  children,  since  they  are  not  irritating 
to  the  mucous  membrane  and  the  iodine  is  readily  set  free.  Prof.  Dalton 
has,  indeed,  demonstrated  that  the  iodide  of  starch  is  decomposed  in  most  of 
the  liquids  of  the  body  and  the  iodine  liberated. 

In  New  York  City  a  large  proportion  of  the  scrofulous  children  are  cachec- 
tic and  need  iron,  and  the  iodide  of  iron  is  more  frequently  employed,  and 
with  good  results,  than  any  other  iodine  compound.  The  syrup  of  the  iodide 
of  iron,  which  is  readily  absorbed,  should  be  given  in  one-  to  two-drop  doses 
three  times  daily  to  a  child  of  six  months,  and  one  additional  drop  be  added 
for  each  additional  year.  x\mong  the  vaunted  remedies  of  scrofula  are  phos- 
phoric acid  and  the  phosphate  of  lime.  I  have  not  employed  these  agents 
without  at  the  same  time  using  other  remedies,  and  cannot  say,  therefore,  to 
what  extent  they  have  been  curative  in  my  practice.  Probably  there  is  no 
better  combination  of  remedies  for  the  strumous  diathesis  than  the  following, 
which  is  now  used  in  some  of  the  institutions  of  New  York,  and  which  we 
have  already  recommended  in  the  treatment  of  rachitis : 

R.  01.  morrhuse,  2  parts; 

Syr.  calcis  lactophosphat.,  1  part ; 

AquEe  calcis,  1  part.     Misce. 

Dose ;  One  teaspoonful  to  a  dessertspoonful  three  or  four  times  daily.  The 
syrup  of  the  iodide  of  iron  should  be  given  at  the  same  time  in  three  daily 
dJoses,  but  not  mixed  with  the  above  preparation  of  oil  and  lime,  as  a  double 
decomposition  occurs  from  the  admixture. 

The  internal  use  of  mercury  as  an  antidote  for  scrofula  is  now  generally 
discarded.  Unless,  perhaps,  in  those  cases  in  which  the  diathesis  is  imme- 
diately dependent  on  syphilis,  its  use  for  this  purpose,  from  what  we  know 
of  its  therapeutic  effects,  would  probably  be  more  injurious  than  beneficial. 


214  SCROFULA. 

Among  the  medicines  which  have  from  time  to  time  been  employed  for  the 
cure  of  scrofula,  some  of  which  have  had  considerable  reputation,  but  have 
nearly  fallen  into  disuse,  are  walnut-leaves,  sarsaparilla,  elecampane,  conium, 
digitalis,  horseradish,  compounds  of  silver,  gold,  arsenic,  baryta,  and  bromine. 
It  is  probable  that  none  of  these  has  any  effect  on  scrofula  or  scrofulous  ail- 
ments except  such  as  improve  the  appetite  and  general  health,  as  horseradish. 

The  same  hygienic  measures  are  required  in  the  treatment  of  scrofula 
as  are  employed  in  the  prophylaxis  of  it.  The  nursing  infant  should 
have  healthy  breast-milk,  and  if  its  mother  belong  to  a  tubercular  or  scrof- 
ulous family  or  be  feeble,  a  healthy  wet-nurse  should  be  employed,  or  it 
should  be  sent  to  the  country,  where  suitable  cow's  milk  as  well  as  pure  air 
can  be  obtained.  The  expressed  juice  of  beef  slightly  boiled,  the  peptonized 
beef  or  beef  tea  prepared  as  recommended  for  rachitic  infants,  given  several 
times  daily  in  small  quantity  to  infants,  aid  materially  in  restoring  a  better 
nutrition  of  the  tissues.  Obviously,  similar  care  is  necessary  in  the  selection 
and  preparation  of  the  food  of  children  who  have  passed  beyond  the  period 
of  infancy.  While  the  diet  should  be  highly  nutritious,  it  should  be  plain 
and  easily  digested,  and  given  at  sufficient  intervals,  so  as  not  to  overtax 
digestion.  The  cow's  milk  employed  should  be  of  the  best  quality,  and  for 
young  children  it  may  be  best  to  peptonize  it. 

Fresh  air,  outdoor  exercise,  daily  bathing,  personal  and  domiciliary  clean- 
liness, are  very  necessary  for  the  successful  treatment  of  the  diathesis.  Since 
scrofula  is  comparatively  infrequent  in  farming  sections,  scrofulous  families 
are  greatly  benefited  by  farm-life,  with  all  the  accessories  to  health  which 
pertain  to  it.  The  use  of  sea-air  and  sea-bathing  has,  according  to  the  testi- 
mony of  several  observers,  been  very  eiBcacious.  Dr.  F.  P.  Henry  states 
that  no  other  remedial  measure  is  so  efficacious  as  these  (^Annual  of  Univer. 
Med.  Sci.,  1889).  Dr.  Valcourt,  who  is  in  charge  of  the  Maritime  Hospital 
at  Cannes,  where  scrofulous  children  receive  daily  sea-baths  during  a  consider- 
able part  of  the  year,  read  an  interesting  paper  in  commendation  of  its  use 
before  the  Paediatric  Section  of  the  Ninth  International  Medical  Congress 
in  1887-  Alexander  quotes  the  statistics  prepared  by  Cazin,  which  show 
that  the  mortality  of  scrofulous  children  is  much  less  in  the  hospital  at  Barek, 
where  sea-bathing  is  employed,  than  in  two  Parisian  hospitals  (Liverp.  Medico- 
CMr.  Jonr.,  1888.) 

The  local  scrofulous  ailments  require  additional  and  special  treatment. 
Those  located  on  the  cutaneous  and  mucous  surfaces  are  less  dangerous,  as 
a  rule,  than  the  deeper-seated  inflammations  ;  still,  they  should  be  promptly 
treated,  not  only  for  the  inconvenience  and  annoyance  which  they  cause,  but 
because  they  may  give  rise  to  hyperplasia  of  the  neighboring  glands,  as  we 
have  stated  elsewhere.  Thus,  pharyngitis  may  cause  a  peripharyngeal  ade- 
nitis and  abscess,  and  a  bronchitis  may  cause  adenitis  of  the  bronchial  glands, 
with  the  probability  of  their  cheesy  degeneration.  The  so-called  bronchial 
phthisis  is  believed  to  result,  in  a  large  proportion  of  cases,  from  a  strumous 
bronchitis  which  has  been  allowed  to  continue  uncontrolled  by  medicine,  and 
a  similar  state  of  the  mesenteric  glands  may  result  from  intestinal  catarrh. 
Inflammation  of  the  skin  or  mucous  surface  occurring  in  the  strumous  requires 
the  continued  use  of  antistrumous  remedies,  conjoined  with  such  treatment, 
designed  to  act  locally,  as  is  appropriate  for  the  case. 

It  is  the  common  practice  to  treat  the  enlarged  glands  of  struma  by  daily 
applications  over  them  of  the  stronger  iodine  preparations.  This  treatment 
does  not  cause  absorption  of  the  redundant  gland-substance.  It  causes  pro- 
liferation of  the  epidermic  cells,  and  quickens  the  cell-change  in  the  adjacent 
gland  and  accelei'ates  suppurative  inflammation.  I  once  produced  accidentally 
such  an  amount  of  vesication  over  an  enlarged,  hard,  and  apparently  indo- 


TREATMENT.  215 

lent  gland  in  an  infant  of  fourteen  months  that  I  was  very  anxious  lest  a 
sore  should  result  which  would  heal  with  difficulty,  and  yet,  instead  of  dis- 
persion of  the  glandular  swelling,  the  pathological  processes  were  so  promoted 
that  suppuration  and  discharge  of  pus  occurred  by  the  time  that  the  cuticle 
had  re-formed. 

We  know  no  better  substance  for  the  local  treatment  of  strumous  adenitis 
than  iodine,  and  it  should  be  applied,  in  my  opinion,  in  such  a  manner  that 
it  is  absorbed  with  the  least  possible  irritation  of  the  gland.  The  following 
will  be  found  useful  ointments  and  solutions  for  the  treatment  of  these  cases : 

R.  Potas.  iodidi,  ^]\ 

Ung.  stramonii,         ,^. 

To  be  rubbed  over  the  gland  several  times  daily.  It  should  not  be  applied  as 
a  plaster,  since  it  is  too  irritating  and  will  vesicate.  I  have  known  a  gland- 
ular swelling  which  had  continued  about  three  months  to  disappear  in  three 
weeks  under  its  use  in  connection  with  internal  remedies.  Lanolin  may  be 
employed  in  place  of  the  stramonium  ointment,  inasmuch  as  it  is  believed  to 
be  more  readily  absorbed  than  most  oleaginous  substances.  Another  useful 
iodine  mixture  for  these  cases  is  the  following : 

R.  Liq.  iodinii  composita, 

Glycerinse,  equal  parts. 

To  be  applied  as  an  inunction.  Glycerin  renders  the  skin  soft  and  in  a  state 
favorable  for  absorption. 

In  Thu  Medical  Press  and  Clrcidar  for  August  3,  1870,  J.  Waring  Curran 
states  that  he  has  used  with  great  success  what  he  designates  a  new  iodine 
paint,  consisting  of  half  an  ounce  of  iodine,  the  same  quantity  of  iodide  of 
ammonium,  twenty  ounces  of  rectified  spirits,  and  four  ounces  of  glycerin. 

3Iercurial  ointments  have  been  recommended  by  writers  of  reputation  for 
the  treatment  of  these  glands.  I  have  employed  them  and  known  them  to  be 
employed,  but  cannot  say  that  I  have  ever  observed  any  benefit  whatever 
from  their  use.  In  the  children's  class  at  the  Out-door  Department  at  Bel- 
levue  we  have  discarded  them  entirely  for  this  purpose,  although  both  the 
citrine  and  white  precipitate  ointments,  diluted  with  an  equal  quantity  of 
lard,  have  been  used  with  apparent  benefit  for  chronic  coryza  of  a  strumous 
nature,  and  also  occasionally  for  external  otitis  of  the  same  nature. 

In  a  paper  read  at  the  meeting  of  the  British  Medical  As.sociation  in  1870 
by  Mr.  Jordan,  the  writer  recommends,  as  attended  with  success,  vesication, 
not  over  the  gland,  but  at  a  little  distance  from  it — as,  for  example,  behind 
the  neck — for  treatment  of  the  cervical  glands.  But  a  mode  of  treatment 
which  seems  so  unlikely  to  be  beneficial  requires  stronger  proof  of  its  utility 
than  has  yet  been  presented. 

The  application  of  cold  over  an  inflamed  lymphatic  gland  and  the  adjacent 
inflamed  connective  tissue  is  a  useful  adjuvant  to  the  treatment  in  many  cases 
at  an  early  stage.  A  small  India-rubber  bag  containing  ice,  or  muslin  fre- 
quently wrung  out  of  ice-water  and  applied  over  the  inflamed  parts,  contracts 
the  vessels,  diminishes  the  activity  of  the  morbid  process  going  on  under- 
neath, and  aids  materially  in  the  resolution.  When  the  gland  becomes  so 
actively  inflamed  or  the  inflammation  so  advanced  that  redness  of  the  skin 
occurs,  applications  of  iodine  are  no  longer  proper.  They  increase  the  local 
disease.  There  is  no  longer  any  probability  of  resolution  of  the  gland,  and 
poultices  should  be  applied. 

It  is  important  that  the  diseases  of  the  osseous  system  should  receive 


216 


SCROFULA. 


Fig.  23. 


early  treatment,  but,  unfortunately,  it  is  in  reference  to  these  inflammations 
that  error  of  diagnosis  is  frequently  made.  Thus  I  have  known  periostitis, 
with  the  diffused  redness  of  the  skin  and  heat  which  it  produces,  to  be  mis- 
taken for  erysipelas,  until  the  diagnosis  was  corrected  from  its  persistence 
and  non-extension.  It  is  remarkable  that  strumous  arthritis  sometimes  appears 
in  two  or  more  joints  at  once,  as  in  the  case  related  below.  I  have  known  it 
to  occur  nearly  simultaneously  in  three  joints,  though  only  for  a  brief  time 
in  two  of  the  joints,  while  it  was  chronic  in  the  other.  Hence,  the  fact  that 
this  inflammation  is  often  mistaken  for  inflammatory 
rheumatism,  and  treated  as  such  for  some  days  till  its 
nature  becomes  apparent,  and  in  like  manner  the  febrile 
movement,  lassitude,  abdominal  pain,  etc.  of  vertebral 
caries  are  in  a  large  proportion  of  cases  attributed  to 
something  else,  and  the  true  disease  not  suspected  till 
irreparable  damage  has  occurred,  or  much  longer  con- 
finement and  treatment  required  than  would  have  been 
necessary  with  an  earlier  diagnosis. 

The  common  strumous  inflammations  of  the  osseous 
system  which  involve  the  joints,  as  Pott's  disease,  hip 
disease,  and  white  swelling,  are  usually  quite  amenable 
to  treatment,  early  applied,  which  ensures  complete 
rest ;  but,  as  a  rule,  cases  neglected  or  wrongly  treated 
go  from  bad  to  worse.  There  are  exceptions,  for  a  case 
may  do  well  or  terminate  with  moderate  deformity 
without  treatment,  as  in  the  following  interesting 
instance,  which  also  shows  the  difficulty  which  often 
attends  diagnosis : 

Anna  D .  aged  six  years,  came  to  the  children's 

class  in  the  Out-door  Department  at  Bellevue  in  Feb- 
rury,  1877,  with  the  following  history  :  Her  health  was 
good  till  two  years  ago,  when  she  complained  of  pain 
of  a  mild  form  in  both  knees.  Her  parents  attributed 
it  to  her  rapid  growth,  and  she  was  always  able  to 
walk  with  little  suffering.  Slowly  but  steadily  these 
She  has  had  no  pain  in  other  joints,  and  no  member 
of  the  family  has  had  rheumatism  except  a  grandparent.  She  walks  without 
complaint  to  the  rooms  of  the  Bureau.  The  affected  joints  are  about  equally 
swollen,  and  it  is  evident  on  examination  that  they  contain  some  serous  effu- 
sion. Direct  pressure  is  not  painful,  but  pressing  the  bones  together  with  a 
twisting  or  rotating  movement  gives  some  pain.  She  is  pale  and  has  a  stru- 
mous aspect.  A  sister  of  fifteen  years  has  a  similar  swelling  of  one  knee 
which  began  at  the  age  of  seven  or  eight  years,  but  which  has  received  no 
regular  treatment,  has  not  prevented  the  free  use  of  the  limb,  and  has  given 
her  little  inconvenience. 

The  physicians  who  have  examined  this  child,  one  of  whom  is  an  expert 
in  orthopaedic  surgery,  agree  that  the  disease  is  strumous  and  not  rheumatic, 
and  that  it  did  not,  during  two  years  of  neglect  and  unrestrained  motion,  go 
on  to  suppuration  and  destruction  of  the  joints  was  probably  due  to  her  good 
general  health. 

Though  the  result  in  the  above  case  was  good,  since  there  was  little 
impairment  in  the  use  of  the  joints  and  no  suffering,  yet  delay  and  neglect 
in  the  treatment  of  those  strumous  inflammations  which  involve  the  joints 
are  exceedingly  dangerous,  for  if  left  to  themselves  they  most  frequently 
end  in  suppurative  inflammation  and  ulceration,  with  all  the  sad  conse- 
quences which  these  entail.     Strumous  inflammations  of  the  osseous  system 


joints  began  to  swell. 


STRUMOUS  OPHTHALMIA.  217 

now  receive  more  early  and  aorrect  treatment  than  formerly,  and  orthopaedia, 
almost  unknown  till  within  the  last  twenty  years,  has  become  an  important 
branch  of  surgery.  Formerly  in  New  York,  especially  in  the  tenement- 
houses,  we  often  met  emaeiated  bed-ridden  children  with  strumous  osteitis 
and  arthritis,  their  limbs  swollen  and  painful  in  motion,  and  offensive  from 
the  discharge,  for  the  most  part  shunned  by  physicians,  and  with  no  prospect 
of  relief  except  by  amputation.  Now  this  spectacle  is  comparatively  infre- 
quent. The  early  symptoms  of  these  diseases  being  better  understood  and 
sooner  recognized,  the  plaster-of-Paris  or  starch  dressing  to  ensure  immo- 
bility, or  ingeniously  devised  steel  splints  which  produce  extension  and  allow 
motion  of  the  limb  without  friction  of  the  inflamed  surfaces,  coming  into 
general  use,  a  large  proportion  of  cases  do  not  go  beyond  the  first  stage  and 
are  cured. 

Strumous  Ophthalmia. 

[Written  by  Dr.  O.  D.  Pomeroy,  Surgeon  to  the  Manhattan  Eye  and  Ear  Hospital.] 

Strumous  ophthalmia  in  young  children,  as  described  by  the  older  writers, 
is  simply  a  keratitis  or  inflammation  of  the  cornea,  and  is  usually  of  the  fol- 
lowing varieties :  phlyctenular  or  herpetic  keratitis  and  diffuse  or  paren- 
chymatous keratitis.  Perhaps  it  is  a  misnomer  to  designate  these  affections 
strumous.  This  general  principle  governs  most  cases  of  these  inflamma- 
tions— to  wit,  depressed  vital  energy,  which  is  a  prominent  characteristic  of 
the  strumous  diathesis.  As  is  well  known,  the  cornea  is  a  tissue  of  low 
vitality,  and  any  constitutional  state  accompanied  by  depression  predisposes 
to  an  attack  of  keratitis.  One  of  the  commonest  hospital  experiences  is  to 
see  a  mild  case  of  catarrhal  conjunctivitis  which  should  be  self-limiting 
gradually  extend  to  the  cornea,  causing  an  ulcerative  keratitis.  I  believe  all 
ophthalmic  surgeons  hold  that  the  presence  of  corneal  disease,  not  dependent 
on  an  obvious  or  specific  cause,  points  to  diminished  vitality  on  the  part  of 
the  patient. 

Herpetic  or  Phlyctentilar  Keratitis  is  the  most  frequent  variety  of 
corneal  disease  in  children.  It  is  a  question  whether  it  commences  with  a 
vesicle  on  the  cornea  or  a  papule ;  but  in  either  case  it  soon  becomes  an 
ulcer.  Ciliary  injection  probably  precedes  it,  although  this  can  by  no  means 
be  always  observed.  In  some  patients  the  characteristic  symptom — to  wit, 
photophobia — may  exist  for  a  long  time  without  injection  of  the  eyeball  or 
any  corneal  changes  whatever,  but  sooner  or  later  it  is  probable  that  other 
characteristic  signs  of  the  disease  will  make  their  appearance.  The  photo- 
phobia is  frequently  accompanied  by  blepharospasm,  making  it  wellnigb 
impossible  to  separate  the  eyelids.  When,  however,  this  is  accomplished, 
abundant  tears  gush  forth,  the  child  exhibiting  signs  of  extreme  distress. 
When  the  vesicle  or  papule  is  in  a  state  of  ulceration  in  the  earlier  stage, 
there  may  only  be  seen  a  minute  loss  of  corneal  tissue,  without  any  opacit 
whatever.  Soon,  however,  the  ulcer  becomes  more  or  less  opaque,  perhaps 
seeming  to  be  only  a  minute  whitish  spot  on  the  cornea.  This  usually  shows 
the  commencement  of  reparative  action.  If  the  disease  continue  long,  a 
general  conjunctivitis  sets  in,  more  especially  of  the  ocular  conjunctiva. 
Frequently  there  will  be  only  one  or  not  more  than  two  or  three  ulcers,  but 
in  exceptional  cases  the  cornea  may  have  the  periphery  studded  with  phlyc- 
tenulae,  which,  instead  of  promptly  healing,  proliferate  so  as  to  form  elevated 
nodules,  the  so-called  ''scrofulous  nodular  bands."  If  the  ulcers  in  any  case 
continue  long,  a  number  of  blood-vessels  shoot  out  from  the  conjunctival 
border  of  the  cornea,  quite  up  to  the  ulcer,  producing  what  may  be  termed 
a  vascular  keratilis.     The  discharge  from  the  eye  is  often  very  acrid,  causing 


218  SCROFULA. 

eatarrli  of  the  lachrymal  canals,  and  even  of  the  nares.  Herpetic  or  ecze- 
matous  eruptions  on  the  cheeks  or  the  lip  near  the  nostrils  are  often  seen,  and 
may  sometimes  appear  to  be  the  cause  of  the  disease  rather  than  the  eflfect. 
In  this  condition  the  upper  lip  may  swell  considerably,  giving  the  patient  a 
very  "  strumous  "  appearance. 

The  DURATION  of  phlyctenular  keratitis  is  exceedingly  variable ;  two  or 
three  weeks  may  bring  it  to  a  close  or  it  may  continue  many  months.  The 
patient's  general  condition  probably  determines  its  duration  as  much  as  any 
other  factor.  If  an  ulcer  perforate  the  cornea,  staphyloma  and  anterior 
synechia  may  result,  rendering  recovery  more  tedious  and  incomplete.  The 
DIAGNOSIS  of  this  malady  is  not  difficult.  The  photophobia  so  characteristic 
of  keratitis  is  present  in  no  other  disease  except  iritis,  and  this  disease  chil- 
dren rarely  have ;  the  little  speck,  spot,  or  abrasion  on  the  cornea,  together 
with  the  intolerance  of  light,  is  wellnigh  diagnostic.  Photophobia  is  present 
in  most  forms  of  corneal  disease,  though  not  in  all.  The  causes  of  phlyc- 
tenular keratitis  are  as  follows :  Any  condition  of  the  system  known  as 
strumous,  or  whatever  tends  to  lower  the  vital  powers  of  the  patient,  aifords 
a  predisposing  cause.  Exposure  to  cold  or  sudden  change  of  temperature  is 
the  common  exciting  cause,  leaving  out  of  the  question  any  cutaneous  dis- 
eases. Naturally,  any  cause  which  produces  a  conjunctivitis  may  also  pro- 
duce this  disease  secondarily.  The  process  of  dentition  may  have  something 
to  do  with  the  eye  disturbance,  or  any  disorder  of  the  intestinal  canal ;  the 
latter,  however,  being  rather  predisposing  than  exciting  causes.  This  dis- 
ease also  frequently  occurs  in  patients  affected  with  aural  or  nasal  catarrh, 
but  the  condition  of  such  children  trenches  closely  on  the  state  designated 
^'  strumous." 

The  PROGNOSIS  in  a  large  number  of  cases  is  very  favorable.  The 
opacities  of  the  cornea  left  after  the  healing  of  the  ulcerations  are  the 
principal  difficulties  in  the  way  of  a  good  recovery.  If  the  opacities  are 
in  the  proper  substance  of  the  cornea,  we  are  not  certain  that  they  will  dis- 
appear by  absorption,  though  they  may.  Nothing  is  more  difficult  than  to 
determine  this  point.  In  the  epithelial  and  Bowman's  layers,  as  well  as  the 
posterior  layer,  opacities  readily  disappear.  When  the  ulcer  perforates  the 
cornea  we  have  an  anterior  synechia  and  the  appearance  known  as  myo- 
■cephaloii,  which  usually   disfigures  the  eye  more  or  less  for  life. 

One  discouraging  point  about  these  opacities  is  that,  although  they  dis- 
appear, the  cornea  is  left  with  a  somewhat  distorted  curvature,  causing  irreg- 
ular astigmatism,  and  if  they  chance  to  be  near  the  centre  of  the  cornea 
great  disturbance  to  vision  results.  I  have  often,  in  fitting  spectacles, 
noticed  that  the  patient's  vision  was  less  than  normal,  and  on  investigation 
have  found  a  history  of  an  infantile  keratitis  which  had  done  all  the  mis- 
chief. In  those  cases  described  as  having  "  scrofulous  nodular  bands  "  the 
proliferative  nodules  are  very  likely  to  undergo  a  variety  of  degenerations 
which  do  not  end  in  a  properly  restored  cornea.  One  great  difficulty  in  mak- 
ing an  exact  statement  here  is  the  tendency  of  the  keratitis  to  recur,  and  it 
cannot  be  determined  where  the  process  will  cease  after  a  number  of 
recurrences. 

Treatment. — As  the  fifth  nerve  presides  over  the  ciliary  vaso-motory 
system  of  the  corneal  nutritive  supply,  it  is  obvious  that  treatment  calcu- 
lated to  correct  any  of  its  morbid  manifestations  would  be  rational.  Such  is 
found  to  be  the  fact.  Sulphate  of  atropia,  in  solution  of  one  to  two  grains  to 
the  ounce,  dropped  into  the  eye  three  times  daily,  is  probably  superior  to  any 
other  treatment.  It  inclines  to  break  up  the  orbicular  spasms,  relieving  the 
photophobia  and  ciliary  neuralgia,  diminishes  vascularity,  and  contributes 
more  to  the  relief  of  the  patient  than  any  other  one  remedy.     If  the  pain 


STRUMOUS  OPHTHALMIA.  219 

be  severe,  the  atropine  may  be  used  six  or  eight  times  daily,  or  it  may  be 
even  instilled  every  fifteen  or  twenty  minutes  until  pain  is  relieved.  If  an 
over-eflfeet  be  reached,  the  patient  complains  of  dryness  in  the  throat,  possi- 
bly pain  in  the  head,  or  h6  may  have  other  cerebral  disturbances,  when  the 
drops  may  be  discontinued  for  a  time.  Muriate  of  pilocarpine  in  two-grain 
solutions  may  be  used  in  a  similar  manner  and  for  the  same  purpose  ;  but  it 
contracts  the  pupil  and  renders  the  accommodation  tense,  the  very  opposite 
to  the  atropine  eifect.  I  have  not  as  much  confidence  in  this  remedy.  A  2 
per  cent,  solution  of  cocaine,  instilled,  will  sometimes  relieve  the  spasm  and 
pain  temporarily.  Powdered  calomel  may  be  dusted  into  the  eye  every 
second  day.  A  small  quantity  only  should  be  u.sed,  since  it  is  apt  to  col- 
lect in  masses  which  act  as  foreign  bodies  (we  desire  to  produce  irritation  for 
a  few  minutes  only).  A  drachm  of  table-salt  to  a  pint  of  water  may  be  used 
to  bathe  the  eyes  freely  four  or  five  times  a  day,  used  warm  or  cold  accord- 
ing to  the  patient's  pleasure,  although  warm  applications  are  more  likely  to 
be  well  received.  Red  precipitate  ointment  (R.  Vaseline,  .^^j  ;  hyd.  ox.  rub. 
in  very  fine  powder,  gr.  j  to  ij.  M.)  placed  under  the  eyelids  every  day  or 
two,  is  often  very  beneficial ;  also  the  yellow  precipitate  ointment,  made  in 
the  same  manner,  has  a  similar  effect.  Occasionally  the  ulcers  show  a  disin- 
clination to  heal,  when  they  may  be  touched  with  Arg.  nit.,  gr.  x  to  xxx  ; 
aquae  dist.,  5J.  M.  Wind  a  bit  of  absorbent  cotton  on  a  probe,  dip  this  into 
the  solution,  and  touch  the  ulcer,  but  no  other  point.  Cupri  sulph.,  in  solu- 
tion of  the  same  strength,  may  be  used  for  the  same  purpose.  A  platinum 
probe,  heated  to  a  red  heat  in  a  spirit  lamp,  is  much  used  at  present.  A  few 
drops  of  a  2  per  cent,  solution  of  cocaine,  previously  instilled,  will  prevent 
pain  from  these  applications.  A  protective  bandage  exerting  moderate  pres- 
sure on  the  eye  sometimes  does  good,  but  it  should  not  feel  uncomfortable. 
If  there  be  much  spasm  of  the  orbicularis,  however,  it  is  not  indicated.  If 
the  pain  in  the  eye  continue  and  the  orbicularis  be  in  a  state  of  spasm,  can- 
tholysis  may  be  performed  ;  that  is,  divide  the  external  canthus  so  as  to  cause 
the  lid  no  longer  to  press  hard  upon  the  eyeball,  and  close  the  wound  thus 
made  by  stitching  the  skin  to  the  conjunctiva  above  and  below  the  incision, 
and  placing  one  stitch  in  the  extreme  outer  canthus.  The  result  of  the 
operation  is  temporarily  to  break  the  power  of  the  orbicularis,  so  as  to 
arrest  the  spasm.  This  measure  accomplishes  in  some  cases  what  nothing 
else  will. 

If  the  eye  be  painful,  without  spasm  of  the  lid,  and  there  be  great  pho- 
tophobia, whether  the  eyeball  be  too  hard  or  not,  paracentesis  may  be  done. 
The  mode  of  performance  is  described  in  the  treatment  of  ophthalmia  neonati 
in  another  place  in  this  book.  After  a  while  the  accompanying  conjunctivitis 
may  need  treatment  in  the  ordinary  way.  Indeed,  astringents  may  often  be 
used  quite  early  to  obviate  the  irritating  effects  which  occasionally  result 
from  the  use  of  atropine.  If  an  ulcer  refuse  to  heal  after  the  treatment 
already  laid  down,  iridectomy  may  be  performed,  although  this  is  not  often 
resorted  to.  Occasionally  an  ulcer  may  be  cut  across  by  passing  a  narrow 
Graefe's  knife  through  it,  making  a  puncture  on  one  side  and  a  counter-punc- 
ture on  the  opposite  side,  and  then  cutting  out  quite  through  the  ulcer,  divid- 
ing it  into  two  equal  parts.  All  needful  treatment  for  the  constitutional 
condition  of  the  patient  should  be  attended  to.  So  necessary  are  fresh  air 
and  sunlight  that  I  would  never  shut  the  patient  in  a  dark  room.  Rlue  or 
smoke-colored  glasses  may  be  worn  to  protect  the  eyes  from  a  strong  light, 
and  in  some  cases  the  eyes  may  be  protected  by  a  bandage  of  some  dark 
material,  so  that  the  patient  may  be  taken  for  an  airing  without  suffering.  I 
would,  however,  advise  to  accustom  the  eyes  to  the  light  as  much  as  possible 
without  causing  pain. 


220  SCROFULA. 

In  Parench3raiatous  or  Diffuse  Keratitis  we  have  quite  a  diiFerent 
array  of  symptoms.  The  margin  of  the  cornea  near  the  limbus  may  show  a 
decided  zone  of  injection  of  the  conjunctival  and  episcleral  vessels.  It  may 
be  so  excessive  as  to  consist  apparently  of  a  rosy  ring  surrounding  the  cornea. 
These  vessels  after  a  time  shoot  inward,  and  may  involve  a  large  part  or  even 
the  whole  of  the  cornea.  In  other  cases,  designated  non-vascular  diffuse 
keratitis,  the  injection  is  very  slight  indeed,  and  sometimes  apparently  want- 
ing altogether.  In  either  case,  however,  the  same  consequences  result :  the 
cornea  becomes  diffusely  clouded,  the  process  generally,  but  not  always,  com- 
mencing at  the  limbus.  This  cloudiness  may  be  quite  without  lines  or  dots 
of  opacity,  like  ground  glass.  Again  it  may  appear  composed  of  innumer- 
able minute  opaque  points  or  lines  running  in  various  directions.  At  firsts 
the  corneal  epithelium  escapes,  presenting  a  regular  and  uniform  polish,  but 
afterward  it  becomes  opaque.  Again,  if  the  process  involve  the  whole  of  the 
cornea,  minute  opaque  spots  may  be  seen  in  Descemet's  membrane,  giving  it 
some  of  the  characteristics  of  keratitis  punctata.  In  the  earlier  stages  there 
may  be  some  pain  and  intolerance  of  light,  but  as  a  rule  the  disease,  for  a 
corneal  affection,  is  comparatively  painless.  The  duration  of  this  disease  is 
never  short ;  it  may  continue  for  many  months,  and  it  shows  a  strong  tend- 
ency to  relapse.  The  most  frequent  causes  are  hereditary  syphilis  and 
struma.  Mr.  Hutchinson  of  London  always  examines  the  teeth  of  these 
patients  to  see  if  there  be  anything  characteristic  of  hereditary  syphilis. 
As  similar  teeth  are  often  noticed  in  strongly-marked  strumous  subjects,  it 
becomes  doubly  interesting  to  make  the  observation.  One  point  is  apparent 
in  most  of  these  cases :  that  there  are  in  almost  every  patient  some  signs  of 
badly-developed  physique — that  is,  faulty  tissue-elaboration.  As  a  rule,  both 
eyes  sooner  or  later  become  affected,  pointing  to  a  constitutional  origin  of  the 
affection. 

In  TREATMENT  we  are  often  disappointed  in  our  efforts.  At  the  first,  if 
there  be  pain  or  photophobia,  atropine  may  be  instilled  and  the  eyes  bathed 
with  warm  or  tepid  water  several  times  a  day.  Tonics  or  alteratives  are 
always  indicated.     One  of  the  most  useful  prescriptions  is  the  following : 

R.  Hydrarg.  chlor.  corros.,        gr.  j.,  ad  jss; 
Tine,  cinchon.  comp., 

Syr.  aurantii,  dd.  ^iv.     Misce. 

Dose :  One  teaspoonful  three  times  daily  after  eating. 

Iodide  of  potassium  is  frequently  given,  and  may  very  properly  alternate 
with  the  mercurial ;  children  will  bear  very  large  doses  of  the  iodide,  and 
indeed  they  are  often  necessary  in  order  to  obtain  the  curative  effects  of  the 
drug  ;  I  would  suggest  from  three  to  twenty  grains  three  times  daily,  well 
diluted  with  water.  Both  these  remedies  may  be  continued  for  months,  but 
ptyalism  should  always  be  avoided.  Cod-liver  oil  with  extract  of  malt  may 
be  administered.  Whatever  tends  to  improve  the  patient's  general  condition 
is  indicated.  Exercise  in  the  fresh  air  is  good,  but  the  pernicious  effects  of 
cold  must  be  avoided.  Paracentesis  of  the  cornea  rarely  does  good,  but  occa- 
sionally iridectomy  may  be  of  benefit.  The  complication  of  iritis  or  irido- 
choroiditis  is  not  common,  though  it  does  occur.  When  the  disease  becomes 
very  chronic  there  will  be  hardly  vascularity  enough  for  the  purposes  of 
repair.  This  being  the  case,  stimulating  collyria  may  be  used,  similar  to 
those  indicated  in  conjunctivitis.  Olive  oil  and  spirits  of  turpentine,  in  equal 
parts,  may  be  applied  to  the  eye  every  second  day.  Bathing  with  warm 
water  sufiiciently  to  congest  the  eye  will  sometimes  be  serviceable.  An  attack 
of  acute  conjunctivitis  has  been   known  to  do  good.     But,  do  what  we  may, 


ETIOLOGY.  221 

this  affection  sometimes  runs  on  unchecked  for  a  very  long  time.  It  rarely 
destroys  the  sight,  but  I  recently  treated  a  case  from  the  beginning,  and  in 
spite  of  treatment  there  was  only  perception  of  light  remaining.  I  have 
heard  of  only  one  other  similar  case.  From  some  recent  experiences  I  am 
inclined  to  believe  that  bichloride  of  mercury  internally  and  atropine  as  a 
collyrium  are  of  as  much  value  as  any  other  agents  in  the  treatment  of 
this  obstinate  malady. 


CHAPTER    III. 

TUBERCULOSIS. 

The  term  "  tuberculosis  "  is  applied  to  a  disease  which  is  characterized 
by  the  formation  of  small  tubercles  or  nodules  in  one  or  more  organs. 
Though  more  prevalent  in  some  countries  or  localities  than  in  others,  it 
occurs  in  all  or  nearly  all  parts  of  the  globe  from  which  we  have  exact 
information,  and  it  has  been  more  destructive  to  human  life  than  any  other 
one  disease. 

Etiology. — One  of  the  most  important  discoveries  of  recent  years 
relating  to  the  etiology  of  diseases  is  that  of  the  specific  principle  of  tuber- 
culosis. It  has  long  been  suspected  by  observing  physicians  that  a  specific 
•cause  did  exist,  and  that  this  disease  is  to  a  certain  extent  infectious,  but  it 
is  only  recently  that  patient  microscopic  investigations  have  triumphed  over 
the  difficulties  which  surround  this  subject,  and  have  detected  the  micro- 
organism which  has  been  so  fatal  to  the  human  race.  The  honor  of  its  dis- 
covery belongs  mainly  to  Dr.  Koch  of  Berlin.  In  his  investigations  Koch 
invariably  found  a  certain  bacillus  in  all  recent  tubercles,  proving  beyond  a 
•doubt  that  they  always  accompany  the  development  of  the  tubercular  nodule. 
By  inoculating  guinea-pigs,  rabbits,  and  cats  with  tubercular  material  he 
communicated  tuberculosis,  reproducing  the  tubercular  nodule,  in  which  he 
always  found  the  same  bacillus.  But  it  still  remained  to  determine  the  rela- 
tion of  the  bacillus  to  the  tubercle,  whether  it  was  merely  an  accidental 
accompaniment,  or  whether  it  sustained  a  causal  relation,  producing  the 
nodule  by  its  irritating  action  on  the  cellular  elements  of  the  part  where  it 
happened  to  lodge.  After  many  trials  Koch  succeeded  in  preparing  a  pabu- 
lum in  which  the  bacilli  grew  and  reproduced  their  kind.  By  adding  a  little 
of  the  first  cultivation  to  the  pabulum,  he  produced  a  second  cultivation,  and 
after  a  series  of  cultivations  he  produced  a  bacillus  which  was  evidently 
freed  from  all  other  substances.  With  the  bacillus  of  the  last  cultivation  he 
was  able  to  produce  the  tubercular  nodule,  having  all  the  characteristics 
•which  are  observed  when  it  is  developed  in  the  usual  way  in  man.  Different 
micro-organisms  take  coloration  differently,  and  Koch  was  enabled  to  dis- 
criminate the  tubercular  bacillus  under  all  circumstances  from  other  microbes 
by  the  peculiar  color  imparted  to  it. 

The  tubercle  bacilli  have  the  form  of  "  delicate  rods  from  a  quarter  to 
half  the  diameter  of  a  blood-corpuscle  in  length."  The  more  severe  the 
tuberculosis,  the  greater  the  number  of  bacilli.  They  occur  not  only  in  the 
recent  tubercle,  but  also  in  immense  numbers  in  the  periphery  of  the  caseous 
masses  of  a  tubercular  patient.  They  are  found  not  only  elsewhere,  but  also 
in  the  interior  of  the  giant-cells,  as  many  as  twenty  even  in  some  cells.  They 
•do  not  seem  to  have  the  power  of  movement,  and  oval  spores  are  found  in 


222  TUBERCULOSIS. 

some  of  them.     They  grow  in  a  temperature  of  86°  to  104°  F.,  and  not  in  a 
temperature  outside  these  limits. 

As  might  be  expected,  these  microscopical  researches  of  Koch  have 
attracted  wide  attention,  and  have  led  to  a  repetition  of  his  experiments  by 
many  pathologists,  and  to  new  experiments  relating  to  the  etiology  of  tuber- 
culosis. The  result  has  been  to  establish  more  firmly  the  views  of  Koch,  and 
the  doctrine  that  tuberculosis  is  a  specific  disease,  and  that  the  bacillus  is  the 
specific  principle,  appears  to  be  fully  established. 

Among  the  most  thorough  and  convincing  researches  bearing  on  the 
causal  relation  of  micro-organisms  to  tuberculosis,  growing  out  of  Koch's 
discovery,  were  those  contained  in  a  report  to  the  London  Association  for  the 
Advancement  of  Medicine  by  Research  (Practitioner  ;  London  Lancet,  March 
17,  1883).  Experiments  were  made  with  the  cultivated  bacilli  obtained  from 
Koch.  "  Twelve  animals  were  inoculated  with  these  organisms,  chiefly  into 
the  anterior  chamber  of  the  eye,  and  all  of  them  became  tuberculous,  and 
that  more  rapidly  than  after  inoculation  of  tuberculous  material.  The  tuber- 
cles produced  in  these  cases  were  infective  and  caused  tuberculosis  in  other 
animals.     On  examination  of  tuberculous  material  Koch's  tubei'cle  bacilli  are 

always  found,  though  in  varying  numbers About  eighty  organs  of 

tuberculous  animals  and  thirty-six  cases  of  human  tuberculosis  were  examined, 
and  in  all  of  these,  without  exception,  tubercle  bacilli  were  found." 

The  discovery  of  Koch  has  already  proved  of  great  importance  as  an  aid 
in  diagnosis,  for  the  sputum  of  tubercular  patients  contains  the  bacillus. 
Tubercular  sputum  affords  a  soil  in  which  the  bacillus  thrives  and  multiplies, 
as  it  does  in  the  tissues  of  a  tubercular  patient,  and  by  careful  microscopie 
examination  we  are  able  to  discover  it  in  this  sputum,  while  it  is  absent 
from  non-tubercular  sputum.  According  to  Frisch  (^Wiener  med.  Woch.,. 
No.  46,  1883),  the  bacilli  were  found  without  an  exception  in  the  sputum 
of  140  patients  with  confirmed  tuberculosis,  while  the  sputum  of  150^ 
non-tubercular  patients  was  in  every  instance  free  from  them.  Heitler 
{Wiener  med.  Woch.,  No.  43,  1883)  examined  the  sputum  of  140  tuber- 
cular patients,  1  of  whom  had  miliary  tubercles,  and  1  other  caseous 
pneumonia.  All  the  other  cases  were  chronic  and  were  grouped  by  the  author 
as  follows :  1st,  6  cases  of  old  infiltration  of  the  apices  of  the  lungs,  cured 
with  the  persistence  of  dulness  on  percussion,  without  rales;  no  bacilli 
observed.  2d,  12  cases  of  tuberculosis  with  slight  dulness  and  dry  rales. 
In  2  of  these,  notwithstanding  marked  physical  signs,  fever  was  absent  and. 
the  tubercular  process  was  arrested  apparently  ;  no  bacilli.  In  the  sputum 
of  the  remaining  10  cases  bacilli  were  present  in  all  the  examinations  except 
2.  The  third  group  contained  cases  of  advanced  and  progressive  tuberculosis,, 
and  the  fourth  group  cases  of  advanced  chronic  phthisis,  but  with  remissions. 
In  the  sputum  of  these  two  groups  bacilli  were  always  observed.  That  Heit- 
ler in  6  instances  witnessed  the  disappearance  of  bacilli  when  the  tubercular 
process  was  arrested  is  an  interesting  fact,  as  showing  the  relation  of  the 
bacilli  to  tuberculosis.  He  examined  the  sputum  of  29  non-tubercular 
patients,  patients  with  pneumonia,  bronchitis,  bronchial  dilatation,  and  putrid 
bronchitis  with  gangrene,  and  in  no  instance  found  the  bacilli  of  tuberculosis. 

As  usually  happens  when  a  great  discovery  is  announced,  there  are  dis- 
sentients; there  are  those  apparently  competent  to  express  an  opinion,  as 
Spina  and  Formad,  who  do  not  accept,  or  only  partly  accept,  the  views  of 
Koch.  But  the  testimony  of  many  observers,  constantly  accumulating,  tends 
to  establish  more  securely  the  doctrine  of  the  parasitic  origin  of  tuberculosis, 
and  it  is  now  apparently  as  securely  established  as  most  doctrines  in  pathology. 

Koch's  discovery  necessitated  revision  of  the  teachings  long  accepted 
relating  to  tuberculosis.     The  tubercle  nodule  is,  as  we  will  see,  an  aggre- 


ETIOLOGY.  223 

gation  of  cells  produced  from  the  cellular  elements  of  the  part  where  the 
nodule  appears  through  a  proliferating  process  caused  by  an  irritant,  and  in 
the  light  of  our  present  knowledge  we  consider  the  bacillus  to  be  the  irritant. 
A  local  corpusculation  and, a  cellular  nodule  may  be  produced  in  the  lungs  or 
elsewhere  by  the  lodgment  of  a  non-spccitic  irritant,  whether  organic  or  inor- 
ganic, as  putrid  cheese,  particles  of  dust,  or  metallic  particles,  and  thus  far  no 
cells  have  been  discovered  in  nodules  thus  produced  which  are  characteristic 
of  tuberculosis.  The  giant-cells  which  at  one  time  were  thought  to  be  pecu- 
liar to  the  tubercular  nodule  have  been  found  in  growths  of  another  nature, 
as  in  gummata.  The  characteristic  and  peculiar  element  in  the  tubercular 
nodule  is  the  bacillus. 

It  has  long  been  the  belief  from  clinical  observations  in  Southern  Europe, 
and  of  certain  observing  physicians  in  the  temperate  regions  of  Europe  and 
America,  that  phthisis  is  contagious,  and  the  acceptance  of  the  parasitic 
theory  will  probably  soon  render  this  belief  an  established  principle  in  pathol- 
ogy. Already  many  instances  have  been  published  in  the  journals  which 
appear  to  show  the  infectiousness  of  tubex'culosis,  as  the  following :  In  an 
inland  town  in  Europe  a  midwife  with  advanced  phthisis  had  been  in  the 
habit  of  blowing  into  the  mouths  of  new-born  infants,  and  so  many  of  them 
perished  of  tubercular  disease  as  to  excite  attention  and  cause  alarm,  while 
those  attended  by  a  healthy  midwife  remained  well.  Dr.  E.  I.  Kempf  relates 
the  following  striking  example  in  the  Louisville  Medical  News  for  Mai'ch  22, 
1884: :  In  the  fall  of  1880  a  girl  of  eighteen  years,  whose  brother  had  died  of 
consumption,  was  found  to  have  tubercles  at  the  apices  of  both  lungs.  She 
belonged  to  a  sisterhood,  and  slept  in  the  general  dormitory  with  the  other 
sisters.  In  four  months  nine  of  her  companions  began  to  cough  and  were 
found  to  have  tubercles.  No  one  of  the  sisterhood  had  pi'eviously  had  dis- 
ease of  this  kind.  Dr.  A.  Ollivier,  physician  to  I'Hopital  des  Enfants-malades, 
Paris,  states  that  a  family  having  uniform  robust  health  occupied  two  small 
rooms  opening  into  a  narrow  court.  The  parents,  a  young  son,  and  the  baby 
slept  in  one  of  the  rooms.  An  older  son.  who  had  been  living  elsewhere, 
contracted  phthisis,  returned  home,  and  slept  in  the  same  apartment.  He 
died  January  16,  1883.  His  mother,  who  was  constantly  at  his  bedside, 
began  to  cough,  emaciated,  and  died  of  the  same  disease  in  the  following 
May.  Seven  days  after  the  death  of  the  mother  the  infant  had  tubercular 
meningitis,  of  which  it  perished ;  and  the  older  child,  who  occupied  the  same 
apartment,  sickened  and  died  like  the^ mother.  The  father  only  survived  of 
those  who  occupied  the  small  room  (^Etudes  d' Hygiene  puhlique^  1886).  The 
fact  that  wives  devoted  in  their  attendance  on  consumptive  husbands  fre- 
quently perished  of  the  same  disease  physicians  in  various  countries  have 
long  remarked,  but  it  has  usually  been  attributed  to  the  depressed  state  of 
system  incident  to  long  watching  and  grief,  and  not  to  any  contagious  prop- 
erty. But  now  that  a  clearer  insight  has  been  obtained  into  the  nature  of 
tuberculosis,  and  both  microscopical  researches  and  clinical  facts  indicate  its 
communicability,  more  caution  will  be  exercised  in  the  intercourse  with 
patients. 

The  recent  experiments  of  Cornet  (  Wiener  vied.  Wcichen..,  June  2,  1888) 
appear  to  show  that  the  walls  and  furniture  of  a  room  occupied  by  a  phthis- 
ical patient  may  be  infected  by  the  lodgment  of  the  tubercle  bacillus  upon 
them,  so  that  any  one  occupying  this  apartment  subsequently  is  in  danger  of 
contracting  the  disease.  He  rubbed  the  walls  and  bedsteads  in  the  ward  occu- 
pied by  phthisical  patients  with  disinfected  sponges,  avoiding  such  surfaces  as 
might  be  infected  by  the  hands  and  sputum  of  patients ;  94  animals  were 
inoculated  with  these  sponges,  and  52  of  them  died,  apparently  of  causes 
different  from  tuberculosis  ;  the  remaining  44  were  killed  after  forty  days,  and 


224  TUBERCULOSIS. 

20  of  them  had  tubercles.  168  animals  were  inoculated  with  the  dust  from 
the  walls  of  rooms  occupied  by  phthisical  patients  in  family  practice.  Of 
these  animals  90  died  soon  afterward.  Of  the  remaining  78,  34  contracted 
tuberculosis.  In  control-experiments,  the  dust  being  used  from  surgical 
wards,  operating-rooms,  and  from  crowded  thoroughfares,  the  result  was  neg- 
ative as  regards  the  production  of  tuberculosis.  "  It  has  been  abundantly 
demonstrated  by  numerous  experiments  that  the  milk  from  tuberculous  cows  is 
capable,  when  ingested,  of  causing  tuberculosis.  How  serious  is  this  danger 
may  be  seen  from  the  statistics  of  Bollinger,  who  found  the  milk  from  cows 
affected  with  extensive  tuberculosis  infectious  in  80  per  cent,  of  the  cases, 
and  that  from  cows  with  moderate  tuberculosis  infectious  in  33  per  cent,  of 

the  cases Bollinger  estimates  that  at  least  5  per  cent,  of  the  cows  in 

dairies  are  tuberculous.  From  statistics  furnished  me  by  Mr.  A.  W.  Clement, 
V.  S.,  the  number  of  tuberculous  cows  in  Baltimore  which  are  slaughtered  is 
not  less  than  3  to  4  per  cent."  ^ 

The  causal  relation  of  scrofula  to  tuberculosis  we  have  considered  elsewhere, 
but  we  may  here  repeat  that  scrofulous  ailments,  especially  the  caseous  prod- 
ucts, afford  the  soil  which  is  favorable  to  the  growth  and  multiplication  of 
the  bacilli.  Hence  these  microbes  are  not  infrequently  found  in  scrofulous 
products,  showing  that  the  tubercular  has  supervened  on  the  scrofulous  dis- 
ease. Kanzler  treats  of  the  relation  of  scrofula  to  tuberculosis  in  the  Berlin, 
klin.  Woch.,  January  14,  1884.  He  believes  that  the  two  diseases  are  distinct, 
but  that,  as  expressed  by  the  French  reviewer,  la  scrofide  offre  vn  terrain  de 
predilection  pour  le  developpement  de  la  tuherculose.  He  has  discovered  bacilli 
only  in  a  minority  of  the  local  manifestations  of  scrofula,  never  in  glands 
which  had  not  undergone  suppuration  or  caseation,  never  in  eczema,  impetigo, 
suppurative  otitis  media,  and  never  in  the  nasal,  conjunctival,  pharyngeal, 
and  vaginal  catarrhs  of  the  scrofulous.  It  is  not  till  degenerative  changes 
have  occurred  in  the  inflammatory  products  of  scrofula  that  the  bacilli  of 
tuberculosis  appear,  indicating  the  supervention  of  the  latter  disease. 

Anatomical  Characters  of  the  Tubercle. — As  Virchow  pointed  out, 
the  tubercular  nodule  when  recent  is  semi-translucent  and  small,  attaining 
about  the  size  of  a  millet-seed  and  consisting  mainly  of  cells.  The  cells  of 
which  it  is  chiefly  composed  resemble  the  white  corpuscles  of  the  blood  in 
appearanpe  and  size,  but  some  are  smaller  and  others  larger  than  those  cor- 
puscles. They  have  been  designated  the  lymphoid  cells.  Each  cell  when 
fully  developed  has  a  bright  homogeneous  nucleus,  small  and  spherical  or 
large  and  oval,  and  nucleoli.  A  large  cell  sometimes  contains  two  or  more 
nuclei.  The  lymphoid  cells  appear  to  be  developed  from  the  cellular  element 
of  the  connective  tissue.  This  is  Virchow 's  belief.  In  addition  to  these  cells, 
which  constitute  the  greater  part  of  the  tubercle,  large  uninuclear  cells  are 
also  observed,  designated  epithelioid  cells.  They  resemble  large  and  swollen 
endothelial  or  epithelial  cells,  and  they  are  believed  by  pathologists  to  be  pro- 
duced from  these  cells,  which  lie  within  the  area  of  the  nodule.  A  third  cell 
also  occurs,  known  as  the  giant-cell  from  its  size.  It  has  many  nuclei,  and 
occupies  chiefly  the  central  part  of  the  nodule.  All  these  cells,  as  has  been 
recently  shown,  occur  in  other  pathological  products  besides  the  tubercular 
nodule,  and  no  one  of  them  is  therefore  characteristic  of  it.  But  the  element 
which  is  of  greatest  importance,  since  it  sustains  a  causal  relation  to  the 
disease,  was,  as  we  have  seen,  the  last  discovered.  The  bacillus  is  always 
found  in  the  recent  tubercle  lying  without  the  cells,  as  we  have  stated,  but 
also  in  the  interior  of  the  giant-cells,  for  which  it  appears  to  have  an  affinity.  A 
fibrous  network  with  more  or  fewer  blood-vessels  surrounds  the  cells  and  holds 
them  together.     The  blood-vessels  belong  to  the  normal  tissues,  and  are  not 

^  Prof.  W.  H.  Welch's  Address  before  the  Amer.  Med.  Asso.,  1889. 


ETIOLOGY.  225 

a  new  growth,  the  tubercle  having  developed  around  them.     The  tubercles 
are  single  or  in  clusters,  forming  masses  of  considerable  size. 

When  the  tubercle  has  attained  a  certain  age,  caseation  always  occurs 
in  its  centre  and  extends  .outward,  causing  an  opaque  and  yellowish-white 
dead  mass,  in  which  fragramentary  cells  can  be  observed  under  the  micro- 
scope. Caseation  is  now  known  to  be  a  form  of  decay  which  is  common  to 
pathological  products  of  different  kinds,  and  is  not  peculiar  to  tuberculosis, 
as  was  supposed  before  the  time  of  Yirchow.  It  occurs  in  consequence  of 
abundant  exudation  or  cell-formation  and  the  compression  and  obliteration 
of  vessels.  It  is  therefore  more  common  in  scrofula  than  in  any  other  dis- 
ease, since  scrofulous  inflammations  afford  the  conditions  in  which  it  is  espe- 
cially liable  to  occur.  The  yellow  tubercle  is  therefore  only  an  advanced  stage 
of  the  semi-transparent  or  miliary  tubercle.  In  the  cheesy  metamorphosis 
granules  of  fat  are  deposited  within  and  around  the  cells,  and  the  cells  shrivel 
and  disintegrate.  The  shrunken  granular  and  fragmentary  cells  were  believed 
to  be  the  true  tubercular  cells  until  Virchow  pointed  out  their  character. 
When  the  tubercle  or  tubercular  mass  becomes  yellow  or  caseous,  and  circu- 
lation ceases  in  it,  it  is  surrounded  by  a  vascular  zone  in  which  circulation 
still  continues.  It  is  very  seldom,  perhaps  never,  absorbed,  although  parti- 
cles of  it  may  enter  the  lymphatics  or  blood-vessels  and  be  carried  elsewhere 
with  the  bacilli.  It  is  an  irritant,  producing  inflammation  in  the  surrounding 
tissues,  with  thickening,  induration,  and  abundant  production  of  pus-cells, 
which  mingle  with  the  elements  of  the  tubercle.  Its  history  henceforth  is 
that  of  an  abscess,  and  ulceration  and  discharge  of  the  liquefied  substance 
upon  one  of  the  free  surfaces  is  the  common  result.  In  rare  instances  the 
tubercle,  instead  of  cheesy  degeneration,  undergoes  fibroid  degeneration  or 
cretefaction. 

Various  pathological  conditions  furnish  the  soil  in  which  the  bacillus 
obtains  lodgment  and  grows,  and  in  this  way  becomes  a  cause  of  tubercu- 
losis. Cheesy  pneumonia  and  exhausting  suppurative  surfaces  often  afford 
a  nidus  favorable  for  the  development  of  the  tubercle  bacillus.  During  epi- 
demics of  measles  many  cases  occur  of  cheesy  pneumonia  ending  in  tuber- 
culosis. Cheesy  and  disintegrating  lymphatic  glands,  as  the  bronchial,  often 
become  tubercular. 

Anatomical  Characters  in  Infancy  and  Childhood, — The  anatom- 
ical characters  of  tuberculosis  in  the  first  years  of  life  vary  in  certain  par- 
ticulars from  the  form  which  they  present  in  the  adult,  but  after  the  age  of 
three  years  the  diff"erences  are  fewer  and  less  pronounced  than  previously. 

Tubercular  laryngitis,  so  common  in  the  adult,  is  absent  in  a  large  pro- 
portion of  cases  under  the  age  of  three  years,  and  when  present  it  has  little 
intensity.  Ulceration  of  the  larynx  very  seldom  occurs.  This  has  been 
attributed  to  the  fact  that  there  is  so  little  expectoration  in  young  children, 
the  sputum  being  an  irritant.  Niemeyer,  however,  does  not  consider  the 
sputum  of  tuberculosis  sufficiently  irritating  to  cause  laryngitis  and  laryn- 
geal ulceration  ;  but  the  arguments  in  favor  of  this  mode  of  causation,  in . 
my  opinion,  more  than  counterbalance  those  which  have  been  presented 
against  it. 

I  have  never  met  a  case  of  tubercular  ulceration  of  the  larynx  or  trachea 
in  the  post-mortem  examination  of  young  childi'en,  nor  do  I  recollect  ever 
treating  a  case  in  which  there  was  that  degree  of  dysphonia  which  indicated 
ulceration.  Rilliet  and  Barthez,  in  more  than  300  necropsies  of  tubercular 
cases,  found  no  ulcers  in  the  larynx  or  trachea  under  the  age  of  three  years, 
but  met  8  cases  between  the  ages  of  three  and  ten  years,  and  8  between  ten 
and  fourteen  years.  The  ulcers,  whether  seated  in  the  larynx  or  in  the 
trachea — and  they  are  in  most  cases  in  the  former,  since  the  inequalities 
15 


226  TUBERCULOSIS. 

upon  the  surface  of  the  larynx  favor  the  retention  of  the  sputum — are  com- 
monly small,  superficial,  round  or  elongated,  and  with  little  thickening  or 
infiltration  of  their  borders.  Occurring  in  the  folds  of  the  mucous  mem- 
brane— as,  for  example,  around  the  vocal  cords — their  form  is  usually  elon- 
gated. 

Bronchitis  is  not  infrequent.  This  inflammation  is  due  to,  and  depend- 
ent on,  the  pulmonary  tubercles,  and  is  therefore  most  intense  in  the  part  of 
the  lung  where  the  tubercles  are  most  abundant  and  farthest  advanced. 
Consequently,  it  is  more  intense  on  one  side  than  on  the  other,  and  it  may 
be  unilateral.  It  differs  in  this  respect  from  idiopathic  bronchitis,  which  is 
commonly  nearly  uniform  on  the  two  sides.  It  differs  also  in  the  fact  that 
it  is  sometimes  accompanied  by  ulcerations.  The  ulcers  are  round  or  elon- 
gated in  the  direction  of  the  axes  of  the  tubes,  and,  like  those  of  the  larynx 
or  trachea,  are  superficial.  Circumscribed  inflammation  may  attack  a  bron- 
chial tube,  as,  indeed,  the  trachea,  and  give  rise  to  ulceration  and  perforation 
from  the  pressure  of  a  diseased  lymphatic  gland  external  to  the  tube.  This 
subject  will  be  treated  of  hereafter. 

Lungs. — It  is  well  known  that  in  the  adult  tubercles  are  always  present 
in  the  lungs  if  they  occur  in  any  part  of  the  system.  I  have  met  2  cases 
in  which  the  lungs  were  free  from  tubercles  in  36  post-mortem  examinations 
of  children  who  died  of  tuberculosis.  One  of  the  two  was  an  infant,  but  its 
exact  age  is  not  stated  in  the  records.  It  had  cheesy  degeneration  of  the 
thymus  and  bronchial  glands,  enlargement  of  the  mesenteric  glands,  but 
without  cheesy  degeneration,  and  disseminated  tubercles  in  liver  and  spleen. 
The  other,  fifteen  months  old  at  death,  had  tubercular  meningitis,  with  nume- 
rous granulations  upon  the  convexity  of  the  brain,  and  the  other  usual 
lesions  of  meningeal  inflammation,  with  bronchial  and  mesenteric  glands 
slightly  enlarged  and  cheesy,  and  one  of  the  former  softened.  In  1  case, 
then,  in  18  the  lungs  had  escaped  the  disease.  Rilliet  and  Barthez  in  their 
statistics  of  the  state  of  the  lungs  in  infancy  and  childhood  found  these  organs 
non-tubercular  in  47  cases  in  312,  and  Hillier  in  25  cases  in  160.  Therefore, 
the  lungs  were  exempt  from  tubercles  in  about  1  case  in  7.  But  it  is  to  be 
recollected  that  the  observations  of  these  physicians  were  made  at  a  time 
when  all  cheesy  degenerations  were  thought  to  be  tubercular,  so  that  their 
published  statistics  may  not  have  been  strictly  accurate. 

Pulmonary  tubercles  in  children  under  the  age  of  three  years  are,  as  a 
rule,  discrete  and  disseminated  through  the  lungs.  In  cases  at  this  age 
which  have  advanced  to  a  fatal  termination  we  find  yellow  tubercles  from 
the  size  of  a  pin's  head  to  that  of  a  shot  in  the  different  lobes ;  many  still  semi- 
transparent  if  the  disease  have  been  of  short  duration,  but  if  protracted 
most  of  them  yellow,  and  here  and  there  one  softened  and  surrounded  by 
condensed  fibrous  tissue.  Around  the  semi-transparent  or  gray  tubercles, 
many  of  which  were  growing,  and  therefore  were  in  the  state  of  active  cell- 
proliferation  at  the  time  of  death,  vascular  zones  can  often  be  detected  by 
the  naked  eye. 

Under  the  age  of  three  years  tuberculosis  exhibits  but  little  tendency, 
perhaps  none,  to  affect  the  upper  lobes  sooner  or  in  greater  degree  than 
the  lower. 

The  following  are  the  statistics  relating  to  the  site  of  the  tubercles  in  the 
lungs  in  the  cases  which  I  have  examined ;  all,  it  is  to  be  remembered,  were 
under  the  age  of  three  years : 

Cases. 

Tubercles  disseminated  throughout  the   lungs 26 

Tubercles  disseminated  throughout  the  two  upper  lobes 3 

Tubercles  disseminated  through  right  middle  lobe  and  left  lower 
lobe  only 1 


ETIOLOGY.  Til 

Cases. 

Tubercles  disseminated  through  left  upper  lobe  only 2 

Tubercles    disseminated    (lew    and    semi-transparent)    in     left    lung 

only 1 

Tubercles  disseminated  In   three   points   in   right   and   two   in   left 

lung       1 

No  tubercles   in  lungs 2 

36 

Between  the  ages  of"  three  and  fifteen  years  statistics  show  that  the 
upper  lobes  are  more  liable  to  tubercles  than  the  lower ;  but  the  difference  in 
liability  is  not  great.  In  many  cases  occurring  in  this  period  the  different 
lobes  are  affected  nearly  simultaneously,  and  not  very  infrequently  the  upper 
lobe  is  the  last  which  is  involved.  In  October,  1866,  I  made  the  post-mor- 
tem examination  of  a  boy  who  died  in  the  Children's  Service  of  Charity 
Hospital  at  the  age  of  fifteen  years,  and  small  scattered  tubercles  were 
found  in  the  lower  lobe  of  the  left  lung,  while  all  other  portions  of  these 
organs  were  healthy.  Rilliet  and  Barthez,  who  include  in  the  same  statistics 
all  cases  from  birth  to  the  age  of  fifteen  years,  found  gray  semi-transparent 
tubercles — 

Cases. 

In  the  right  superior  lobe  in 63 

In  the  right  middle  lobe  in 43 

In  the  right  lower  lobe  in 55 

In  the  left  superior  lobe  in 65 

In  the  left  inferior  lobe  in 54 

The  same  observers  found  yellow  tubercles  in  the 

Eight  superior  lobe  in ,    .  40 

Eight   middle  lobe  in 28 

Eight  inferior  lobe  in  .    .    - 39 

Left  superior  lobe  in 35 

Left  inferior  lobe  in 31 

Tubercle,  especially  when  softening  commences,  is  itself  an  irritant, 
exciting  inflammation  around  it.  Inflammation  occurring  from  this  cause 
is  obviously  likely  to  be  protracted,  continuing  for  weeks  or  months  unless 
the  tubercular  matter  be  eliminated  by  ulceration.  The  highly  vascular  and 
delicate  lungs  of  the  young  child  are  very  liable  to  inflammation  when  they 
are  the  seat  of  tubercles,  and  as  the  tubercles  are  disseminated,  the  pneumo- 
nia is  commonly  more  extensive  than  when  it  occurs  from  ordinary  cases. 
In  fifteen,  or  nearly  one-half,  of  my  cases  there  was  pneumonia  afi'ecting 
portions  of  one  or  more  lobes  or  an  entire  lobe.  From  the  extent  and  posi- 
tion of  the  solidified  portions  it  was  obvious  that  in  most  instances  the 
inflammation  originated  from  the  irritating  effect  of  the  tubercular  matter,  while 
in  others  it  was  due  to  hypostatic  congestion,  occurring  in  consequence  of 
the  long-continued  recumbent  position  and  feebleness  of  circulation.  In 
these  15  cases  the  seat  and  extent  of  the  pneumonia  were  as  follows : 

Cases. 

Nearly  entire  right  lung 2 

Nearly  entire  middle  and  lower  lobe  of  right  lung 1 

Entire  left  upper  lobe 2 

A  considerable  part  of  both  lungs 1 

Posterior  parts  of  both  lower  lobes 4 

Posterior  part  of  left  lung 1 

Left  lower  lobe,  and  right  middle  and  lower  lobes 1 

Left  upper  lobe  (contained  a  large  cavity)  and  posterior  part  of  left 

lower  lobe 1 

Nodules  of  inflamed  lung  around  tubercles 2 


228  TUBERCULOSIS. 

The  inflammation  in  about  one-third  of  the  cases  was  due  to  hypostasis,  since 
it  occurred  in  depending  portions,  extended  but  little  into  the  lungs,  and  sus- 
tained no  relation  to  the  amount  of  tubercle.  It  was  in  the  stage  of  red — or, 
more  rarely,  of  gray — hepatization. 

In  7  of  the  cases  there  were  pulmonary  cavities  as  large  in  proprotion  as 
we  ordinarily  find  in  tuberculosis  of  the  adult.  The  seat  of  1  was  in  the 
right  lower  lobe  ;  of  2,  the  left  upper  lobe  ;  of  1,  the  right  upper  lobe ;  of 
another,  the  right  lung,  its  exact  seat  not  stated ;  and  in  the  remaining  case 
the  cavity,  which  was  the  largest  of  all,  occupied  the  interior  of  all  three 
lobes  on  the  right  side.  Some  idea  of  the  size  of  these  cavities  may  be 
learned  by  the  following  extracts  from  the  records  :  1st  Case.  "  A  small 
superficial  cavity  communicating  on  one  side  with  a  bronchial  tube,  and  on 
the  other  side  with  a  small  circumscribed  collection  of  pus  in  the  pleural 
cavity."  2d  Case.  "  Cavity  of  the  size  of  a  hickory-nut."  3d  Case.  "  Cavity 
of  the  size  of  a  large  hickory-nut."  4th  Case.  "  Cavity  three-fourths  of  an 
inch  in  diameter."  5th  Case.  "  A  large  abscess."  6th  Case.  "  The  cavity 
occupied  nearly  the  whole  of  the  interior  of  the  left  upper  lobe."  7th  Case. 
"  About  half  the  right  lung  excavated  into  a  cavity  which  extended  through 
the  three  lobes." 

Circumscribed  pleuritis,  produced  by  tubercles  underneath  the  pleura,  was 
observed  in  7  cases.  It  was  ordinarily  attended  by  little  exudation  except 
the  fibrin,  but  in  1  case  a  sufficient  amount  of  serum  had  been  exuded  to 
compress  considerably  the  lung.  Pus  was  not  observed  in  any  notable 
quantity. 

Emphysema  was  present  in  several  cases,  chiefly  in  the  upper  lobes,  some- 
times vesicular,  with  fulness  or  bulging  of  the  lung,  an  anaemic  appearance 
of  it,  and  doughy,  inelastic  feel.  In  other  caees  emphysema  was  interstitial, 
producing  little  bladders  of  air  under  the  pleura,  especially  toward  the  root 
of  the  lung,  or  separating  the  lobules  by  wedge-shaped  or  irregular  inter- 
spaces filled  with  air.  In  one  case  air  had  escaped  from  an  emphysematous 
bladder  into  the  right  pleural  cavity,  causing  pneumothorax  and  collapse  of 
the  lung. 

Next  to  the  lungs,  the  bronchial  glands  are  more  frequently  diseased  than 
any  other  organs  in  the  tuberculosis  of  infancy  and  childhood.  They  undergo 
the  successive  structural  changes  which  characterize  glandular  inflammations 
— to  wit,  hyperplasia — and  more  or  fewer  of  them  cheesy  degeneration  and 
softening.  In  the  state  of  hyperplasia  their  firmness  is  diminished  and  they 
have  a  pale  flesh-color.  Cheesy  degeneration  commences  in  one  or  more 
points  in  the  gland,  sometimes  in  the  peripheral,  sometimes  in  the  central 
portion,  and  it  extends  till  the  whole  gland  presents  the  well-known  cheesy 
appearance.  When  the  gland  softens  the  thick  liquid  has  a  puriform  appear- 
ance, consisting  of  amorphous  matter,  fatty  particles,  and  the  shrivelled  and 
disintegrated  cells  of  the  gland.  Soon  pus-cells  occur,  and  their  number 
increases.  The  cheesy  gland  may  or  may  not  be  tubercular.  If  it  be  tuber- 
cular, the  tubercle  bacillus  will  be  found  in  it. 

Rilliet  and  Barthez  state  that  the  bronchial  glands  were  tubercular 
(caseous)  in  249  cases  in  children,  while  the  lungs  were  tubercular  in  265. 
All  cheesy  glands,  it  is  to  be  recollected,  they  considered  tubercular.  In  4 
of  the  36  cases  which  I  have  examined  no  record  was  preserved  of  the  state 
of  the  bronchial  glands ;  in  1  case  there  was  no  perceptible  hyperplasia  and 
no  cheesy  degeneration  ;  in  2  there  was  hyperplasia,  but  no  cheesy  degener- 
ation, while  in  the  remaining  29  cases  cheesy  degeneration  had  occurred  in 
some  of  the  glands  or  in  parts  of  them,  with  occasional  softening.  The 
enlarged  and  caseous  bronchial  glands  afi"ord  an  explanation  in  part  of  the 
fact  that  the  symptoms  in  the  tuberculosis  of  young  children  difi'er  from  those 


ETIOLOGY. 


229 


in  the  adult,  since  Louis  found  the  bronchial  glands  involved  in  only  28  per 
cent,  of  the  adult  cases  of  tuberculosis  which  he  examined,  and  Lombard  in 
only  9  per  cent.  A  gland  pressing  upon  the  recurrent  laryngeal  or  pneu- 
mogastric  nerve  or  the  trachea  may  give  rise  to  dyspnoea  and  a  cough  ;  or 
on  the  descending  vena  cava  or  one  of  the  venae  innominatse  to  congestion  of 
the  brain  and  meninges,  intracranial  serous  effusion,  and  even  thrombosis  in 
the  cranial  sinuses.  That  a  softened  bronchial  gland  is  not  infrequently 
eliminated  from  the  system  by  ulceration  into  a  bronchial  tube  or  into  the 
trachea  is  well  known.  In  one  case  which  I  observed  the  ulceration  had 
destroyed  portions  of  three  of  the  cartilaginous  rings  of  a  bronchus,  and  the 
aperture  was  plugged  by  a  cheesy  fragment  of  a  softened  gland  which  pro- 
truded. Occasionally,  it  is  stated  by  authors,  the  ulceration  is  into  one  of  the 
large  vessels  of  the  mediastinum,  or  even  into  the  oesophagus. 

The  following  is  an  example  of  bronchial  phthisis  as  it  commonly  occurs. 
This  case,  which  is  not  included  in  the  foregoing  statistics,  was  seen  almost 
daily  by  me  during  its  entire  progress:  On  September  3,  1874,  I  examined 
an  infant  in  the  New  York  Infant  Asylum  who  had  wheezing  respiration 
during  the  last  eight  days.  The  wheezing  occurred  both  in  inspiration  and 
expiration,  and  also,  though  less  pronounced,  during  sleep ;  pulse  96,  respi- 
ration 40,  temperature  normal.  Its  mother,  who  had  charge  of  it,  and  had 
till  recently  wet-nursed  it,  had  unequivocal  symptoms  of  tuberculosis  for 
several  months.  The  child  was  pallid  and  its  flesh  was  soft  and  flabby. 
The  fauces  were  perhaps  a  little  redder  than  usual,  but  were  otherwise  nor- 
mal, and  a  careful  exploration  of  the  chest  revealed  no  cause  of  the  embar- 
rassed respiration.  Auscultation  and  percussion  gave  a  negative  result.  In 
the  latter  part  of  September  a  troublesome  diarrhoea  occurred,  which  con- 
tinued more  or  less  till  near  death.  The  temperature  on  September  28th, 
October  8th,  10th,  and  11th,  was  100^,  100°,  99^°,  and  100°.  The  pulse  on 
October  10th  and  11th  was  120  and  126.  On  October  8th  the  percussion- 
sound  over  the  upper  part  of  the  right  lung  seemed  somewhat  duller  than 
on  the  other  side,  though  the  respiration  was  not  observed  to  be  notably 
changed  in  the  area  of  the  dulness.  There  was  but  little  cough  during  the 
entire  sickness.  Death  occurred  on  October  20th.  At  the  autopsy  the 
bronchial  glands  were  found  enlarged  and  cheesy,  and  underneath  the  right 
bronchus,  near  the  bifurcation,  was  a  softened,  almost  diffluent  gland,  as 
large  as  a  small  hickory-nut  and  compress- 
ing the  bronchus.  This,  no  doubt,  had 
produced  the  wheezing  respiration,  which 
had  been  the  chief  local  symptom.  The 
lungs,  spleen,  and  in  less  degree  the  liver, 
contained  numerous  small  miliary  tuber- 
cles. Certain  of  the  mesenteric  glands 
were  also  cheesy,  but  to  a  less  extent  than 
the  bronchial.  The  disease  of  the  bron- 
chial glands  was  evidently  primary,  the 
tubercles  of  the  lungs  and  abdominal  or- 
gans being  apparently  quite  recent.  The 
accompanying  woodcut,  from  a  photograph 
by  Mr.  Mason,  the  photographer  at  Belle- 
vue  Hospital,  represents  a  posterior  view 
of  the  lungs  and  air-passages. 

In  no  case  have  I  found  tubercles  in 
the  heart    or    pericardium,   though    they 

have  been  observed  in  rare  instances  in  the  latter.  The  mesenteric  glands 
were  enlarged  by  hyperplasia  and  more   or  less  cheesy  in  30  cases,  were 


Fig.  24. 


230  TUBERCULOSIS. 

apparently  normal  in  2  cases,  while  in  tte  remaining  4  cases  their  condition 
was  not  stated.  In  most  of  the  patients  the  mesenteric  glands  were  smaller 
and  less  cheesy  than  the  bronchial,  but  in  a  few  instances  they  were  larger 
than  the  bronchial  and  more  cheesy. 

It  is  a  noteworthy  fact,  as  bearing  on  the  causal  relation  of  these  glands 
to  tubercles,  that  not  infrequently  the  amount  of  hyperplasia  and  cheesy 
degeneration  occurring  in  the  former  was  very  considerable,  while  the  tuber- 
cles in  the  lungs  or  elsewhere  were  small,  even  minute,  semi-transparent,  and 
apparently  of  recent  formation.  It  was  evident  in  such  cases  that  the  gland- 
ular hyperplasia  and  degeneration,  bronchial  or  mesenteric,  or  both,  preceded 
the  tubercular  disease,  and  furnished  the  conditions  favorable  for  the  lodg- 
ment and  propagation  of  the  tubercle  bacillus.  Since  the  cases  which  fur- 
nished the  above  statistics  occurred  my  clinical  experience  with  tuberculosis 
has  greatly  increased,  but  nothing  new  or  diiferent  has  been  observed  at 
autopsies. 

Abdominal  Viscera. — In  children  tubercles  in  the  solid  organs  of  the 
abdomen  rarely  give  rise  to  appreciable  symptoms,  since  they  are  small  and 
disseminated,  not  impairing  materially  the  function  of  the  part  in  which  they 
are  located.  On  the  other  hand,  peritoneal  and  intestinal  tubercles  and  the 
enlarged  and  cheesy  mesenteric  glands  give  rise  to  symptoms  which  require 
description.  The  most  frequent  seat  of  peritoneal  tubercles  is  upon  the 
attached  surface  of  the  peritoneum,  where  they  are  formed  in  the  connective 
tissue.  They  are  distinctly  seen  through  the  peritoneum,  and  cause  some 
prominence  of  it.  Exceptionally  their  seat  is  upon  its  free  surface.  Every 
portion  of  the  peritoneum,  whether  visceral,  parietal,  or  omental,  is  liable  to 
tubercles,  but  general  tuberculization  of  so  extensive  a  surface  seldom 
occurs  in  any  one  case.  The  tubercles  are  spherical  or  lenticular,  and  most 
of  them  small.  Sometimes  they  are  very  numerous,  but  so  minute  as  to  be 
scarcely  visible.  They  are  gray  or  yellow  according  to  their  age.  Peri- 
toneal tubercles  often  produce  circumscribed  peritonitis,  causing  adhesion  of 
opposite  surfaces.  The  tubercles  in  themselves  cannot  be  detected  by  exter- 
nal palpation  ;  but  masses  composed  of  tubercles  and  inflammatory  products 
are  sometimes  so  large  that  they  can  be  felt  through  the  abdominal  walls. 

The  symptoms  of  peritoneal  tuberculosis  are  attributable,  for  the  most 
part,  to  the  peritonitis.  Among  them  may  be  enumerated  abdominal  tender- 
ness or  pain,  meteorism,  ascites — usually  slight — and  derangement  of  the 
bowels,  commonly  diarrhoea.  Since  tubercles  in  this  situation  occur,  in  most 
cases,  subsequently  to  tubercles  elsewhere,  the  symptoms  which  have  been 
described  are  associated  with  and  are  subordinate  to  others. 

Stomach  and  Intestines. — The  most  common  seat  of  gastro-intestinal 
tubercles  is  the  small  intestine,  and  more  frequently  its  lower  portion,  near 
the  ileo-csecal  valve,  than  its  upper  or  central.  They  are  rare  in  the  duo- 
denum or  contiguous  part  of  the  jejunum.  They  are  developed  ordinarily 
in  the  connective  tissue,  either  that  lying  under  the  mucous  or  the  serous 
surface. 

Gastro-intestinal  tubercles  are  often  accompanied  by  ulceration  of  the 
adjacent  mucous  membrane.  But  in  a  certain  proportion  of  cases,  probably, 
the  tubercles  do  not  cause  the  ulcers,  for  ulceration  of  this  membrane  is  not 
infrequent  in  the  tuberculosis  of  children,  when  there  are  no  tubercles  in  the 
walls  of  the  stomach  or  intestines.  The  following  statistics  of  Rilliet  and 
Barthez  relating  to  this  point  will  aid  to  an  understanding  of  the  symptoms : 

rr  u      1      •  n      <•    i  u    T  )  with  ulcers,  6  cases. 

lubercles  in  walls  of  stomach,  7  cases,  i     •.!      ..     i  ^ 

'  '  {  without  ulcers,  1  case. 

Ulcers  of  gastric  mucous  membrane,  without  gastric  tubercles,  14  cases. 


SYMPTOMS.  231 

„  ,       ,       .  11    •   .    .-        oo  f  with  ulcers,  70  cases. 

Tubercles   in   small   intestine,  82  cases,  J  ^j^j^^^^  ^jj^^^^  ^2  cases. 

Ulcers  without  tubercles  in  small  intestine,  51  cases. 

™  ,       ,       .      ,  •   t.    r        1-  (  with  ulcers,  10  cases. 

Tubercles   in   large   intestine,   lo   cases,  |  ^^.^j^^^^  ^,J^^^^  ^  ^^^^^^ 

Ulcers  in  large  intestine,  without  tubercles,  47  cases. 

The  ulcers  have  vascular,  thickened,  and  infiltrated  borders.  Their  diam- 
eters vary  from  a  line  to  half  an  inch  or  more,  and  their  general  form  is 
circular,  or,  if  two  or  more  unite,  irregular.  Tubercular  ulcers  of  the 
stomach  are  mostly  in  the  great  curvature,  those  in  the  small  intestines  in 
the  ileum  and  lower  part  of  the  jejunum,  and  those  of  the  large  intestine  in 
the  ci\3cum. 

The  following  table  exhibits  the  state  of  the  principal  abdominal  viscera 
in  the  36  cases  embraced  in  my  statistics : 

Liver.  Spleen.  Kidneys. 

Tubercular 12  22  1 

Non-tuberoular 16  6  21 

Not  stated 8  8  14 

Fatty 5  0  0 

In  no  instance  did  I  observe  tubercular  softening  in  the  abdominal  organs, 
and  a  large  proportion  of  the  tubercles  in  the  liver,  spleen,  and  kidneys  were 
still  in  the  first  stage.  In  the  5  cases  in  which  the  liver  was  recorded  fatty 
this  state  of  the  organ  was  obvious  to  the  sight,  as  it  is  in  tuberculosis  of 
the  adult.  A  moderate  excess  of  fat  in  the  hepatic  cells  may  have  been 
present  in  some  of  the  other  cases,  but  it  was  not  sufiicient  to  be  appreciable 
without  the  microscope.  It  is  to  be  remarked  that  in  the  5  cases  in  which 
the  liver  was  recorded  fatty  this  organ  contained  no  tubercles.  The  spleen 
is  seen  to  have  been  the  most  frequent  seat  of  tubercles  of  all  the  viscera, 
except  the  lungs.  In  14  cases  the  intestines  were  examined ;  and  in  5 
tubercles  discovered,  developed  in  their  connective  tissue.  The  intestinal 
tubercles  were  small,  and  ulceration  had  occurred  of  the  mucous  membrane 
which  covered  them. 

The  brain  was  examined  in  15  cases.  In  12  the  amount  of  cerebro- 
spinal fluid  varied  from  ^ss  to  .^v  by  estimation.  In  2  others  the  records 
state  that  there  was  a  considerable  amount  of  this  fluid,  the  exact  quantity 
not  being  given,  while  in  the  remaining  case  congestion  of  the  brain  and 
meninges  was  noticed,  but  nothing  was  recorded  in  regard  to  the  amount  of 
cerebro-spinal  fluid.  The  increase  of  the  cerebro-spinal  fluid  in  tuberculosis 
is  attributable  to  wasting  of  the  brain,  a  hi/drocpjyhalns  ex  vacuo,  and  in  some 
cases  to  passive  congestion  and  serous  transudation,  due  to  feeble  circulation, 
or  obstructed  flow  from  the  pressure  of  bronchial  glands  on  the  vessels  within 
the  thorax,  as  already  stated. 

Tubercles  were  present  in  the  pia  mater  in  3  cases :  in  2  with  fibrinous 
exudation  ;  in  the  other  without  fibrin  or  other  evidence  of  inflammation. 
Tubercular  meningitis  is  described  in  another  part  of  this  book. 

Symptoms. — The  symptoms  in  tuberculosis  of  children  arise  in  part  from 
the  diathesis  and  in  part  from  the  tubercles.  Before  the  period  of  tubercles 
there  are  signs  of  failing  health,  such  as  loss  of  appetite,  flabbiness  of  the 
soft  parts,  or  emaciation,  lassitude,  and  loss  of  strength.  These  symptoms 
continue  after  the  formation  of  tubercles,  and  increase. 

The  features  are  ordinarily  pallid,  but  during  the  paroxysms  of  fever,  to 
which  tubercular  patients  are  subject,  they  may  be  flushed.  Lividity  of  the 
features,  due  to  imperfect  decarbonization  of  the  blood,  occurs  if  there  be 
enlarged  bronchial  glands  which  compress  the  vessels  within  the  thorax,  or 


232  TUBERCULOSIS. 

if  there  be  extensive  pulmonary  tuberculization  or  pulmonary  tuberculiza- 
tion, whether  extensive  or  not,  which  is  complicated  by  capillary  bronchitis 
or  pneumonia. 

The  skin  is  nearly  natural,  or  it  loses  its  flexibility  and  softness  and 
becomes  dry  and  rough.  In  some  patients  there  is,  at  times,  general  or  par- 
tial furfuraceous  desquamation  of  the  skin,  due  to  exaggerated  development 
of  the  epidermis.  Children,  like  adults,  notwithstanding  the  general  dry- 
ness of  the  surface,  are  liable  to  perspirations  at  night  and  in  sleep.  This 
symptom  is  less  frequent  at  the  commencement  than  at  an  advanced  period, 
in  acute  than  in  chronic  cases,  and  in  those  under  three  or  four  months  than 
in  older  children.  It  is  more  abundant  about  the  head  and  limbs  than  else- 
where, and  is  sometimes  confined  to  these  parts. 

Anasarca  is  not  infrequent.  It  sometimes  arises  from  obstructed  circula- 
tion in  consequence  of  compression  of  the  thoracic  vessels  by  enlarged 
lymphatic  glands  ;  in  other  cases  it  is  due  to  diminished  plasticity  of  the 
blood,  a  result  of  the  tubercular  cachexia.  The  latter  is  the  more  common 
cause.  It  is  not  an  important  symptom,  on  account  of  the  small  amount  of 
serous  transudation  and  the  character  of  the  parts  in  which  it  occurs. 

Emaciation,  already  alluded  to,  is  early,  constant,  and  progressive.  Under 
the  age  of  six  or  eight  months  it  is  less  marked  than  in  older  children,  many 
preserving  considerable  rotundity  of  features  and  form  even  in  advanced 
tuberculosis.  The  failure  of  the  strength  corresponds  in  amount  and  prog- 
ress with  the  emaciation.  Slight  at  first,  and  exhibited  only  by  a  degree  of 
lassitude,  it  gradually  increases,  till  for  weeks  before  death  the  little  patient 
is  fatigued  by  the  ordinary  muscular  movements,  and  is  inclined  to  be  quiet. 

The  nervous  system  is  not  ordinarily  afiected  except  in  cases  of  intra- 
cranial tubercles.  In  acute  tuberculosis  or  tuberculosis  complicated  by 
severe  inflammation  there  may  be  agitation  and  delirium,  especially  at 
night. 

In  most  patients  the  mucous  membrane  of  the  buccal  cavity  presents  its 
normal  appearance,  with  the  exception  of  a  moist  fur  upon  the  tongue  and  a 
paler  hue  than  normal  of  its  surface  generally.  In  acute  tuberculosis  and  in 
cases  complicated  by  inflammation  the  tongue  is  sometimes  dry  and  brown. 
The  appetite  may  be  normal  till  the  close  of  life  or  it  is  poor  or  changeable. 
Occasionally  it  is  increased,  although  the  disease  is  progressing.  The  bowels 
are  regular  or  relaxed.  Diarrhoea  may  be  a  prominent  symptom,  even  when 
there  are  no  intestinal  tubercles  or  ulceration.  Meteorism  and  fulness  of  the 
abdomen  are  common. 

Fever,  constant,  but  usually  with  evening  exacerbation,  is  rarely  absent. 
It  continues  for  weeks  or  months.  During  the  exacerbation  the  pulse  rises 
to  120,  140,  or  even  to  180  beats  per  minute,  and  there  is  a  corresponding 
exaltation  of  the  temperature,  which  in  the  latter  part  of  the  day,  without 
inflammatory  complication,  ranges  from  100°  to  102°  or  103°.  The  febrile 
movement  is  a  symptom  of  diagnostic  value  as  regards  the  nature  of  the  dis- 
ease, though  it  does  not  indicate  the  seat  of  the  tubercles. 

In  addition  to  the  symptoms  now  described,  there  are  special  symptoms 
due  to  tuberculization  of  the  different  organs.  In  young  children,  on  account 
of  the  fact  already  referred  to — to  wit,  the  tendency  to  a  generalization  of 
tubercles — there  is  often  a  blending  of  the  symptoms  which  arise  from  dif- 
ferent organs,  but  with  care  it  is  not  difficult  in  most  instances  to  isolate  and 
refer  them  to  their  proper  source.  The  following  are  the  symptoms  which 
arise  from  tuberculization   of  the  more  important  organs: 

Encephalon. — The  symptoms  produced  by  tubercles  of  the  encephalon 
vary  according  to  their  seat  and  size  and  the  structural  changes  in  surround- 
ing parts  to  which  they  give  rise.     Meningeal  tubercles,  which  are  located 


SYMPTOMS.  233 

for  the  most  part  in  tlic  meshes  of  the  pia  mater,  and  ordinarily  along  the 
course  of  the  small  arteries,  are,  as  a  rule,  small,  not  more  than  a  line  in 
diameter,  and  they  may  remain  latent  for  a  considerable  time.  In  the 
majority  of  cases,  however,  they  sooner  or  later  cause  meningitis,  the 
symptoms  of  which  are  well  known  and  need  not  be  described.  But 
tubercles  in  this  situation  do  sometimes  give  rise  to  symptoms  when 
there  is  no  meningeal  inflammation.  They  occasion  congestion  of  the  sur- 
rounding vessels  and  serous  transudation,  and,  if  developed  on  the  under 
surface  of  the  pia  mater,  they  may  produce  symptoms  by  encroaching  upon 
and  irritating  the  brain  ;  for  they  are  sometimes  so  much  imbedded  in  the 
convolutions  that  careful  examination  is  required  in  order  to  determine  that 
they  are  meningeal  and  not  cerebral.  Among  these  symptoms  may  be 
mentioned  headache,  frontal  or  occipital,  sometimes  intermittent,  nausea, 
melancholy,  and  in  certain  cases  the  symptoms  produced  by  serous  trans- 
udation. 

The  symptoms  of  c(:rebral  are  in  part  similar  to  those  of  meningeal 
tuberculosis,  but  in  most  cases  others  of  a  neuropathic  character  are 
present,  which  serve  for  differential  diagnosis.  The  differences  as  regards 
the  symptoms  of  different  patients  having  cerebral  tubercles  are  attribut- 
able in  part  to  their  size  and  rapidity  of  growth,  but  more  to  the  differ- 
ence in  their  seat ;  for  any  part  of  the  brain  may  be  the  seat  of  tubercles, 
though  certain  portions,  as  the  cerebellum,  are  more  frequently  affected  than 
others. 

The  child  with  cerebral  tubercles  is  quiet,  but  irritable  and  easily  excited. 
Delirium  is  not  common,  but  many  before  the  close  of  life  exhibit  a  degree 
of  mental  dulness.  The  headache,  common  in  cases  of  cerebral  as  well  as 
meningeal  tubercles,  may  be  nearly  general,  or  it  is  frontal,  parietal,  or  occip- 
ital according  to  the  seat  of  the  tubercles.  It  is  often  lancinating,  often 
intermittent. 

Clonic  convulsions  occur  toward  the  close  of  life.  Exceptionally,  they 
are  among  the  earliest  symptoms.  Observations  have  failed  to  establish  any 
relation  between  the  seat  of  the  tubercles  and  the  localization  of  the  convul- 
sions. The  convulsions  inay  be  unilateral,  while  the  tubercles  are  in  both 
hemispheres  ;   or  general,  while  the  tubercles  are  on   one  side  only. 

The  severity  and  duration  of  the  convulsive  attacks,  and  the  frequency 
of  their  occurrence  in  tuberculosis  of  the  brain,  vary  greatly  in  different 
patients.  They  have  been  attributed  to  softening  of  the  cerebral  substance, 
which  sometimes  occurs  immediately  around  the  tubercles,  to  local  conges- 
tions excited  by  them,  and  also  to  serous  effusions  in  the  ventricles.  The 
convulsions  sooner  or  later  end  in  paralysis  or  coma. 

Contraction,  or  tonic  spasm  of  certain  muscles,  is  sometimes  observed. 
Its  most  frequent  seat  is  in  the  muscles  of  the  back  and  of  one  or  both  of 
the  lower  extremities.  It  is  a  late  symptom.  It  occurs  in  those  cases  in 
which  there  is  softening  around  the  tubercles,  and  usually  in  the  muscles  of 
the  opposite  side. 

Paralysis  is  also  a  late,  but  not  an  infrequent,  symptom.  It  is  preceded 
by  headache,  and  sometimes,  as  already  stated,  by  convulsions.  Occurring 
as  a  symptom  of  tuberculosis  of  the  brain,  it  is  due  either  to  pressure  on  a 
cranial  nerve  or  to  compression  and  perhaps  softening  of  the  cerebral  sub- 
stance. The  paralysis  may  be  paraplegic,  commencing  as  feebleness  of  the 
lower  extremities,  and  increasing  until  it  becomes  complete,  or  more  or  less 
complete,  hemiplegia.  In  paraplegia  due  to  tubercles  of  the  brain  the  cere- 
bellum is,  as  a  rule,  their  seat ;  while  paralysis  of  one  side  or  of  certain  mus- 
cles of  one  side  indicates  tubercles  of  the  opposite  cerebral  hemisphere ;  but 
there  are  exceptions.     Paralysis  of  the  third  cranial  nerve  gives  rise  to  ptosis 


234  TUBERCULOSIS. 

— of  the  sixth,  to  paralysis  of  the  external  motor  nerves  of  the  eye,  and 
therefore  to  internal  strabismus. 

Feebleness  or  loss  of  vision,  inequality,  oscillation,  and  finally  dilatation 
of  the  pupils,  are  not  infrequent  symptoms  of  tuberculosis  of  the  brain,  and 
they  possess  great  diagnostic  value.  Atrophy  of  the  optic  nerve,  causing 
amaurosis,  sometimes  results  from  tubercles  as  well  as  other  tumors  of  the 
brain.  Atrophy  of  this  nerve  occurs  not  only  when  the  tubercles  are  so 
located  as  to  press  on  the  optic  tract,  in  which  case  the  explanation  is  appa- 
rent, but  also,  in  certain  patients,  when  the  tubercles  are  in  other  parts  of 
the  brain.  In  these  last  cases  it  is  thought  by  Brown-Sequard  and  others 
that  the  imperfect  nutrition  of  the  nerve  is  due  to  contraction  of  its  nutrient 
vessels,  produced  by  the  tubercles  through  reflex  action. 

In  tuberculosis  of  the  brain  symptoms  pertaining  to  the  respiratory,  cir- 
culatory, and  digestive  systems  are  either  absent  or  are  quite  subordinate  to 
those  of  a  neuropathic  character.  Slowness  of  the  pulse,  with  or  without 
intermittence,  has  sometimes  been  observed,  and  it  is  therefore  a  symptom  of 
some  diagnostic  value.  Toward  the  close  of  life  both  pulse  and  respiration 
are  usually  accelerated.  Vomiting,  constipation,  and  retraction  of  the  abdo- 
men, which  are  so  common  in  meningitis,  are  only  occasional  symptoms. 

Bronchial  Grlands. — During  the  progress  of  tuberculosis,  hyperplasia, 
cheesy  degeneration,  and  softening  of  various  lymphatic  glands  may  occur 
throughout  the  body,  but  the  bronchial  and  mesenteric  are  not  only  those 
which  are  most  frequently  affected,  but  they  are  the  only  glands,  unless  in 
exceptional  instances,  which  materially  increase  the  danger  or  give  rise  to 
special  symptoms.  These  symptoms  either  have  a  mechanical  cause — to  wit, 
the  pressure  exerted  by  the  enlarged  glands  on  contiguous  parts — or  they  are 
due  to  softening  of  the  glands  and  consecutive  inflammation  and  ulceration. 

The  following  are  the  principal  symptoms  due  to  compression  ;  some  of 
them  are  not  infrequent,  others  are  rare :  Compression  of  the  pulmonary 
veins  retards  the  flow  of  blood  from  the  lungs  to  the  left  auricle,  giving  rise 
to  congestion  and,  in  extreme  cases,  oedema  of  the  lungs,  with  sanguineous 
extravasation  into  the  lung-substance,  congestion  of  the  right  cavities  of  the 
heart,  hepatic  veins,  and  of  the  systemic  capillaries  generally.  Compression 
of  the  pneumogastric  nerve  or  of  the  recurrent  laryngeal,  which  is  the  motor 
nerve  of  the  laryngeal  muscles,  modifies  the  voice  and  produces  a  cough 
which  is  often  spasmodic.  The  cough  resembles  that  of  pertussis,  and  has 
been  mistaken  for  it,  but  it  is  not  so  violent  or  protracted.  The  voice,  clear 
and  natural  at  first,  becomes  by  degrees  hoarse  or  feeble  from  deficient  inner- 
vation of  the  laryngeal  muscles. 

An  enlarged  gland  or  mass  of  glands  lying  against  the  trachea  or  one  of 
the  bronchial  tubes  (this  may  occur  with  tubes  up  to  the  third  or  fourth 
division),  and  pressing  its  walls  inward,  obviously  obstructs  more  or  less  the 
current  of  air.  If  there  be  considerable  obstruction,  a  loud,  sonorous  rale  is 
produced,  which  is  heard  distinctly  at  a  distance  from  the  chest,  obscuring 
other  rales.  It  is  loudest  when  the  patient  is  agitated,  and  it  sometimes 
intermits.  Feeble  respiratory  murmur,  dyspnoea,  and  a  cough  are  not  infre- 
quent in  bronchial  phthisis.  Diminished  intensity  of  the  respiratory  murmur 
is  general  or  partial,  according  to  the  seat  of  the  compression.  It  has  been 
most  frequently  observed  at  the  summit  of  the  lungs.  In  certain  patients 
this  symptom  is  not  constant,  the  respiration  being  for  a  time  feeble  and 
then  normal.  The  dyspnoea  may  be  a  prominent  and  distressing  symptom, 
the  alae  nasi  dilating,  and  the  inframammary  region  sinking  with  each  respira- 
tion. The  cough  which  occurs  when  a  gland  presses  on  the  trachea  or  bron- 
chial tube  is  due  to  the  tracheitis  or  bronchitis  to  which  the  pressure  gives 
rise.     If  ulceration  occur  at  the  point  of  pressure,  the  cough  continues  as 


PHYSICAL  SIGNS.  '  235 

long  as  the  ulcer  remains.  Compression  of  the  larj^e  veins  within  the  thorax 
which  return  blood  from  the  head  and  upper  extremities  causes  more  or  less 
congestion  of  these  parts,  with,  perhaps,  transudation  of  serum  in  the  sub- 
■cutaneous  connective  tissue  and  within  the  cranium.  Rarely,  a  softened 
gland  by  ulceration  gives  rise  to  other  symptoms  than  those  mentioned — to 
wit,  hemorrhage  by  ulceration  into  a  vessel  or  pleuritis  or  pneumonitis  if  the 
ulceration  be  toward  the  lungs. 

Improvement  in  the  condition  of  the  patient  affected  with  bronchial 
phthisis  is  not  unusual.  It  may  be  permanent,  but  in  most  patients  it  is 
temporary,  so  that  in  a  few  weeks  or  months  the  symptoms  are  as  severe  as 
before.  The  improvement  is  due  to  softening  and  elimination  of  a  gland 
which  had  given  rise  to  symptoms  by  its  mechanical  effect  or  by  the  inflam- 
mation  which  it  had  excited. 

Physical  Signs — From  Tuhercular  Bronchud  Glands. — These  are  absent 
or  obscure  in  the  incipient  disease  when  the  glands  are  small,  and  they  are 
most  marked  in  those  cases  in  which  the  glands  are  so  large  as  to  press  on 
the  thoracic  walls,  since  they  then  become  the  medium  for  the  tran.smission 
of  sounds  to  the  ear.  The  part  of  the  thorax  against  which  they  most  fre- 
quently press  is  the  dorsal  vertebrae  from  the  first  to  the  sixth,  and  each 
side  of  the  vertebrae,  and  less  frequently  the  upper  third  of  the  sternum. 
The  physical  signs  are  dulness  on  percussion  over  the  interscapular  space, 
and  perhaps,  though  to  a  less  extent,  over  the  upper  part  of  the  sternum, 
and  bronchial  respiration  in  the  same  situations.  Occasionally  a  bruit  can 
be  detected,  due  to  the  pressure  of  a  gland  on  one  of  the  large  vessels  of  the 
chest. 

Lungs. — A  cough  is  one  of  the  earliest  and  most  persistent  of  the  symp- 
toms of  pulmonary  tuberculosis.  It  is  so  rarely  absent  that  those  of  large 
experience  do  not  meet  with  more  than  one  or  two  such  cases.  It  varies  in 
severity  and  frequency.  If  the  tuberculosis  be  acute  and  its  course  rapid, 
the  cough,  even  from  its  commencement,  is  frequent,  so  as  to  weary  the 
patient  and  deprive  him  of  needed  rest.  But  in  ordinary  cases — that  is, 
when  the  disease  is  chronic — it  commences  gradually,  attracting  at  first  little 
attention  by  its  infrequency,  but  becoming  more  frequent  and  painful  as  the 
malady  advances. 

Ordinarily,  the  cough  is  dry  in  the  first  weeks  or  months,  but  it  becomes 
looser  in  the  course  of  the  disease,  from  the  greater  amount  of  bronchial 
inflammation.  In  exceptional  instances  it  has  a  spasmodic  character,  like 
that  produced  b}''  pressure  of  an  enlarged  bronchial  gland  on  the  pneumo- 
gastric  or  recurrent  laryngeal  nerve.  This  occurs  from  the  accumulation  of 
viscid  mucus  in  one  or  more  of  the  bronchial  tubes,  usually  in  dilated  por- 
tions of  them,  from  which  it  is  with  difficulty  expectorated. 

The  respiration  in  pulmonary  tuberculosis  is  accelerated  in  proportion  to 
the  degree  of  tuberculization.  Tuberculization  of  a  considerable  part  of 
both  lungs  gives  rise  to  dyspnoea,  especially  when,  as  is  ordinarily  the  case, 
bronchial,  pulmonary,  or  pleuritic  inflammation  has  supervened.  Pneumonitis 
or  pleuritis  gives  rise  to  the  expiratory  moan,  and  as  these  inflammations, 
when  induced  by  tubercles,  are  protracted,  this  symptom  may  continue  for 
weeks  or  months. 

Patients  under  the  age  of  six  years  do  not  expectorate,  or  but  rarely. 
After  this  age  expectoration  is  not  common  in  the  commencement  of  pul- 
monary tuberculosis,  but  in  the  confirmed  disease  it  is  a  pretty  constant 
attendant  of  the  cough.  Haemoptysis  is  also  rare  under  the  age  of  six  years, 
and  less  frequent  subsequently  than  in  the  adult.  It  is  most  likely  to  occur 
in  those  cases  in  which  there  is  already  passive  congestion  of  the  lungs  pro- 
duced by  the  pressure  of  enlarged  bronchial  glands  in   the  manner  already 


236  TUBERCULOSIS. 

described.     Patients  old  enough  to  express  tteir  sensations,  sometimes  com- 
plain  of  fugitive  pains  under  the  sternum  or  between   the  shoulders. 

In  young  children  the  physical  signs  of  incipient  pulmonary  tuberculosis 
are  wanting,  or  are  so  obscure  as  not  to  be  readily  recognized.  This  is  due 
to  the  small  size  and  dissemination  of  the  tubercles.  In  older  children  the 
physical  signs  appear  early,  and  are  readily  recognized,  because,  as  a  rule, 
the  tubercles  are  aggregated,  and  are  more  frequently  at  the  apices  of  the 
lungs,  as  in  the  adult,  than  elsewhere.  In  the  advanced  disease,  whether  in 
infancy  or  childhood,  when  inflammation  and  more  or  less  destruction  of  the 
lung-substance  have  occurred,  the  physical  signs,  so  far  from  being  obscure, 
enable  us  in  most  cases,  in  connection  with  the  history,  to  make  an  imme- 
diate and  positive  diagnosis. 

In  young  children  affected  with  pulmonary  tuberculosis  the  irregular  and 
imperfect  expansion  of  the  lungs  produces  by  degrees  changes  in  the  shape 
of  the  thorax  which  are  apparent  on  inspection.  In  some,  the  lungs  being 
habitually  imperfectly  inflated,  the  obliquity  of  the  ribs  is  increased,  and 
the  thorax  consequently  elongated,  while  its  antero-posterior  and  transverse 
diameters  are  diminished.  This  obviously  increases  the  convexity  or  arch 
of  the  diaphragm,  so  that  this  muscle  sometimes  lies  against  the  thoracic 
walls  as  high  as  the  ninth  or  even  eighth  rib.  If  the  costal  cartilages  are 
yielding,  there  are  anterior  flattening  of  the  chest  and  depression  of  the 
sternum  ;  if  they  are  firm  on  account  of  the  more  advanced  age,  the  chest 
remains  circular. 

Another  shape  of  the  thorax  is  not  infrequent  in  feeble  tubercular  chil- 
dren, especially  infants,  who  have  suffered  from  repeated  attacks  of  bron- 
chitis. It  occurs  also  in  the  non-tubercular  if  the  conditions  which  favor  it 
are  present.  The  conditions  are,  on  the  one  hand,  feebleness  of  the  patient, 
with  diminished  force  of  respiration  and  impaired  resiliency  of  the  ribs,  and 
on  the  other  obstruction  by  mucus  of  one  or  more  of  the  bronchial  tubes. 
Occlusion,  more  or  less  complete,  of  a  bronchial  tube,  and  consequent 
obstruction  to  the  current  of  air,  produce  a  corresponding  degree  of  col- 
lapse in  the  portion  of  lung  to  which  the  tube  leads.  The  parts  which  col- 
lapse are,  in  most  cases,  the  lower  lobes  and  the  thin  anterior  margins  of  the 
upper  lobes.  This  causes  lateral  depression  of  the  lower  ribs,  except  such 
as  are  pressed  outward  by  the  abdominal  viscera  and  an  anterior  projection 
of  the  lower  part  of  the  sternum.  The  shape  of  the  thorax  in  these  cases 
diff"ers  from  that  in  rachitis  in  the  fact  that  the  lateral  depression  does  not 
extend  to  the  upper  ribs,  nor  does  the  upper  part  of  the  sternum  project. 

Certain  precautions  should  be  observed  in  examining  the  chest  by  per- 
cussion and  auscultation.  The  child  should  sit  or  recline,  with  the  arms  and 
shoulders  in  the  same  position  on  the  two  sides,  and  the  axis  of  the  trunk 
straight.  Inclination  of  the  trunk  to  either  side,  raising  or  depressing  a 
shoulder,  may  produce  an  appreciable  diff"erence  in  the  two  sides  as  regards 
the  physical  signs.  Percussion  of  the  two  sides  should  be  practised  at  the 
same  stage  of  respiration.  A  slight  difference  in  the  degree  of  resonance 
does  not  afford  proof  of  disease  unless  it  be  observed  at  different  exami- 
nations ;  for  in  feeble  children  it  often  happens  that  all  portions  of  the  lungs 
do  not  expand  alike,  so  that  where  we  have  noticed  slight  dulness  at  one 
visit,  it  may  by  the  next  have  disappeared,  or  even  at  the  same  visit,  if  for- 
cible inspirations  be  excited. 

The  physical  signs  ascertained  by  palpation,  auscultation,  and  percussion 
are,  as  in  the  adult,  vocal  fremitus,  bronchial  respiration,  bronchophony,  and 
dulness  on  percussion.  In  those  cases  in  which  the  tubercles  are  mainly  at 
the  apices  of  the  lungs,  diminished  expansion  of  the  infraclavicular  region  is 
observed  during  inspiration,  and  this  part  of  the  thoracic  wall  is  permanently 


DIAGNOSIS.  237 

depressed,  so  that  the  clavicles  are  unusually  prominent.  If  there  be 
emphysema,  this  flattening  does  not  occur  or  is  slight.  Dulness  on  percus- 
sion, though  more  frequently  observed  in  the  infraclavicular  region  than 
elsewhere,  may  be  present  in  difterent  isolated  places.  If  pneumonia  super- 
vene, the  dulness  not  infrequently  extends  over  a  considerable  part  of  one 
lung.  The  cracked-pot  sound  is  often  observed  on  percussion,  but  it  pos- 
sesses little  diagnostic  value.  It  can  be  produced  when  there  is  no  pul- 
monary disease  by  percussion  over  a  bronchus. 

Bronchial  respiration  and  bronchophony  are  important  signs,  as  indicating 
solidification  of  the  lung,  but  they^  do  not  show  whether  the  solidification  be 
tubercular  or  pneumonic  or  the  two  conjoined.  This  must  be  determined 
by  the  history  of  the  case,  the  extent  of  surface  over  which  these  signs  are 
heard,  and  their  per.sistence.  When  the  tubercles  begin  to  soften  and  the 
lung-tissue  breaks  up,  moist  rales  appear,  often  hoarse  and  gurgling,  obscur- 
ing the  bronchial  respiration.  A  cavity  in  the  lung,  or  pneumothorax,  is 
attended  by  the  same  physical  signs  as  in  the  adult. 

Pleura. — Little  need  be  said  in  reference  to  the  symptoms  and  physical 
signs  of  tuberculosis  of  the  pleura,  since  this  affection  is  in  most  instances 
associated  with  tuberculosis  of  the  lungs,  and  is  not  distinguishable  from  it. 
But  now  and  then  the  pleural  tubercles  are  numerous  and  large,  giving  rise 
to  symptoms,  while  those  of  the  lungs  are  small,  few,  and  without  symptoms 
or  attended  by  symptoms  which  are  quite  subordinate.  Either  the  costal 
or  visceral  portion  of  the  pleura  may  be  the  seat  of  tubercles.  They  are 
developed  directly  under  the  pleura  or  upon  its  free  surface.  They  maj 
occur  in  the  newly-formed  connective  tissue  which  results  from  pleuritis. 
Those  located  upon  the  free  surface  or  under  the  costal  pleura  rarely  soften, 
while  those  under  the  visceral  pleura  sometimes  soften  and  cause  ulceration. 
Occasionally  numerous  aggregated  tubercles  form  a  firm  continuous  layer 
upon  the  surface  of  the  pleura,  preventing,  if  upon  the  visceral  pleura,  full 
expansion  of  the  lung.  This  may  give  rise  to  a  degree  of  dulness  on  per- 
cussion and  feebleness  of  the  respiratory  murmur.  Ordinarily,  however,  in 
this  form  of  tuberculosis  the  symptoms  and  physical  signs,  so  far  as  any  are 
observed,  are  due  to  the  pleuritic  inflammation  which  the  tubercles  excite. 

Stomach  and  Intestines. — The  symptoms  in  tuberculo.sis  of  the  stomach 
and  intestines  vary  according  to  the  seat  and  stage  of  the   tubercles. 

Tubercles,  whether  gastric  or  intestinal,  are  not  at  first  accompanied  by 
symptoms  or  the  symptoms  are  obscure  and  ill-defined.  Symptoms  arise 
when  inflammation  occurs  in  the  tissues  in  which  the  tubercles  are  imbedded 
or  upon  which  they  lie,  and  through  their  irritating  action.  Diarrhoea  is  one 
of  the  most  common  and  persistent  of  the  .symptoms.  The  alvine  discharges 
are  brown  and  thin,  and  sometimes,  in  advanced  cases,  very  offensive.  They 
may  be  streaked  with  blood  which  has  escaped  from  the  ulcers.  Intestinal 
tubercles,  developed  immediately  underneath  the  peritoneal  coat,  sometimes 
cause  local  peritonitis,  usually  of  little  extent.  This  gives  rise  to  circum- 
scribed pain,  tenderness,  and  more  or  less  meteorism. 

Diagnosis. — It  is  evident  from  the  foregoing  description  of  symptoms 
that  the  diagnosis  of  incipient  tuberculosis  is  much  more  difficult  in  children 
than  adults.  Before  commencing  the  examination  it  is  best  to  learn  the 
hereditary  tendencies  of  the  family  and  the  history  of  the  patient,  especially 
as  regards  antecedent  diseases  or  debilitatina;  asrencies,  and  the  duration  of 
the  symptoms. 

Early  and  accurate  diagnosis  of  tuberculo.sis  in  the  child,  as  well  as  in 
the  adult,  is  now  rendered  possible  by  the  discovery  of  the  tubercle  bacillus 
in  1882  by  Koch.  This  bacillus,  abounding  in  the  sputum  as  well  as  in  the 
affected  organs  of  phthisical  patients,  having  a  slender  rod-like  form,  having 


238  TUBERCULOSIS. 

a  length  varying  from  one-fourth  to  the  entire  diameter  of  the  red  blood-cor- 
puscles, and  susceptible  of  a  peculiar  staining  by  the  aniline  colors  which 
differentiates  it  from  all  other  bacilli,  is,  as  we  have  stated  above,  believed  to 
be  uniformly  present  in  tuberculosis  and  absent  in  other  conditions. 

Children  with  tuberculosis  of  the  lungs  expectorate  comparatively  little, 
but  sufficient  sputum  can  probably  be  obtained  in  most  instances  for  the 
purpose  of  diagnosis.  The  presence  of  the  bacillus  indicates  clearly  the 
tubercular  nature  of  the  disease. 

Tuberculosis  of  the  encephalon  is  diagnosticated  with  more  difficulty  than 
that  of  the  thoracic  or  abdominal  organs ;  but  certain  of  these  organs  are  in 
most  patients  tubercular  at  the  same  time,  and  the  knowledge  of  the  fact 
that  they  are  affected  aids  in  the  diagnosis  of  the  disease  of  the  brain  or  its. 
meninges.  Among  the  symptoms  of  intracranial  tuberculosis  which  possess 
diagnostic  value  may  be  mentioned  cephalalgia  and  more  or  less  fever,  with 
exacerbations  in  the  commencement  of  the  disease,  and,  at  a  more  advanced 
period,  strabismus,  inequality  or  irregular  action  of  the  pupils,  impairment 
of  vision,  retraction  of  the  head,  and  convulsive  movements  or  paralysis. 

In  certain  cases  careful  observation  and  discrimination  of  symptoms  are 
requisite  in  order  to  determine  whether  they  arise  from  intracranial  tubercles, 
or  from  congestion  of  the  brain  caused  by  obstruction  in  the  venous  circu- 
lation by  the  pressure  of  enlarged  bronchial  glands. 

The  diagnosis  of  bronchial  phthisis,  when  the  glands  are  still  small,  is. 
necessarily  uncertain,  on  account  of  the  absence  of  symptoms.  When  they 
have  increased  in  size  and  are  so  located  as  to  press  on  the  pneumogastric  or 
recurrent  laryngeal  nerve,  producing  the  spasmodic  cough  already  described, 
the  differential  diagnosis  between  that  disease  and  pertussis  may  be  made  by 
attention  to  the  following  facts  :  Bronchial  phthisis  occurs  singly  and  is  non- 
contagious, while  pertussis  occurs  as  an  epidemic  and  with  evidences  of 
contagion.  There  are  no  successive  stages — to  wit,  those  of  catarrh,  par- 
oxysmal cough,  and  decline — as  in  that  disease,  and  the  cough,  though  par- 
oxysmal, is  short  and  without  whoop  or  vomiting. 

In  feeble  children  with  inherited  tubercular  diathesis,  emaciation,  sweats, 
and  a  chronic  cough,  with  the  absence  of  pulmonary  symptoms,  should  excite 
suspicions  that  the  bronchial  glands  are  involved.  The  evidence  is  almost 
conclusive  if  the  cough  become  paroxysmal  and  there  be  a  loud,  persistent 
tracheal  or  bronchial  rale. 

In  certain  patients  affected  with  this  form  of  tuberculosis  we  have  seen 
that  the  prominent  symptoms  are  due  to  compression  of  one  or  more  of  the 
large  vessels  in  the  chest.  Compression  of  these  vessels,  and  consequent 
retarded  circulation,  may  be  confidently  referred  to  enlarged  bronchial  glands, 
since  aneurism,  carcinomatous  or  other  tumors,  which  would  produce  a  sim- 
ilar result,  are  very  rare  before  puberty.  Sometimes  the  diagnosis  is  rendered 
certain  by  the  physical  signs  observed  by  auscultation  and  percussion  over 
the  sternum  and  the  interscapular  space.  The  condition  of  the  external 
glands  should  also  be  observed,  as  those  of  the  axilla,  neck,  and  groin. 

The  diagnosis  of  pulmonary,  though  more  readily  made  than  that  of 
intracranial  and  bronchial,  tuberculosis  is  often  difficult  and  uncertain.  This 
is  in  part  explained  by  the  fact  that  the  tubercles  are  so  frequently  dis- 
seminated, while  emaciation  and  a  chronic  cough  are  not  infrequent  from 
other  causes  than  tubercles.  Rachitis,  intestinal  worms,  dentition,  simple 
tracheal  or  bronchial  inflammation,  may  be  attended  both  by  a  chronic  cough 
and  emaciation.  Caution  is  therefore  requisite  in  order  to  avoid  a  grave  error 
in  diagnosis.  Precipitancy  in  the  diagnosis  of  doubtful  cases  is  worse  than 
indecision,  and  it  is  often  best  to  postpone  an  expression  of  opinion  as  to  the. 
nature  of  the  disease  till  the  case  has  been  observed  a  few  days. 


DIAGNOSIS. 


239 


The  significance  and  importance  of  the  symptoms,  physical  signs,  and 
other  facts  on  which  a  diagnosis  must  be  based  have  already  been  sufficiently 
pointed  out.  It  is  difficult — in  fact,  in  certain  cases  impossible — to  dis- 
criminate by  the  physical  signs  between  simple  cheesy  pneumonia  and  cheesy 
pneumonia  which  has  ended  in  the  formation  of  tubercles.  The  patient  has 
an  attack  of  catarrhal  pneumonia,  but  instead  of  absorption  of  the  inflam- 
matory product,  cheesy  infiltration  occurs,  and  the  lung  in  places  becomes 
infiltrated  with  pus,  softens,  and  breaks  down.  The  patient  presents  the 
symptoms  and  physical  signs  of  phthisis.  He  may  recover  after  a  protracted 
sickness  or  may  die.  The  disease  may  remain  a  pneumonia  ;  but  this  is  a 
condition  of  the  lungs  which  favors  the  development  of  tubercles,  and  in  a 
certain  proportion  of  cases  tubercles  do  form  in  the  last  weeks  of  life. 
Though  the  differential  diagnosis  in  such  cases  between  cheesy  pneumonia 
and  tuberculosis  supervening  on  pneumonia  is  impossible  by  the  physical 
signs,  practically  the  discrimination  is  unimportant,  as  the  same  treatment 
is  required.  But  it  is  obvious,  from  the  facts  now  ascertained  in  reference 
to  the  tubercle  bacillus,  that  in  all  cases  of  doubtful  diagnosis  the  sputum, 
if  it  can  be  obtained,  should  be  examined  microscopically.  If  the  bacillus 
be  present,  the  diagnosis  of  tubercular  disease  may  be  considered  certain. 

Fig.  25. 


^-^t:^^^V^^'" 


Bacillus  tuberculosis  (Sternberg). 

Advanced  pulmonary  tuberculosis,  except  when  it  supervenes  upon  pneu- 
monia, can  in  most  instances  be  readily  diagnosticated  by  auscultation  and 
percussion  of  the  chest.  Still,  it  is  to  be  recollected,  as  already  pointed  out, 
that  certain  of  the  symptoms  and  physical  signs,  which  occurring  in  the  adult 
would  afford  almost  positive  proof  of  pulmonary  tuberculosis,  not  infrequently 
have  a  different  origin  in  children. 

The  diagnosis  of  tubercles  in  the  abdominal  organs  is  facilitated  by  the 
presence  of  symptoms  which  indicate  at  the  same  time  tuberculosis  of  the 
lungs.  Among  the  chief  diagnostic  signs  of  tuberculosis  of  the  peritoneum 
may  be  mentioned  meteorism   and  a   degree  of  tenderness  on  pressure,  but 


240  TUBERCULOSIS. 

there  is  danger  of  mistaking  the  tympanitic  state  of  the  intestines  common 
in  ill-nourished  infants  and  the  rachitic,  or  the  fulness  due  to  an  enlarged 
spleen  or  liver,  for  that  occasioned  by  peritoneal  tuberculization,  and  mce 
versa.  The  history  of  the  case  and  a  careful  examination  of  accompanying 
symptoms  and  the  shape  and  feel  of  the  abdomen  usually  suffice  to  establish 
the  diagnosis.  In  simple  gaseous  distension  of  the  abdomen  there  is  an 
absence  of  the  symptoms,  general  and  local,  which  attend  tuberculosis ; 
rachitis  occurs  at  an  earlier  age  than  peritoneal  tuberculosis,  and  digital 
examination,  aided  by  percussion,  enables  us  to  diagnosticate  enlargement  of 
the  liver  or  spleen. 

Tubercular  enlargement  of  the  mesenteric  glands  cannot  be  positively 
diagnosticated  when  they  are  small.  When  they  have  attained  such  a  size 
that  they  can  be  felt  through  the  abdominal  walls,  palpation,  in  connection 
with  the  history  and  symptoms  of  tuberculosis,  suffices  to  establish  the  diag- 
nosis. Enlarged  and  tubercular  mesenteric  glands  can  be  diagnosticated  from 
other  tumors  by  the  fact  that  they  are  tender  on  pressure  and  occupy  the 
umbilical  region.  Fecal  accumulations,  from  which  they  are  to  be  diagnos- 
ticated, are  located  in  the  iliac  or  lumbar  region.  Gastro-intestinal  tuber- 
culosis cannot  be  positively  diagnosticated.  Protracted  diarrhoea  or  frequent 
attacks  of  diarrhoea,  not  readily  controlled  by  medicine  and  occurring  in 
tubercular  cases,  are  probably  associated  with  intestinal  ulceration. 

Prognosis. — It  has  long  been  the  belief  in  the  profession,  as  well  as  among 
the  laity,  that  tuberculosis  is  in  the  end,  with  few  exceptions,  fatal,  whatever 
remedial  measures  are  employed,  and  that,  therefore,  remedies  may  ameliorate 
symptoms,  but  do  not  change  the  result.  But  since  attention  has  been  directed 
to  this  subject  a  sufficient  number  of  observations  have  been  made  to  show  that 
tuberculosis  at  an  early  stage  can  in  a  considerable  number  of  cases  be  cured 
or  rendered  latent.  The  late  Professor  Austin  Flint,  in  his  treatise  on  Phthisis, 
published  in  1875,  stated  that  of  670  phthisical  cases  which  came  under  his 
observation,  he  ascertained  by  auscultation  and  percussion  that  the  disease 
had  been  cured  in  44  and  was  non-progressive  in  31  others.  But  the  most 
convincing  proof  of  the  curability  of  tuberculosis  is  furnished  by  the  post- 
mortem examination  of  those  who  have  died  of  other  diseases.  A  cretaceous 
or  fibroid  state  of  the  apex  of  the  lung,  without  tubercles  elsewhere,  may  be 
regarded  as  certain  evidence  of  arrested  tuberculosis.  Now.  two  of  the 
curators  of  large  New  York  hospitals  inform  me  that  they  frequently  find 
cretaceous  or  fibroid  degeneration  at  the  apex  of  the  lung,  without  tubercles 
elsewhere,  in  the  autopsies  in  these  institutions.  One  of  these  gentlemen, 
whose  examinations  are  in  the  dead-house  of  Bellevue  Hospital,  states  that 
this  evidence  of  arrested  tuberculosis  is  present  in  at  least  one-fourth  of  the 
cadavers  which  he  examines,  and  the  Bellevue  Hospital  patients  come  from 
the  most  crowded  and  insalubrious  tenement-houses  of  the  city,  and  have  led 
a  life  of  poverty  and  privation,  and  frequently  of  dissipation.  The  London 
Lancet  (September  22,  1888)  states  that  M.  Vibert  has  examined  the  records 
of  the  necropsies  in  the  Paris  Morgue,  and  that  in  131  subjects  whose  death 
had  been  sudden  from  violence  or  acute  diseases,  the  lesions  of  pulmonary 
tuberculosis  were  present  in  25,  and  in  17  of  these  the  tubercles  had  under- 
gone the  cretaceous  or  fibroid  change,  and  were  practically  cured.  It  is  cer- 
tain, therefore,  that  tuberculosis  of  the  adult  in  its  commencement,  and  when 
affecting  only  a  small  portion  of  the  lung,  is  often  cured  or  rendered  per- 
manently latent. 

It  is  now  known  that  ordinary  serum  circulating  in  the  blood-vessels 
possesses  marked  germicidal  properties,  and  therefore  measures  which  benefit 
the  general  health  and  impi-ove  the  quality  of  this  important  constituent  of 
the  blood  have  a  curative  effect  as  regards  tuberculosis.    The  tubercle  bacillus 


PROPHYLAXIS.  241 

is  an  irritant  to  the  tissues,  and  in  cases  which  are  cured  or  rendered  latent  it 
becomes  surrounded  by  dense  tissue  which  in  time  undergoes  the  cretaceous 
or  fibroid  degeneration.  The  bacilli  in  the  interior  of  the  mass  may  retain 
their  vitality  for  an  indefinite  time,  but,  being  encapsulated,  they  do  no  harm. 
There  can  be  no  doubt  that  many  adults  have  local  tuberculosis,  and  are  cured 
by  improvement  in  their  general  health  and  in  the  quality  of  their  blood, 
without  suspecting  that  they  have  had  this  disease.  In  young  children, 
especially  in  infants,  tubercles  are  frequently  disseminated  in  the  organs, 
and  recovery  under  such  circumstances  must  be  impossible  or  rare  ;  but  local 
tuberculosis  or  tuberculosis  limited  to  certain  glands,  as  the  bronchial,  is  not 
unusual  in  childhood,  and  this  form  of  the  tubercular  disease  may  be  cured 
by  measures  which  improve  the   general  health. 

Hospital  statistics  show  that  the  average  duration  of  the  disease  is  from 
three  to  seven  months.  Under  favorable  circumstances  it  is  more  protracted, 
even  to  two  or  three  years.  Those  succumb  soonest  who  inherit  a  strongly- 
marked  tubercular  diathesis,  live  in  damp,  dark,  and  ill-ventilated  apartments, 
and  whose  diet  is  scanty  or  of  poor  quality.  Therefore  in  the  poor  quarters 
of  the  city  tuberculosis  presents  a  worse  form  and  pursues  a  more  rapid  course 
than  among  families  in  better  circumstances. 

Favorable  prognostic  signs  are  absence  of  tubercular  diathesis,  good 
appetite  and  general  health,  with  little  emaciation,  infrequency  of  cough,  with 
respiration,  pulse,  and  temperature  nearly  normal.  Such  symptoms  may 
afford  hope  of  recovery  with  judicious  regimenal  and  therapeutic  measures. 
On  the  other  hand,  if  the  symptoms  be  grave  death  is  inevitable,  unless  in 
bronchial  phthisis,  in  which,  even  when  there  is  considerable  urgency  of 
symptoms,  the  offending  gland  is  sometimes  eliminated  by  softening  and 
ulceration,  and  the  patient  improves  temporarily,  if  he  do  not  ultimately 
recover.  Complete  and  permanent  recovery  is,  however,  quite  exceptional  in 
bronchial  phthisis,  as  it  is  in  other  forms  of  the  disease.  As  Liebermeister 
has  said,  recovery  in  any  form  of  tuberculosis,  is  impossible  except  in  incipient 
and  very  limited  forms  of  the  disease. 

Death  in  tuberculosis  of  children  may  occur  from  exhaustion  induced  by 
the  general  disease  or  from  the  local  effects  of  the  tubercles.  Thus,  in 
intracranial  tuberculosis  it  may  result  from  meningitis  ending  in  convulsions 
and  coma  ;  in  pulmonary  tuberculosis,  from  dyspnoea,  though  more  frequently 
from  exhaustion  ;  in  that  of  the  bronchial  glands,  from  dyspnoea  or  hemor- 
rhage ;  in  that  of  the  abdominal  organs,  from  peritonitis  or  protracted  diar- 
rhoea. 

Prophylaxis. — Since  tuberculosis  originates  in  so  many  different  ways, 
measures  designed  to  prevent  this  disease  have  a  wide  range.  Precau- 
tionary measures  are  especially  required  in  the  nursing  of  the  tuberculous 
patient.  His  sputum  should  always  be  received  in  a  cup  or  spittoon  contain- 
ing a  disinfectant  liquid,  and  this  vessel  when  emptied  should  be  cleansed 
with  boiling  water  or  a  disinfectant.  Sputum  should  never  be  received  upon 
a  handkerchief  or  cloth  and  allowed  to  dry.  Towels  and  handkerchiefs  should 
be  moist  when  used,  and  immediately  afterward  placed  in  boiling  water  or  a 
disinfectant.  We  have  seen  what  disastrous  results  occur  from  the  dried 
sputum.  Whatever  may  be  said  of  the  innocuousness  of  the  breath  of  the 
phthisical  patient,  based  on  the  supposition  that  the  tubercle  bacillus  has  so 
great  a  specific  gravity  in  its  moist  state  that  it  is  not  exhaled  in  ordinary 
respiration,  nevertheless  the  sad  experience  of  the  midwife  related  in  a 
foregoing  page  should  teach  us  to  avoid  his  breath,  so  far  as  is  com- 
patible with  proper  ministrations  to  him.  The  floors  and  walls  of  his 
apartment  should  occasionally  be  washed  with  a  disinfectant  fluid,  and 
the  bedding,  clothing,  rugs,  and  mats  should  never  be  shaken  in  the  apart- 
16 


242  TUBERCULOSIS. 

ment,  but  outside  the  house.  Ventilation  of  the  apartment  should  be  allowed 
to  the  full  extent  compatible  with  the  safety  of  the  patient.  The  remedies 
which  we  will  hereafter  recommend  in  the  treatment  of  the  patient  are 
destructive  to  the  bacillus,  and  therefore  whenever  employed  have  also  a 
prophylactic  action. 

No  physician  who  has  read  in  the  medical  journals  of  the  last  decade  the 
many  reports  of  cases  in  which  milk  has  been  the  vehicle  of  pathogenic 
organisms  has  failed  to  see  the  urgent  need  of  obtaining  this  indispensable 
article  from  healthy  dairies.  Families  should  insist  on  the  inspection  at 
regular  intervals  of  the  dairies  that  furnish  them  milk,  and  the  exclusion  of 
such  animals  as  exhibit  the  least  sickness.  Moreover,  no  one  with  a  chronic 
cough  should  be  employ-ed  in  milking  or  in  the  subsequent  handling  of  the 
milk.  But  with  the  utmost  endeavor,  on  the  part  of  families  living  at  a  dis- 
tance, to  obtain  milk  free  from  impurities,  no  one  can  state  positively  that  it 
will  not  sooner  or  later  contain  pathogenic  organisms,  as  those  of  diphtheria, 
scarlet  fever,  typhoid  fever,  or  tuberculosis,  so  many  and  unsuspected  are  the 
modes  of  infection.  Fortunately,  heat  at  or  near  the  boiling-point  is  an 
eflPectual  sterilizing  agent,  and  it  can  be  employed  without  diminishing  the 
nutritive  properties  of  milk  or  rendering  it  more  indigestible.  I  do  not  for- 
get the  interesting  experiments  which  have  been  made  to  determine  the  ten- 
acity of  life  of  the  tubercle  bacillus  when  subjected  to  heat  and  cold.  In 
experiments  made  it  is  said  to  outlive  most  of  the  microbes  associated  with 
it.  Schill  and  Fischer  state  that  dried  and  pulverized  tubercular  matter  not 
subjected  to  treatment  retains  its  virulence  six  months,  and  Pietro  states  that 
tubercular  sputum  well  dried  and  maintained  at  77°  retains  its  virulence  nine 
or  ten  months.  But  what  concerns  us  most  at  present  is  the  remarkable 
statement  made  by  Max  Yoelsch  (^Centralb.  fiir  Min.  Med.,  June  30,  1888), 
that  twice  boiling  does  not  entirely  destroy  the  virulence  of  the  tubercle 
bacillus.  I  habitually  direct  that  the  morning  supply  of  milk  designed  for 
children  shall  be  immediately  placed  in  a  steamer  and  subjected  for  two 
hours  to  a  temperature  of  190°  to  200°.  No  pathogenic  microbe  can  prob- 
ably survive  if  subjected  so  long  a  time  to  so  high  a  degree  of  heat.  The 
flesh  of  the  tubercular  animal,  which  it  is  believed  is  often  purchased  by 
unsuspecting  families,  evidently  requires  similar  treatment — that  is,  thorough 
cooking — in  order  to  be  rendered  innocuous.  A  competent  meat  inspector 
should  be  employed  at  each  slaughter-house,  and  all  diseased  meats  be 
rejected ;  but  in  the  present  management  of  the  meat  market  the  only 
sure  method  of  preventing  the  presence  of  living  and  active  bacilli  in 
the   meat  foods   appears  to   be  by   thorough   cooking. 

Outdoor  life,  residence  in  elevated  localities,  where  the  air  is  not  only 
pure  but  rarefied,  the  occupancy  of  sunlit  and  well-ventilated  rooms,  the 
avoidance  of  rooms  or  localities  where  the  air  is  contaminated  by  the  pres- 
ence of  others,  as  in  crowded  schools  or  factories,  or  by  unwholesome  occu- 
pations, and  all  measures  which  promote  the  appetite  and  general  health,  are 
prophylactic,  as  they  are  also  to  a  certain  extent  curative,  of  tuberculosis. 
It  is  evident,  from  what  has  been  stated  above,  that  caseous  substance  occur- 
ring in  any  part  of  the  system,  inasmuch  as  it  sustains  a  close  causal  relation 
to  tuberculosis,  should,  if  practicable,  be  removed  by  surgical  measures. 
Moreover,  since  cheesy  degeneration  results  for  the  most  part  from  inflam- 
mations occurring  in  the  scrofulous,  measures  designed  to  prevent  or  cure 
such  inflammations  or  to  cure  scrofula  have  a  prophylactic  effect  as  regards 
tuberculosis.  The  strumous  child  should  be  watched  with  great  .care,  and 
such  measures  be  employed  as  are  calculated  to  invigorate  his  system.  He 
should  receive  antistrumous  treatment,  both  hygienic  and  medicinal.  Espe- 
cially should  glandular  hyperplasia  and  the  products  of  inflammation,  whether 


TREATMENT.  243 

occurring  in  the  lungs  or  elsewhere,  be,  if  possible,  removed  before  caseation 
occurs.  For  this  purpose  the  old  remedies,  like  cod-liver  oil  and  syrup  of 
the  iodide  of  iron,  given  internally,  and  for  hyperplasia  of  the  subcutaneous 
glands  ointments  like  iodide  of  potassium  in  lanolin,  may  be  advantageously 
employed.  Finally,  one  having  an  abrasion  or  sore  of  the  cutaneous  or 
mucous  surface,  or  catarrh  of  the  air-passages,  as  indicated  by  discharge 
from  the  nostrils,  sore  throat,  or  a  cough,  should  not  attend  as  nurse  or 
otherwise  a  phthisical  patient  until  his  local  ailment  is  cured,  since  the  tuber- 
cle bacillus  is  believed  to  enter  the  system  more  readily  through  a  diseased 
than  a  healthy  surface. 

Treatment. — The  indications  of  treatment  are  twofold :  first,  to  invig- 
orate the  system  in  every  possible  way,  so  that  the  organs  and  tissues  are  in 
a  better  condition  to  resist  the  bacillus  and  the  serum  to  antagonize  and 
desti'oy  it ;  and,  secondly,  the  employment  of  medicinal  agents,  if  such  can 
be  found,  which  are  destructive  to  the  bacillus  and  safe  to  the  patient. 

Measures  designed  to  improve  the  general  health  must  be  chiefly  hygienic, 
and  are  described  in  all  the  text-books.  The  diet  should  consist  of  milk,  the 
meat  preparations,  and  farinaceous  substances,  prepared  in  such  a  way  that 
they  afford  the  maximum  amount  of  nutriment  and  are  easily  digested.  If 
the  digestion  be  poor,  peptonized  food  may  be  advantageously  employed,  and 
pepsin  may  be  taken  with  the  food.  In  1881-82,  Debove  recommended 
gavage  or  forced  feeding  of  consumptives  through  a  flexible  rubber  tube 
having  a  funnel  attachment,  the  tube  being  introduced  into  the  stomach.  He 
employed  meat  preparations,  with  pepsin.  In  the  Medical  News,  October  1, 
1887,  Dr.  S.  Solis-Cohen  of  Philadelphia  also  recommended  gavage  in  the 
treatment  of  phthisis.  A  quart  of  milk,  two  tablespoonfuls  of  beef  powder, 
three  eggs,  fifteen  grains  of  scale  pepsin,  and  thirty  drops  of  dilute  muriatic 
acid  were  warmed  and  administered  twice  daily  through  a  stomach-tube,  a 
patient  eating  what  he  wished  in  the  interval.  Gavage  has  been  employed 
by  certain  European  physicians  in  the  treatment  of  children  suff'ering  from 
various  forms  of  innutrition,  and  it  seems  probable  that  tubercular  patients 
may  be  benefited  by  it  in  some  instances.  In  the  ordinary  mode  of  feeding 
the  predigested  foods  can  often  be  used  with  benefit  by  consumptives,  inas- 
much as  they  have,  for  the  most  part,   feeble  digestion. 

As  regards  the  hygienic  measures  designed  to  arrest  tuberculosis,  the 
most  important,  next  to  the  use  of  proper  food  and  the  employment  of  such 
aids  to  nutrition  as  cod-liver  oil  and  the  alcoholic  preparations,  is  outdoor  life, 
and,  if  possible,  in  localities  having  a  high  altitude.  The  late  Professor  Flint, 
in  examining  the  records  of  62  cases  of  arrested  phthisis  which  came  under 
his  observation,  ascertained  that  the  principal  agent  in  afi"ecting  this  result 
was  exercise  in  the  open  air.  He  therefore  strongly  recommended  this  mode 
of  life  to  consumptives,  and  also  constant  ventilation  of  their  sleeping  apart- 
ments, even  in  the  winter  season,  the  danger  of  taking  cold  being  averted  by 
maintaining  sufficient  warmth  of  air  by  a  fire.  Dr.  James  Blake  has  also 
reported  instances  of  recovery  of  phthisical  patients  who  lived  during  the 
five  or  six  months  of  the  dry  season  in  the  open  air  upon  the  Coast  Range 
of  mountains  in  California  at  an  altitude  of  3000  to  5000  feet.  These 
patients  were  in  the  open  air  night  and  day,  without  even  the  protection 
of  tents. 

Residevce  at  a  High  Altitude. — The  London  Lancet,  May  26,  1888,  con- 
tains the  abstract  of  a  paper  read  before  the  Medico-Chirurgical  Society  of 
London  by  Dr.  Williams,  recommending  residence  at  a  high  altitude  as  an 
efficient  means  of  checking  the  progress  of  tuberculosis.  He  states  that  of 
1-11  patients  who  had  employed  the  high-altitude  treatment,  1-4.13  per  cent, 
were  completely  cured,  29.78  per  cent,  were  much  benefited,  11.34  per  cent. 


244  TUBERCULOSIS. 

were  more  or  less  benefited,  and  17.02  per  cent.,  including  13.47  per  cent, 
who  died,  continued  to  grow  worse.  Drs.  Quain  and  Pollock,  in  discussing 
ttis  paper,  expressed  the  opinion  that  consumptives  who  improve  at  a  high 
altitude  improve  equally  with  the  same  treatment  at  lower  elevations ;  in 
other  words,  that  residence  at  a  high  altitude  does  not  influence  the  result. 
Brehmer,  on  the  other  hand,  believes  that  the  inhabitants  have  immunity 
from  tuberculosis  at  an  altitude  of  1500  feet  in  Germany,  of  4500  to  5000 
feet  in  Switzerland,  and  10,000  to  15,000  feet  at  the  equator  {Die  Therapie 
Chronische  Lunijenheschwerden^  Wiesb.,  1887).  The  most  apparent  and  notable 
peculiarity  in  the  air  at  high  elevations,  apart  from  its  purity,  is  its  rarefac- 
tion. At  an  altitude  of  9000  feet  above  the  level  of  the  sea  it  is  said,  from 
observations  made,  that  the  air  is  so  rarefied  that  three  times  the  usual 
exercise  of  the  lungs  is  required  to  meet  the  demands  of  the  system.  Dr. 
Mays  states  in  a  paper  published  in  the  Medical  News,  November  27,  1886, 
that  the  Quichua  Indians,  on  the  lofty  plateaus  of  Peru,  constantly  breath- 
ing a  rarefied  air,  "  acquire  enormous  dimensions  "  of  the  chest,  due  to  an 
increase  in  the  size,  and  perhaps  number,  of  the  air-cells.  More  numerous 
and  more  exact  observations  are  required  in  order  to  determine  whether  or  to 
what  extent  residence  at  a  high  altitude  is  beneficial  to  consumptives,  and, 
if  it  exerts  a  controlling  effect  on  the  disease,  whether  this  result  is  due  to 
the  increased  pulmonary  expansion  and  activity  or  to  other  causes.  Certainly, 
from  observations  already  made,  we  are  justified  in  recommending  outdoor 
life  in  a  mild  and  equable  climate,  and  also  residence  at  high  elevations  if  the 
cold  is  not  too  severe. 

Residence  in  the  Evergreen  Forests  and  the  Use  of  Turpentine. — In  an 
interesting  paper  read  before  one  of  the  societies,  and  subsequently  pub- 
lished, Dr.  A.  L.  Loomis  states  his  belief  that  the  terebinthinate  vapors  in 
the  evergreen  forests  possess  healing  properties  for  consumptives.  He  quotes 
the  statement  of  Ringer  that  turpentine  employed  as  a  medicine  enters  the 
blood,  and  may  be  detected  in  the  breath,  the  perspiration,  and  in  an  altered 
form  in  the  urine  of  the  patient.  The  presence  of  the  vapor  of  turpentine 
in  the  pine  forest.  Dr.  Loomis  remarks,  cannot  be  doubted,  and  its  "  local  and 
constitutional  eflfects,"  he  adds,  "  are  those  of  a  powerful  germicide  as  well  as 
stimulant."  Dr.  Loomis  quotes  the  opinion  of  Mr.  Kingsett  that  turpentine, 
during  its  oxidation,  evolves  the  peroxide  of  hydrogen,  and  therefore  by  the 
"  oxidation  of  the  terebinthinates  there  is  produced  in  extensive  pine  forests 
an  almost  illimitable  amount  of  peroxide  of  hydrogen,  which  renders  the 
atmospheres  of  such  forests  antiseptic."  He  believes  that  the  peroxide  of 
hydrogen  so  abundantly  produced  in  pine  forests  "  successfully  arrests  putre- 
factive processes  and  septic  poisoning,"  and  therefore  he  recommends  resi- 
dence in  the  pine  forests  as  one  of  the  most  efficient  means  of  relieving  the 
symptoms  of  tuberculosis  and  retarding  the  progress  of  this  fatal  malady. 
At  high  altitudes  the  coniferous  or  evergreen  trees  usually  predominate,  and 
if  the  views  of  Professor  Loomis  be  substantiated  by  future  investigations, 
it  may  be  that  the  benefit  believed  to  be  obtained  by  consumptives  at  high 
elevations  is  partly  due  to  the  exhalations  from  these  trees. 

The  bacteriologists  who  have  cultivated  the  tubercle  bacillus,  and 
observed  the  action  upon  it  of  the  various  agents  which  have  been  employed 
and  extolled  by  clinical  observers,  state  that  most  of  these  agents  do  not 
penetrate  the  tubercular  mass — that  while  they  may  destroy  the  superficial 
bacilli,  they  do  not  affect  those  more  deeply  seated,  and  therefore  fail  to 
arrest  the  disease.  But  turpentine  and  its  derivatives  appear  to  penetrate 
the  tissues  as  deeply  as  almost  any  other  agent,  and  therefore,  if  they  are 
sufficiently  antiseptic  and  not  too  irritating,  we  may  expect  good  results 
from  their  judicious  use.     But  it  is  probable  that  they  are  less  efficient  as 


TREATMENT.  245 

germicides  than  some  of  the  other  agents  which  can  be  safely  employed,  and 
therefore  should  be  recommended  only  as  adjuvants,  or  as  remedies  which 
may  give  some  relief  to  the  catarrhal  and  other  symptoms  without  exerting 
any  marked  antiseptic  actibn.  Hohnfeld  states  that  he  applied  oil  of  turpen- 
tine to  fresh  colonies  of  the  micrococcus  prodigiosus  and  staphylococcus 
aureus,  and  that  it  exerted  little  destructive  or  retarding  effect  on  these 
micro-organisms.'  These  experiments  would  lead  us  to  distrust  the  germi-' 
cide  action  of  turpentine  and  the  terebinth  in  ate  preparations  in  tuberculosis, 
for  the  tubercle  bacillus  is  tenacious  of  life  beyond  most  other  microbes. 
But  the  alleged  good  results  of  teaspoonful  doses  of  the  oil  of  turpentine  in 
that  other  microbic  disease,  diphtheria,  certainly  justify  the  experimental 
use  of  the  agent  in  tuberculosis. 

Terebene,  produced  by  the  action  of  gaseous  hydrochloric  acid  on  tur- 
pentine, has  been  prescribed  in  tuberculosis  and  chronic  bronchial  catarrhs, 
with  some  apparent  benefit.  An  adult  should  take  ten,  increased  to  twenty, 
drops  three  times  daily.  A  child  can  take  a  dose  proportionate  to  the  age. 
The  following  formula  has  been  recommended : 

R.  Terebene,  3iv; 

Pulv.  acaciae,  3"j ! 

Aquce,  .^ij; 

Syr.  zingiberis,  3J.     M. 

Dose  :  One  teaspoonful  three  times  daily  for  an  adult ;  a  dose  proportionate  to  the  age 
for  children. 

Terebene  can  also  be  employed  in  inhalation  fi'om  Robinson's  inhaler,  or, 
properly  diluted,  from  the  hand-  or  steam-atomizer.  It  has  been  adminis- 
tered in  ten-drop  doses  to  some  of  the  adult  consumptives  in  my  wai'ds  in  the 
Charity  Hospital,  and  the  resident  physician  who  had  charge  of  these  cases 
writes  me  as  follows  :  "  I  am  satisfied  that  in  nearly  all  cases  of  dyspnoea  it 
is  of  value.  In  some  it  affords  marked  relief,  and  I  have  had  patients  tell 
me  that  it  gave  the  most  relief  of  anything.  Others  say  that  it  aff"orded 
some  relief.  It  makes  expectoration  in  some  patients  markedly  more  easy 
and  the  sputum  much  thinner  ;  in  others  the  effect  is  only  slight  or  moderate." 
It  probably  aids  in  relieving  the  catarrh  which  accompanies  tuberculosis. 

Hot-air  Inhalations. — Halter  states  that  workers  in  a  limekiln,  breathing 
dry  air  at  a  temperature  of  122°  to  156°  F.,  were  exempt  from  phthisis  dur- 
ing a  period  of  fifteen  years  in  a  locality  where  this  disease  was  common. 
He  also  states  that  the  most  favorable  temperature  for  the  growth  of  the 
bacilli  is  98.6°  to  104°  F.,  and  that  a  temperature  of  105.8°  destroys  them. 
Moreover,  his  experiments  have  shown  him  that  the  inhalation  of  dry  air  at 
a  temperature  of  248°  to  256°  raises  the  temperature  of  the  expired  air  to 
about  109.7° — a  degree  of  heat  which,  he  says,  is  fatal  to  the  bacillus.^  Dr. 
E.  Krull  states  that  for  more  than  two  years  he  has  treated  consumptives 
with  the  inhalation  of  hot  air  heated  to  132°  F.,  and  that  this  raised  the 
temperature  of  the  expired  air  to  not  less  than  107.6°,  and  incipient  cases 
seemed  to  derive  benefit  fi-om  this  treatment.  Dr.  Weigert  of  Berlin  has 
constructed  an  apparatus  for  the  inhalation  of  hot  air  which  was  employed  for 
a  time  in  the  wards  of  Charity  Hospital,  but  it  did  not  seem  to  give  as  much 
relief  as  the  antiseptic  inhalations  which  have  been  used  by  the  same  patients. 

Dr.  Trudeau  of  Saranac  Lake  prescribed  the  hot-air  treatment  in  four  cases 
four  hours  each  day,  the  temperature  of  the  inhaled  air  being  392°  F.  The  first 
and  second  patients  improved  slightly  at  first,  but  refused  the  treatment,  the 
one  after  one  month,  and  the  other  after  six  weeks.     The  third  patient  was 

^  Forlschriite  der  MerUein,  October  1,  1887. 

^  Berliner  klinische  Wochenschrift,  September  3,  1888. 


'246  TUBERCULOSIS. 

treated  three  months  without  the  least  appreciable  effect.  The  fourth  patient 
was  treated  four  months,  with  manifest  improvement  in  her  physical  signs 
and  general  health,  but  no  more  improvement  than  frequently  occurs  from 
any  new  mode  of  treatment.  In  all  the  cases  the  sputum  was  examined 
before,  during,  and  after  the  treatment,  and  in  every  examination  the  tuber- 
cle bacillus  was  present.  The  result  claimed  for  the  hot-air  treatment  had 
not  been  obtained — that  is,  the  destruction  of  the  bacilli ;  and  if  they  are 
not  destroyed  in  the  sputum,  certainly  they  are  not  in  the  tissue  of  the  lung. 
Therefore  there  can  be  little  doubt  that  the  hot-air  inhalations,  so  far  from 
coming  into  general  use.  will  be  discarded,  not  only  because  they  are 
unpleasant  to  the  patient,  but  are  inefficient.  There  is  always  a  large  amount 
of  residual  air  in  the  alveoli,  and  there  can  be  little  doubt  that  in  the  hot-air 
inhalations  the  air  in  the  alveoli  and  terminal  bronchial  tubes  never  attains 
the  elevation  of  temperature  of  the  air  that  is  inhaled,  nor  of  that  which 
is  exhaled.  Moreover,  as  we  have  seen,  the  tubercle  bacillus  resists  the 
destructive  action  of  high  temperature.  It  is  said  to  retain  its  vitality 
in   liquids  which  have   been  twice  heated  to  the  boiling-point. 

Creosote. — Of  the  many  medicines  which  have  been  recently  employed 
in  the  treatment  of  tuberculosis,  creasote  appears  to  have  given  more  gen- 
eral satisfaction  than  any  other.  I  am  informed  that  the  late  Dr.  Cammann, 
the  inventor  of  the  binaural  stethoscope,  employed  it  twenty  years  ago  in 
the  treatment  of  tuberculosis,  but  it  was  seldom  prescribed  for  this  disease 
until  within  the  last  decade.  In  the  Berliner  Minische  Wochenschriftj  July 
20,  1886,  Von  Brunn  states  that  he  has  treated  1700  phthisical  patients  in 
the  last  eight  years  with  creasote,  giving  to  adults  not  less  than  six  to  eight 
drops  in  twenty-four  hours.  He  employed  it  in  solution  with  tincture  of 
gentian  and  wine,  and  believes  that  he  obtained  good  results,  especially  in 
acute  unilateral  cases.  Professor  Sommerbrodt  states^  that  he  employed 
creasote  in  about  5000  phthisical  cases  during  the  preceding  nine  years.  At 
first  he  used  Bouchard's  solution  of  creasote,  and  afterward  gelatin  capsules, 
each  containing  three-fourths  of  a  grain  of  creasote  and  three  minims  of  the 
balsam  of  Tolu.  The  amount  of  creasote  administered  daily  to  the  patients 
who  were  adults  was  increased  gradually  from  one  capsule  to  not  less  than 
nine.  As  many  as  600  to  2000  capsules  were  given  to  each  patient  without 
a  break.  In  many  cases  the  improvement  Avas  marked,  not  only  in  the 
symptoms  and  in  the  general  health,  but  also  in  the  physical  signs.  He 
believes  that  he  has  cured  cases  by  insisting  on  a  continuance  of  the  treat- 
ment. To  show  the  good  effect  of  creasote,  he  cites  the  case  of  a  student 
of  sixteen  years,  with  tuberculosis  of  the  right  lung,  who  took  three  cap- 
sules three  times  daily,  or  about  seven  and  a  half  grains  per  diem.  His 
cough  abated,  his  weight  increased  six  pounds  in  two  months,  his  expectora- 
tion had  ceased.  Instead  of  the  dull  percussion  sound  over  the  apex  of  the 
right  lung,  only  a  slight  rhonchus  was  observed,  and  his  general  health  had 
greatly  improved. 

Many  others  who  have  employed  creasote  during  the  last  two  or  three 
years,  both  in  this  country  and  in  Europe,  report  favorable  results.  Striim- 
pell  says  that  it  produces  no  ill  effects,  and  in  large  doses  it  frequently  causes 
improvement  in  such  symptoms  as  the  cough,  expectoration,  and  appetite,  but 
he  doubts  whether  it  exerts  any  marked  curative  effect  upon  the  disease.  It 
has  been  employed  during  the  last  year  in  Charity  Hospital,  and  the  resident 
physician  who  had  charge  of  the  ward  in  which  it  was  used  writes  to  me 
that  it  "  seems  to  possess  some  staying  influence  over  the  progress  of  the 
disease."  In  the  New  York  Foundling  Asylum  creasote  in  cod-liver  oil  has 
been  administered  during  the  last  year  to  the   few  phthisical  patients  under 

^  Medical  Chronicle,  July,  1887. 


TREATMENT.  247 

treatment,  in  doses  of  one  drop  three  or  four  times  daily  to  children  of  three 
or  four  years,  and  Dr.  Lynde,  the  resident  physician,  thinks  that  it  has  been 
the  most  useful  of  the  remedies  employed. 

During  the  past  year  I  .have  pre.scribed  creasote  for  internal  use  in  the 
following  formula  : 

R.  (.'reasoti  (Morson's), 
Spiriti  fliloroibrmi, 
Alcoholis,  da.  5Si3.     M. 

Dose  for  an  adult,  nine  drops  three  times  daily  in  half  a  teacupful  of  water 
containing  a  tablespoonful  of  brandy  or  two  tablespoonfuls  of  wine.  The  nine 
drops  of  the  mixture,  containing  three  of  the  creasote,  have  been  increased  to 
twelve  drops,  or  four  of  creasote,  and  thus  far  in  my  practice  patients  believe 
that  they  have  been  benefited  by  this  remedy,  and  have  desired  to  continue 
it.  At  the  same  time,  in  some  instances  I  have  recommended  the  inhalation 
of  ten  or  fifteen  drops  of  the  same  mixture  from  Robinson's  inhaler.  This 
dose  of  creasote,  three  or  four  drops,  may  seem  large,  but  it  is  tolerated  Avhen 
sufiiciently  diluted,  though  it  may  be  best  to  commence  with  a  smaller  quan- 
tity. Children  should  of  course  take  doses  proportionate  to  the  age,  the  frac- 
tional part  of  a  drop  being  sufficient  for  infants.  Creasote  has  also  been 
injected  into  the  tubercular  lung  through  the  chest-walls  by  several  physicians, 
a  syringe  provided  with  a  long  and  delicate  needle  being  used.  Rosenbusch 
injected  eight  drops  of  a  3  per  cent,  solution  of  creasote  in  almond  oil  in  two 
places  at  the  seat  of  the  disease,  or  sixteen  drops  in  all.  The  result  was  a 
marked  diminution  of  the  cough,  the  sweats,  the  amount  of  sputum,  and,  in 
recent  cases,  an  increase  in  weight.  The  beech  creasote  was  used,  and  the 
skin  and  apparatus  were  first  sterilized  by  an  antiseptic  lotion.  When  the 
instrument  was  not  introduced  deeply  enough,  a  sharp,  pleuritic  pain  some- 
times occurred,  but  it  soon  abated.  Creasote  appears  to  be  the  most  valuable 
of  the  recent  remedies  recommended  for  tuberculosis,  but  in  order  to  deter- 
mine its  exact  value,  the  proper  mode  of  employing  it,  and  the  size  and  fre- 
quency of  the  dose,  more  extended  observations  are  required.  Friintzel  says 
that  experiments  have  shown  that  this  substance  is  inimical  to  the  growth  of 
the  bacillus  when  mingled  in  minute  quantity  with  a  gelatin  culture-medium, 
and  on  this  fact  is  based  its  internal  administration.  When  it  is  injected  into 
the  lungs  through  the  chest-walls.  Dr.  E.  G.  Janeway  of  New  York  believes 
that  it  is  very  important  that  the  almond  oil  or  other  vehicle  employed  should 
be  first  sterilized. 

In  the  present  state  of  our  knowledge  of  the  use  of  antiseptics  in  the 
treatment  of  tuberculosis  creasote  is  the  one  which  is  most  deserving  of  con- 
fidence and  employment.  In  New  York  City,  in  the  present  epidemic  of 
measles,  in  cases  of  protracted  broncho-pneumonia  with  emaciation,  the 
symptoms  indicating  the  probability  of  cheesy  degeneration  and  commencing 
tuberculosis,  the  patients  being  young  children,  I  am  prescribing  the  hourly 
inhalation  of  the  vapor  of  creasote,  one  part  to  ten  or  fifteen  of  terebene, 
fifteen  to  twenty-five  minims  of  the  mixture  being  dropped  on  blotting-paper 
in  the  bottom  of  a  teacup.  Children  willingly  inhale  this  vapor  five  or  ten 
minutes  at  a  time,  with  some  apparent  relief  of  symptoms.  At  the  same 
time,  I  employ  creasote  internally  if  marked  symptoms  of  tuberculosis  ajjpear. 
The  following  prescription  has  been  considerably  employed . 

R.  Creasote,  TTL31  ; 

Tine,  gentian.,  ^72; 

Alcohol,  .^x ; 

Tokay  or  Malaga  wine,  5V.     Misce. 

Dose :  One  teaspoonful  three  times  daily  to  an  adult ;  a  dose  proportionate  to  the  age 
for  a  child. 


248  TUBERCULOSIS. 

Iodoform. — This  agent,  dissolved  in  ether  and  inhaled,  has  been  recom- 
mended. It  apparently  gives  some  relief  to  the  cough,  and  possibly  to  other 
symptoms,  but  the  belief  that  it  is  destructive  to  the  bacillus  has  been  shown 
to  be  fallacious  by  the  experiments  of  Roosing,  who  inoculated  the  eye  of  a 
rabbit  with  tubercular  matter  mixed  with  iodoform,  and  the  iodoform  did  not 
prevent  or  retard,  but  apparently  accelerated,  the  development  of  tubercle  at 
the  point  of  inoculation  by  its  irritating  eflPect  upon  the  eye.^  Iodoform  can- 
not, therefore,  be  recommended  as  a  curative  agent  in  tuberculosis. 

Biniodide  of  Mercury,  Corrosive  Sublimate. — Miguel  and  Rueff  employed 
a  solution  of  biniodide  of  mercury,  1  part  to  40,000,  as  a  germicide  spray  in 
tuberculosis.  They  state  that  of  27  patients  treated  by  this  spray,  19  improved, 
and  the  remaining  8  were  neither  made  better  nor  worse.  It  is  unfortunate 
that  the  results  of  treatment  by  the  biniodide,  as  observed  by  these  physicians, 
were  not  stated  more  in  detail.  If  they  relied  entirely  on  the  opinions  of  the 
patients,  they  may  have  been  deceived,  for  patients  with  chronic  diseases 
often  believe  for  a  time  that  they  are  benefited  by  new  modes  of  treatment 
when  there  is  no  actual  improvement. 

The  fact  that  corrosive  sublimate,  employed  internally  and  locally  in  the 
treatment  of  diphtheria,  has  the  confidence  of  the  profession  as  an  efficient 
germicide  suggests  its  use  in  the  treatment  of  other  microbic  maladies. 
Moreover,  its  use  in  diphtheria  has  shown  us  what  doses  of  this  powerful 
agent  can  be  safely  prescribed.  I  am  not  aware  that  corrosive  sublimate  has 
been  employed  internally  in  the  treatment  of  tubercular  patients,  but  it  has 
been  used  as  a  spray.  In  the  Charity  Hospital  several  of  the  patients  inhaled 
from  the  atomizer  one  teaspoonful  of  an  aqueous  solution  of  corrosive  subli- 
mate, two  grains  to  the  pint,  every  three  to  six  hours,  and  both  the  patients 
and  house-physicians  believe  that  it  acts  beneficially  in  relieving  symptoms, 
especially  the  cough.  It  cannot  be  doubted  that  the  spray  employed  as  often 
as  every  third  hour  disinfects  the  sputum  to  a  great  extent,  and  destroys  the 
bacilli  upon  the  surface  of  the  larynx,  bronchial  tubes,  and  in  the  alveoli,  but 
whether  benefit  may  accrue  to  consumptives  from  its  internal  use  we  have  not 
sufficient  data  for  determining. 

Another  medicine  which  has  been  considerably  employed  in  Europe,  and 
in  regard  to  which  opposite  opinions  are  expressed,  is  hydrofluoric  acid. 
MM.  Seller  and  Garcin  of  Paris  detailed  the  results  of  their  use  of  this  agent 
in  a  paper  published  in  1887  in  the  Bulletin  de  VAcademie  de  Midecine. 
They  state  that  of  100  tubercular  patients  treated  by  hydrofluoric  acid,  35 
were  cured,  41  exhibited  more  or  less  improvement  in  symptoms,  14  were 
not  benefited,  and  10  died.  They  state  that  in  the  favorable  cases  rapid 
improvement  was  observed  in  the  symptoms,  such  as  the  fever,  night-sweats, 
dyspnoea,  and  expectoration.  Griacomi  of  Berne  employed  a  mixture  of  100 
grammes  of  hydrofluoric  acid  with  300  grammes  of  water  in  a  vessel  over  a 
spirit-lamp :  8  patients  inhaled  the  vapor  one  hour  each  day.  In  1  marked 
relief  occurred  ;  in  another  some  temporary  improvement  took  place  as  regards 
the  appetite  and  dyspncea,  but  in  the  remaining  6  the  result  was  negative. 
No  discomfort  resulted  from  the  inhalation,  though  from  the  well-known  action 
of  hydrofluoric  acid  the  window-panes  became  more  or  less  opaque.  Gager 
has  treated  17  cases  with  the  vapor  of  hydrofluoric  acid  with  the  following 
result :  In  5  the  bacilli  disappeared  from  the  sputum  and  the  auscultatory 
signs  improved  in  a  marked  degree ;  in  7  some  improvement  in  the  physical 
signs  occurred  ;  in  12  the  weight  increased  ;  in  5  cases  no  result.^  Grancher 
and  Chautard  experimented  with  hydrofluoric  acid  on  rabbits,  and  they 
express  the  opinion  that  the  vapor  of  this  agent  does  not  penetrate  sufficiently 

^  London  Lancet,  January  21,  1888. 

*  Deutsche  medicinishe  Wochenschrift,  1888,  p.  597. 


TREATMENT.  249 

to  destroy  bacilli  in  the  depth  of  the  tissues.  Trudeau  states  that  the  vapor 
of  hydrofluoric  acid  is  efficient  as  an  antiseptic,  and  seems  to  possess  greater 
penetrability  than  the  ordinary  antiseptic  sprays ;  but  it  can  only  destroy 
those  bacilli  with  which  the  inhaled  vapor  conies  in  contact;  therefore,  the 
bacilli  imbedded  in  the  tubercular  nodules  and  the  tissues  escape.'  Professor 
Jaccoud  inoculated  guinea-pigs  with  tubercular  sputum  which  had  been  sub- 
jected to  the  action  of  hydrofluoric  acid,  and  produced  tuberculosis  with  this 
sputum  as  certainly  as  with  sputum  not  thus  treated.  From  these  experi- 
ments and  others  performed  under  his  direction  Jaccoud  believes  that  the 
vapor  of  hydrofluoric  acid,  employed  in  any  safe  manner,  does  not  destroy 
the  tubercle  bacillus  or  notably  diminish  its  virulence.'^  Therefore,  the  good 
effects  from  the  use  of  this  medicine  claimed  for  it  by  those  who  first  employed 
it  have  not  been  realized  in  the  practice  of  more  recent  observers,  so  that  we 
cannot  recommend  its  employment  in  the  place  of  remedies  which  have  pro- 
duced favorable  results. 

Rectdl  I)ijfCtions  of  Sulphuretted  Hydrogen. — This  treatment  was  first 
employed  by  Dr.  Bergeon  of  Lyons,  and,  being  highly  recommended  by  him, 
has  been  prescribed  by  many  physicians  in  Europe  and  America.  Its  real 
value  has  now  been  apparently  fully  ascertained.  The  history  of  its  use  is 
instructive,  since  it  shows  how  a  mode  of  treatment  which  is  inert  may  gain 
the  confidence  of  intelligent  physicians.  The  British  Medical  Journal.,  May 
21,  1887,  states  that  Dr.  S.  Cayhill  of  the  Isle  of  Wight  has  employed  Ber- 
geon's  treatment  in  private  and  hospital  practice  with  the  most  encouraging 
results.  He  believes  it  is  the  greatest  advance  ever  made  in  the  therapeutics 
of  pulmonary  diseases.  Dr.  Henry  Bennet  also  notices  favorably  Bergeon's 
treatment  in  the  same  journal  for  December,  1886.  The  late  Dr.  Bruen  of  the 
University  of  Pennsylvania  treated  25  cases  by  Bergeon's  method,  employing 
twice  daily  from  three  quarts  to  a  gallon  of  the  gas  slowly  introduced.  In  nearly 
all  the  cases  the  night-sweats  ceased,  the  cough,  expectoration,  and  frequency 
of  the  pulse  diminished,  and  the  temperature  fell  half  a  degree  to  one  degree. 
On  the  other  hand,  Drs.  Shattuck  and  Jackson  of  Boston  employed  Ber- 
geon's treatment  in  7  cases.  No  odor  of  the  gas  could  be  detected  in  the 
breath  of  these  patients  after  its  use,  and  paper  moistened  with  a  solution  of 
the  acetate  of  lead  was  not  blackened  when  held  before  the  mouth.  The  only 
result  which  might  be  attributed  to  the  enemata  was  some  diminution  in  the 
expectoration.  Professor  Austin  Flint  has  made  experiments  in  order  to 
determine  whether  sulphuretted  hydrogen  introduced  per  rectum  or  by  sub- 
cutaneous injection  enters  the  lungs.  He  tested  the  expired  air  by  holding 
before  the  mouth  white  filter-paper,  moistened  with  a  solution  of  acetate  of 
lead.  He  ascertained  that  sulphuretted  hydrogen  was  not  exhaled  at  all,  or 
was  exhaled  in  small  quantity  and  for  a  period  not  exceeding  three  minutes. 
The  presumption  is,  therefore,  strong  that  sulphuretted  hydrogen  employed 
per  rectum  or  subcutaneously  in  some  instances  does  not  enter  the  lungs,  and 
in  other  instances  enters  them  in  small  quantity  and  is  quickly  expelled. 
Dr.  Grauer  placed  cultures  of  the  tubercle  bacillus  as  well  as  of  other  patho- 
genic germs  in  test-tubes,  and  subjected  them  to  a  current  of  sulphuretted 
hydrogen  from  two  hours  to  a  longer  time,  and  yet  their  vitality  was  pre- 
served, so  that  successful  inoculations  or  cultures  were  produced.  Dr.  E.  C. 
Trudeau  of  Saranac  Lake  says  that  in  May,  1887,  a  tube  containing  a  pure 
culture  of  the  tubercle  bacillus  was  subjected  for  thirty  minutes  to  a  stream 
of  undiluted  sulphuretted  hydrogen  made  from  sulphide  of  iron  and  sulphuric 
acid.  The  conducting  tube  was  pushed  through  the  cotton  and  held  within 
half  an  inch  of  the  coagulated  serum,  and  the  jet  of  gas  allowed  to  pla}'  freely 
on  the  bacilli  upon  its  surface.     The  entire  mass  soon  became  so  blackened 

^  Medical  jVtws,  May  5,  1888.  ^  London  Lancet,  November  10, 


250  TUBERCULOSIS. 

by  the  action  of  the  sulphur  as  to  resemble  dark-gray  paint.  The  microbes 
thus  treated  were  then  mixed  with  the  sterilized  water  and  injected  into  the 
pleural  cavites  of  two  full-grown  rabbits.  These  animals  were  then  placed 
in  a  large  box,  well  fed,  and  kept  under  a  shed  in  the  open  air  all  summer. 
On  October  19th,  one  hundred  and  sixty -two  days  after  the  inoculation,  both 
rabbits  died  within  two  hours  of  each  other,  and  both  were  found  to  have 
cheesy  bronchial  glands  and  advanced  pulmonary  tuberculosis.  The  benefit, 
therefore,  supposed  by  some  to  be  derived  from  Bergeon's  treatment  is  prob- 
ably due  to  hygienic  measures. 

Sulphurous  Acid. — Dr.  Dariex,  in  a  monograph  published  in  the  Bulletin 
general  de  Therapeutique.,  February  29,  1888,  states  that  Galen,  in  the  second 
century,  recommended  the  sulphurous  air  of  volcanoes  for  consumptives.  In 
recent  times  attention  has  been  drawn  to  the  beneficial  effects  of  the  inhala- 
tion of  sulphurous  vapors  in  tuberculosis  by  M.  Salland,  an  army  surgeon. 
A  sergeant  having  this  disease,  which  was  progressing  notwithstanding  active 
medication,  was  placed  in  charge  of  the  rooms  in  the  barracks  in  which  sul- 
phur was  burned  for  disinfecting  purposes.  This  service  obliged  him  to  pass 
nine  hours  each  day  in  a  sulphurous  atmosphere.  At  the  end  of  sixty-five 
days  he  was  cured.  M.  Auriol,  having  observed  the  good  effect  of  the  inhala- 
tion of  sulphurous  acid  upon  certain  consumptives  whose  occupation  com- 
pelled them  to  live  in  an  atmosphere  charged  with  this  gas,  fitted  up  a  room 
for  the  treatment  of  this  disease.  The  flowers  of  sulphur,  slightly  moistened 
with  alcohol,  was  burnt  in  the  corner  of  the  room.  Soon  the  patient  began 
to  have  paroxysms  of  coughing,  but  he  did  not  leave  the  room  until  moistened 
test-paper  began  to  redden  ;  if  the  respiration  was  much  oppressed,  he  left  the 
room  sooner  or  the  window  was  opened.  In  order  to  render  the  vapor  less 
irritating  and  the  paroxysms  of  coughing  less  severe,  a  little  benzoin  or  pow- 
dered opium  was  added  to  the  sulphur.  These  inhalations  were  practised 
morning  and  evening,  the  patient  fasting  and  afterward  exercising  in  the 
open  air.  Appropriate  medication,  according  to  the  symptoms,  completed 
the  treatment.  Seventy  patients,  at  different  stages  of  tuberculosis,  were 
subjected  by  M.  Auriol  to  the  inhalation  of  the  sulphur  vapor.  Their  sputa, 
previously  examined,  contained  bacilli,  and,  inoculated  in  the  guinea-pig, 
caused  phthisis  in  a  short  time.  Thirty  of  these  patients,  who  were  in  incip- 
ient tuberculosis,  obtained  an  arrest  of  the  progress  of  the  disease,  disappear- 
ance of  the  fever  and  sweats,  return  of  the  appetite,  and  increase  in  weight. 
The  bacilli  disappeared  from  the  sputum.  M.  Auriol  believes  that  these 
cases  are  cured,  since  the  improvement  has  continued  more  than  two  years. 
The  tubercles,  he  thinks,  are  transformed  into  fibrous  tissue.  Twenty  others 
■of  the  seventy  tubercular  cases  did  not  have  this  treatment  long  enough  to 
determine  its  value,  or  received  it  in  an  irregular  manner.  Nevertheless,  they 
stated  that  they  derived  benefit  from  it.  The  remaining  20  had  general  tuber- 
culosis and  succumbed  to  the  disease.  M.  Auriol  employed  sulphurous  acid 
in  the  treatment  of  guinea-pigs  that  were  rendered  tuberculous  by  inocula- 
tion. They  improved  in  flesh  and  weight,  and  in  those  that  were  killed  a 
considerable  time  afterward  the  tubercular  nodules  were  found  to  be  trans- 
formed wholly  or  chiefly  into  fibrous  tissue. 

M.  Dujardin-Beaumetz  has  constructed  a  very  ingenious  and  simple  lamp 
for  producing  sulphurous  acid  by  burning  the  bisulphide  of  carbon.  This 
produces  111.3  volumes  of  carbonic  acid  and  141.4  volumes  of  sulphurous 
acid.  The  carbonic  acid  does  not  seem  to  produce  any  injurious  effect,  but, 
on  the  other  hand,  its  anaesthetic  action  increases  the  tolerance  and  diminishes 
the  irritation  of  the  sulphurous  acid.  The  Bulletin  general  de  Therapeutique, 
February  29,  1888,  contains  a  full  description  of  Dujardin-Beaumetz's  appar- 
atus which  is  too  lengthy  for  insertion  here. 


ETIOLOGY.  251 

I  have  described  in  tlie  foregoing  pages  the  most  important  of  the  remedies 
which  have  been  recently  recommended  by  apparently  competant  observers. 
Tliere  are  others  which,  from  their  nature  and  the  limited  trial  which  they 
have  received,  I  have  not  tliought  of  sufficient  importance  to  require  notice. 
Most  of  them  will  probably  soon  be  discarded  by  those  who  now  recommend 
them.  The  hygienic  measures — as  outdoor  life,  residence  at  a  high  altitude, 
free  ventilation  of  sleeping  apartment,  and  the  use  of  the  most  nutritious  and 
easily-digested  food — still  maintain  a  most  important  place  in  the  treatment 
of  tuberculosis.  Of  the  medicines,  creasote  used  internally  and  by  inha- 
lation, the  inhalation  of  sulphurous  acid  vapor,  not  carried  to  the  extent  of 
irritating  the  air-passages,  and  the  use  of  germicide  sprays,  as  of  corrosive 
sublimate,  the  terebinthinate  vapors,  etc.,  appear  to  be  the  most  deserving  of 
recommendation.  But  no  doubt  the  next  ten  years  will  witness  important 
changes  in  the  treatment  of  tuberculosis  based  on  its  microbic  nature,  and 
probably  remedies  not  now  heard  of  will  come  into  use. 


CHAPTER    lY. 

SYPHILIS. 

Syphilis  in  infancy  and  childhood  occurs  under  two  forms — to  wit,  the 
congenital  and  acquired.     The  former  is  the  more  frequent. 

Etiology. — Congenital  syphilis  may  be  derived  from  either  father  or 
mother.  Either  parent,  having  syphilis  in  its  first  or  second  stage,  may 
transmit  it  to  the  offspring,  although  at  the  time  free  from  syphilitic  symp- 
toms. The  mother,  healthy  at  the  time  of  conception  and  contracting 
syphilis  prior  to  the  eighth  month  of  gestation,  may  communicate  the  dis- 
ease to  the  foetus.  Syphilis  contracted  by  the  mother  in  the  eighth  or  ninth 
month  of  gestation  is  less  likely  to  be  communicated  to  the  foetus.  Writers 
mention  the  case  reported  by  Zeissel,  in  which  the  wife,  previously  well,  con- 
tracted syphilis  from  her  husband  between  the  fifth  and  seventh  months  of  ges- 
tation, and  the  infant,  born  at  term,  soon  exhibited  the  eharactei'istic  syphilitic 
lesions.  If  both  parents  have  syphilis  at  the  time  of  conception,  the  infant 
is  almost  necessarily  syphilitic  ;  on  the  other  hand,  if  only  one  parent  be 
syphilitic,  the  infant  may  or  may  not  be  contaminated.  Sometimes  with  such 
parentage  a  part  of  the  children  are  syphilitic  and  a  part  healthy. 

All  syphilographers  agree  that  syphilis  in  its  third  stage  is  not  transmis- 
sible from  parent  to  child,  but  parents  in  this  stage  of  the  disease  are  likely 
to  beget  scrofulous  children.  Hutchinson  of  London  regards  syphilis  as  an 
exanthem,  with  its  periods  of  efilorescenee  and  decline,  and  the  symptoms 
and  ailments  which  characterize  the  so-called  third  stage  he  regards  as 
sequelae.  That  syphilis  is  no  longer  transmissible  after  the  close  of  the 
second  stage  is  shown  by  many  observations.  Thus,  M.  Mireur  relates  the 
history  of  a  man  and  wife  who  were  syphilitic  and  were  never  treated,  but 
their  children  were  without  syphilitic  symptoms. 

Acquired  syphilis  in  infancy  and  childhood  may  be  received  through 
primary  lesions — that  is,  by  reception  of  the  virus  from  a  chancre  or  bubo — 
or  it  may  be  derived  from  certain  of  the  secondary  lesions.  Inoculation  by 
primary  lesions  may  occur  at  the  birth  of  the  infant  from  a  syphilitic  sore  in 
the  vagina  or  upon  the  vulva  of  the  mother  ;  inoculation  in  this  manner  is, 
however,  rare.      Children  may  also  receive  the  virus  from  primary  lesions  on 


252  SYPHILIS. 

the  persons  of  nurses  or  companions.  Infection  in  this  manner  is  sometimes 
accidental  and  sometimes  the  result  of  criminal  conduct.  A  chancre  on  the 
breast  of  the  wet-nurse  not  very  infrequently  communicates  syphilis  to  the 
nursling. 

The  contagiousness  of  "  secondary  manifestations,"  for  a  long  time  doubted, 
is  now  fully  established.  Syphilis  may  be  communicated  by  the  secretion  or 
exudation  of  a  mucous  patch  or  a  secondary  sore.  Hence  the  danger  of 
suckling  by  infected  wet-nurses,  though  they  present  no  symptoms  of  recent 
syphilis.  Excoriations  or  sores  upon  the  nipple  or  breast  of  a  syphilitic 
wet-nurse  may  communicate  the  disease  to  the  nursling  ;  and,  on  the  other 
hand,  mucous  tubercles  or  fissures  upon  the  lips  or  tongue  of  the  infected 
infant  may  be  the  means  of  contaminating  a  healthy  wet-nurse.  Many  such 
cases  are  now  contained  in  the  records  of  medicine.  Vaccination  by  means 
of  the  scab  is  also  a  mode  by  which  syphilis  has  been  communicated.  (For 
further  particulars  in  reference  to  this  subject  the  reader  is  referred  to  our 
remarks  on  vaccination.) 

Syphilis  is  believed  to  be  a  microbic  disease,  but  further  investigations 
are  required  in  order  to  determine  positively  which  microbe  is  the  causal 
agent.  Klebs  obtained  by  cultivation  bacilli  from  rods  and  spherules  which 
he  found  in  indurated  chancres.  With  these  bacilli  he  produced  a  local 
affection  by  inoculation  in  the  monkey  which  resembled,  in  some  respects, 
that  of  syphilis  and  in  other  respects  that  of  tuberculosis.  Ziegler  and  Von 
Rinecker  obtained  negative  results  from  similar  experiments  (Ziegler's  Path. 
Anatomy').  Lustgarten  has  described  a  bacillus  which  occurs  in  syphilitic 
lesions,  and  which  he  distinguishes  from  that  of  tuberculosis  by  colorations 
which  the  latter  receives  and  this  does  not.  Alvarez  and  Tavel  in  1885, 
and  later  Cornil,  describe  a  bacillus  found  in  the  desquamation  of  the  genitals 
which  closely  resembles  Lustgarten's  bacillus  of  syphilis,  but  which  Cornil 
states  can  be  distinguished  from  it  by  certain  differences  in  the  coloration 
(^Ci/clop.  of  Diseases  of  Children,  vol.  i.  168,  Phila.,  1889). 

Dr.  W.  H.  Welch,  the  distinguished  professor  of  pathology  in  Johns  Hop- 
kins University,  has  favored  me  with  the  following  note  relating  to  the  micro- 
organism which  causes  syphilis  : 

Baltimore,  Aug.  14,  1889. 

There  has  hitherto  been  no  satisfactory  demonstration  of  this  organism, 
although  there  have  been  many  claims  to  its  discovery.  The  only  organism  yet 
demonstrated  which  has  any  claims  to  being  considered  the  cause  of  this  disease 

is,  in  my  opinion,  the  bacillus  of  Lustgarten There  is  much  to  be  said  in 

favor  of  the  bacillus  discovered  by  Lustgarten,  and  first  described  by  him  in 
November,  1884,  and  I  think  this  is  the  only  micro-organism  hitherto  observed 
in  syphilitic  lesions  which  possesses  much  interest.  His  work  from  the  first 
attracted  attention,  as  it  was  done  under  the  direction  of  Prof.  Weigert,  one  of 
the  greatest  living  experts  in  this  line  of  study.  The  organism  is  described  by 
Lustgarten  as  a  bacillus  three  to  seven  micro-millimetres  long,  often  slightly  wavy 
in  shape,  and  found  usually  within  the  protoplasm  of  cells  in  syphilitic  products. 
It  was  found  by  Lustgarten  in  all  of  the  syphilitic  products,  including  gummata, 
which  he  examined.  Next  to  Lustgarten's,  the  most  important  studies  of  this 
bacillus  have  been  made  probably  by  Doutrelepont  of  Bonn,  in  co-operation  with 
SchUtz  ;  by  Matterstock  of  Wurzburg;  by  Markase;  and  by  Fordyce.  The 
significance  of  Lustgarten's  discovery  for  a  time  seemed  to  be  overthrown  by  the 
detection  by  Matterstock  and  by  Alvarez  and  Tavel  of  a  bacillus  in  smegma, 
which  these  observers  believed  to  be  identical  with  Lustgarten's  syphilitic  bacillus  ; 
but,  although  strikingly  similar,  these  two  species  of  organism  have  now,  I 
believe,  been  shown  to  be  entirely  different  species,  and  the  smegma  bacillu«  has 
nothing  to  do  with  the  syphilis  bacillus. 

Lustgarten's  bacillus  has  not  been  cultivated,  notwithstanding  repeated 
attempts  to  find  a  medium  suitable  for  its  growth.    It  is  certainly  often,  and  prob- 


CLINICAL  HISTORY.  253 

ably  constantly,  present  in  syphilitic  lesions.  Still,  several  observers  have 
reported  negative  results  in  searching  for  it.  The  reason  of  this  is  probably  the 
extraordinary  difficulty  in  demonstrating  this  organism.  There  is  nothing  in  all 
histological  technique  which  requires  such  an  outlay  of  time  and  patience  as  the 
demonstration  of  the  syphilis  bacillus,  so  that  so  skilled  an  histologist  as 
Weigert  says  that  he  simply  has  not  the  patience  to  work  at  this  subject;  and 
this  is  probably  the  conclusion  of  others  who  have  tackled  it. 

It  is  clear,  however,  that  the  discovery  of  a  peculiar  bacillus  with  remarkable 
staining  properties,  enclosed  within  cells  in  syphilitic  products,  is  something  of 
great  significance — far  greater  than  finding,  as  did  Aufrect,  ordinary  cocci  in 
juice  squeezed  out  of  a  fiat  condyloma,  or  in  mistaking  plasma-cells  for  clumps 
of  cocci,  as  Birch-Hirschfeld  is  known  to  have  done.  When,  in  addition  to  this, 
the  few  good  observers  who,  like  Lustgarten,  have  had  the  patience  and  skill  to 
make  a  satisfactory  study  of  the  question,  claim  to  find  this  peculiar  bacillus  so 
frequently  in  the  lesions  of  syphilis,  I  think  it  must  be  admitted  that  this  bacillus 
has  special  claims  upon  our  consideration.  It  must  be  admitted,  however,  that 
a  complete  demonstration  that  Lustgarten's  bacillus  is  the  specific  cause  of 
syphilis  has  not  as  yet  been  furnished. 

It  may  interest  you  to  know  that  within  the  last  year  or  two  some  interest  has 
attached  to  the  observation  first  made  byKassowitz  and  Hochsinger,  that  strepto- 
cocci are  often  present  in  congenital  syphilis ;  but  I  do  not  think  that  there  can 
be  any  doubt  that  these  streptococci  have  nothing  to  do  with  the  specific  con- 
tagium  of  syphilis  (and,  indeed,  Doutrelepont  has  found  Lustgarten's  bacillus  in 
combination  with  streptococci  in  congenital  syphilis),  but  they  are  evidence  of 
mixed  infection.  They  are  probably  the  ordinary  streptococci  of  suppuration.  It 
is,  however,  of  some  interest  to  have  this  bacteriological  evidence  of  a  clinical  fact 
that  many  cases  of  congenital  syphilis  are  examples  of  mixed  infection.  It  is 
probable  that  some  lesions  of  congenital  syphilis  which  have  been  regarded  as 
specific,  particularly  those  of  a  suppurative  character,  are  due  to  the  secondary 
invasion  of  these  streptococci,  for  which  the  soil  has  been  prepared  by  the  specific 
organism  of  syphilis.  Yours  very  truly, 

VV.  H.  Welch. 

It  is  evident,  in  consequence  of  the  risk  of  begetting  syphilitic  children, 
that  one  who  has  contracted  syphilis  should  not  marry  or  sustain  conjugal 
relations  until  four  years  have  elapsed  from  the  time  of  infection  and  the 
•disease  has  passed  through  its  first  and  second  stages,  and  eighteen  months 
of  treatment  have  been  employed.  We  have  seen  that  hereditary  syphilis 
may  be  inherited  from  either  parent,  although  the  parent  do  not  exhibit  at 
the  time  any  syphilitic  symptoms,  and  that  the  mother,  contracting  syphilis 
<iuring  gestation  even  as  late  as  the  seventh  month,  may  transmit  it  to  her 
infant. 

Clinical  History. — The  effects  of  the  syphilitic  poison  upon  the  devel- 
opment of  the  foetus  and  the  development  and  health  of  the  infant  are  differ- 
ent in  different  cases.  The  foetus,  under  the  influence  of  the  poison,  often 
•ceases  to  grow,  shrivels,  dies,  and  is  expelled  long  before  term  ;  or  it  may  be 
born  alive,  but  prematurely,  and  showing  clear  evidences  of  the  disease  as 
soon  as  it  comes  into  the  world  ;  or,  again,  it  may  be  born  at  term,  but  dead. 
So  frequently  is  syphilis  a  cause  of  non-viability  that,  as  Trousseau  has 
remarked,  this  disease  should  be  suspected  as  the  cause  whenever  a  woman 
repeatedly  aborts.  Abortion  from  syphilis  commonly  occurs  at  or  about  the 
sixth  month  of  gestation.  In  those  cases  in  which  the  foetus  dies  from  syph- 
ilis there  is  often  placental  syphilitic  disease — to  wit,  an  undue  growth  of 
cells  in  the  villi,  which,  compressing  the  vessels,  gives  rise  to  fatty  degenera- 
tion and  prevents  the  requisite  interchange  between  the  maternal  and  foetal 
blood  (Harring,  Frankell).  Frankell  designated  the  change  "granulation-cell 
hypertrophy  of  the  placental  villi."  Virchow  in  one  case  found  a  gummy 
tumor  in  the  maternal  portion   of  the  placenta. 

When  a  foetus  destroyed  by  syphilis  is  expelled,  it  frequently  presents  a 


254  SYPHILIS. 

macerated  appearance,  the  cuticle  being  detached  over  large  patches  of  sur- 
face, and  in  other  parts  raised  in  blebs,  with  a  thin,  puriform,  and  offensive 
fluid  underneath  ;  the  liver  is  occasionally  indurated,  and  abscesses  with  spots 
of  inflammation  are  sometimes  observed  in  the  thymus  gland ;  the  amniotic 
fluid  is  offensive,  turbid,  and  of  a  greenish  or  greenish-brown  appearance. 
If  the  foetus  in  which  syphilitic  manifestations  have  begun  to  occur  have 
reached  a  viable  age  and  be  born  alive,  it  is  small  and  imperfectly  developed, 
often  shrivelled  and  senile  in  appearance.  The  skin  looks  unhealthy,  and  it 
may  exhibit  a  distinct  rash.  Bouchut  saw  a  seven  and  a  half  months'  infant 
born  alive,  with  an  eruption  of  a  copper  color  upon  the  legs  and  arms  and 
onychia  upon  the  fingers  and  toes.  The  bullae  of  pemphigus  are  also  not  infre- 
quent upon  the  skin  at  birth,  or  they  appear  within  a  few  days  (two  or  three) 
after  birth.  The  smallest  are  about  the  size  of  a  split  pea,  but  many  are 
considerably  larger ;  the  largest  consist  of  two  or  more  which  have  coalesced. 
They  contain  a  thin,  greenish,  purulent  matter,  and  appear  most  frequently 
upon  the  palms  of  the  hands  and  soles  of  the  feet,  but  also  in  severe  cases 
upon  the  face  and  over  the  surface  of  the  body.  Recently  I  was  able  to 
diagnosticate  syphilis  in  an  infant  within  a  day  after  birth  by  its  small  size 
and  feebleness  and  the  appearance  of  large  blebs  of  pemphigus  upon  its 
hands,  feet,  fingers,  and  toes,  over  which  the  skin  soon  broke,  leaving  trouble- 
some and  bleeding  sores ;  coryza  commenced  about  the  twelfth  day.  The 
parents  seemed  healthy,  but  I  was  enabled  to  trace  the  syphilitic  taint  to  the 
mother.  Non-syphilitic  pemphigus,  the  result  of  cachexia,  sometimes  appears 
soon  after  birth,  but  its  primary  and  usual  seat  is  around  the  neck  and  upon 
the  body.  I  have  known  it  to  appear  within  the  first  week  of  life,  and  end 
fatally  by  the  close  of  the  second  week.  I  have  not  found  it  difficult  to  dis- 
tinguish it  from  syphilitic  pemphigus  by  the  history  of  the  family  and  its 
absence  from  the  palmar  and  plantar  surfaces  of  the  hands  and  feet.  Con- 
dylomata, mucous  patches,  and  stains  of  a  copper  color  are  the  principal 
syphilitic  affections,  besides  pemphigus,  which  have  been  observed  at  birtL 
on  the  bodies  of  contaminated  infants.  It  is  stated  that  M.  Cullerier  in  ten 
years'  attendance  at  the  Hopital  de  Lorraine  met  only  two  cases  of  syphilitic 
manifestations  at  birth,  and  Victor  de  Meric  only  two  cases  in  forty-six 
infants,  who  were  affected  with  congenital  syphilis  (Bumstead)  ;  but  in  the 
practice  of  others  a  larger  proportion  have  exhibited  symptoms  at  birth. 
Ordinarily,  the  period  in  which  congenital  syphilis  is  first  revealed  by  symp- 
toms is  between  the  fifteenth  and  fortieth  days.  Rarely  the  manifestations, 
of  the  disease  are  delayed  several  months.  M.  Diday  ascertained  the  time  of 
the  commencement  of  symptoms  in  158  cases,  as  follows  : 

Before  the  completion  of  one  month  after  birth,  in 86 

Before  the  completion  of  two  months  after  birth,  in 45 

Before  the  completion  of  three  months  after  birth,  in 15 

At  four  months 7 

At  five  months  .    , 1 

At  six  months 1 

At  eight  months 1 

At  one  year 1 

At  two  years 1 

When  the  symptoms  do  not  occur  until  several  weeks  have  elapsed,  it  is 
probable  that  the  poison  has  been  partially  eradicated  from  the  affected 
parents  by   appropriate  treatment. 

The  nutrition  of  the  infant  who  has  inherited  the  syphilitic  taint,  but 
does  not  exhibit  it  at  birth,  is  for  a  time  good,  but  it  begins  to  be  impaired 
when  the  local  manifestations  of  syphilis  appear  or  soon  after.     The  system. 


CLINICAL  HISTORY.  255 

gradually  wastes  ;  the  skin  loses  its  fresh  and  healthy  appearance  and  becomes 
sallow,  and  after  a  time  more  or  less  wrinkled  ;  the  features  become  pinched 
and  contracted  and  wear  a  sad  expression.  M.  Diday  says:  "Next  to  this 
look  of  little  old  men,  so  common  in  new-born  children  doomed  to  syphilis, 
the  most  characteristic  sign  is  the  color  of  the  skin."  Trousseau  thus 
described  this  discoloration  of  the  surface :  "  Before  the  health  becomes 
affected  the  child  has  already  a  peculiar  appearance ;  the  skin,  especially 
that  of  the  face,  loses  its  transparency  ;  it  becomes  dull,  even  when  there 
is  neither  puffiness  nor  emaciation  ;  its  rosy  color  disappears,  and  is  replaced 
by  a  sooty  tint,  which  i-esembles  that  of  Asiatics.  It  is  yellow  or  like  coffee 
mixed  with  milk,  or  looks  as  if  it  had  been  exposed  to  smoke ;  it  has  an 
empyreumatic  color,  similar  to  that  which  exists  on  the  fingers  of  persons 
who  are  in  the  habit  of  smoking  cigarettes.  It  appears  as  if  a  layer  of  color- 
ing had  been  laid  on  unequally  ;  it  sometimes  occupies  the  whole  of  the  skin, 
but  is  more  marked  in  certain  favorite  spots,  as  the  forehead,  eyebrows,  chin, 
nose,  eyelids — in  short,  the  most  prominent  parts  of  the  face  ;  the  deeper 
parts,  such  as  the  internal  angle  of  the  orbit,  the  hollow  of  the  cheek,  and 
that  which  separates  the  lower  lip  from  the  chin,  almost  always  remain  free 
from  it.  Although  the  face  is  commonly  the  part  most  affected,  the  rest  of 
the  body  always  participates  more  or  less  in  this  tint.  The  infant  becomes 
pale  and  wan." 

The  infant  whose  system  is  profoundly  affected  by  syphilis  rarely  smiles 
and  its  voice  is  feeble  and  plaintive ;  its  frequent,  whimpering  cry  is  quite 
characteristic. 

CorrjTM  is  one  of  the  earliest  and  most  constant  of  the  local  affections  in 
infantile  syphilis.  It  is  slight  at  first,  attracting  little  attention  on  the  part 
of  the  parents,  who  are  not  aware  of  its  significance  and  usually  attribute  it 
to  a  slight  cold  ;  but  it  gradually  increases.  It  gives  rise  to  a  secretion  from 
the  Schneiderian  membrane,  at  first  thin,  but  which  becomes  more  consistent 
and  is  attended  by  the  formation  of  scabs.  The  thickening  of  the  mucous 
membrane  in  consequence  of  the  inflammation  and  the  presence  of  crusts  nar- 
rows the  passage  through  the  nostrils,  so  as  to  produce  snuffling  respiration 
and  sometimes  render  nursing  difficult.  In  severe  cases  respiration  through 
the  nostrils  is  almost  wholly  prevented,  so  that  death  may  occur  from  inanition, 
unless  the  breast  be  milked  into  the  infant's  mouth  or  it  be  fed  with  a  spoon  ; 
but  ordinarily,  even  in  grave  coryza,  it  continues  to  nurse,  though  obliged 
often  to  release  its  hold  of  the  nipple  to  obtain  breath.  It  is  when  the  coryza 
interferes  with  drawing  the  nipple  that  it  first  alarms  the  parents.  The  inflam- 
mation at  the  same  time  may  affect  the  throat  and  larynx,  causing  hoarseness 
of  the  voice.  Ulceration  of  the  Schneiderian  membrane  and  the  adjacent  carti- 
lage or  bone  is  rare  in  infancy  or  childhood,  although  cases  occur  which  are 
even  attended  with  more  or  less  flattening  of  the  nose.  Diday  believes  that 
the  discharge  which  accompanies  coryza  is  in  great  part  due  to  mucous  patches 
developed  on  the  Schneiderian  membrane.  The  upper  lip,  over  which  the  dis- 
charge flows,  becomes  red,  excoriated,  and  more  or  less  incrusted.  The  coryza 
in  most  cases  coexists  with  other  local  syphilitic  affections.  Occasionally  it 
occurs  alone,  and  is  the  only  evidence  of  the  presence  of  the  specific  taint, 
except  such  as  is  afforded  by  the  malnutrition  and  general  appearance  of  the 
patient. 

Mucous  jyatches  occur  in  most  patients.  They  are  developed  either  upon 
the  mucous  surfaces  or  upon  parts  of  the  skin  which  are  thin  and  exposed  to 
friction,  and  such  as  are  moistened  by  secretion  or  transudation  from  the  ves- 
sels underneath.  The  most  common  seat  of  mucous  patches  is  at  the  termi- 
nation of  mucous  canals ;  but  in  infancy,  on  account  of  the  peculiar  delicacy 
of  the  skin,  they  may  occur  upon  almost  any  part  of  the  cutaneous  surface. 


256  SYPHILIS. 

They  are  most  common,  however,  around  the  anus,  upon  the  vulva,  scrotum, 
umbilicus,  labial  commissures,  in  the  axillae,  and  behind  the  ears. 

Mucous  patches  upon  the  skin  present  a  rounded  border  and  are  slightly 
elevated.  Their  color  has  been  compared  to  that  of  skin  which  has  been  soft- 
ened by  the  prolonged  application  of  a  poultice.  Erosions  and  cracks  some- 
times occur  in  the  patches,  from  which  a  thin  liquid  exudes. 

Upon  mucous  surfaces  they  are  less  elevated  than  upon  the  skin,  and  are 
prone  to  ulcerate.  These  ulcerations,  commencing  at  the  centre,  extend,  and 
soon  the  mucous  patch  disappears  and  its  site  is  occupied  by  an  ulcer.  The 
ulcer  may  be  circular,  oval,  elliptical,  crescentie,  or  irregular.  The  arches  of 
the  fauces  are  a  common  seat  of  mucous  patches. 

Roseola  is  an  occasional  symptom  of  infantile  syphilis.  "  It  is  distin- 
guished," says  Diday,  ''  by  patches  of  a  bright  rose  color,  circumscribed, 
irregularly  rounded,  of  various  sizes  (most  frequently  about  as  large  as  one 
of  the  nails)  ;  appearing  by  preference  on  the  belly,  lower  part  of  the  chest, 
neck,  and  inner  surface  of  the  extremities."  The  spots  do  not  readily  and 
fully  disappear  by  pressure. 

Pemphigus,  appearing  soon  after  birth,  has  already  been  alluded  to.  Its 
most  frequent  seat,  whether  occurring  at  birth  or  as  a  subsequent  manifes- 
tation, is,  as  we  have  stated,  the  palms  of  the  hands,  soles  of  the  feet,  the 
fingers,  and  the  toes.  This  eruption  commences  by  a  violet  tint  of  the  skin, 
and  in  the  course  of  twenty-four  to  forty-eight  hours  a  watery  fluid  collects 
underneath,  which  soon  becomes  turbid.  The  skin  peels  off,  and  sometimes 
an  angry  sore  results,  which  bleeds  readily  when  rubbed  or  pressed.  In  other 
and  more  favorable  cases  new  skin  takes  the  place  of  that  which  is  lost.  Pem- 
phigus at  birth  is  a  precursor  of  death,  but  when  it  appears  for  the  first  time 
some  weeks  after  birth,  it  is  a  less  unfavorable  prognostic  sign.  In  cases  of 
recovery  it  disappears,  with  proper  treatment,  in  two  or  three  weeks. 

Acne,  Impetigo^  and  Ecthyma  are  occasionally  observed  in  children  afiiicted 
with  syphilis.  The  indurated  pustules  of  acne  occur  most  frequently  upon 
the  shoulders,  back,  chest,  and  buttocks.  The  pus  is  sometimes  absorbed  and 
in  other  cases  discharged,  leaving  a  small  cicatrix,  which  after  a  time  disap- 
pears. Impetigo  appears  most  frequently  upon  the  face,  and  occasionally 
upon  the  chest,  neck,  axilla,  and  groin.  Unlike  simple  impetigo,  the  syphilitic 
impetiginous  eruption  is  surrounded  by  a  copper-colored  areola.  Ecthyma 
occurs  upon  the  legs  and  buttocks  chiefly.  It  commences  as  violet-colored 
spots,  which  are  soon  transformed  into  pustules.  Ulcers  succeed,  which  in 
reduced  states  of  the  system  sometimes  enlarge  and  endanger  the  safety  of 
the  child.  Of  the  three  pustular  eruptions,  acne,  according  to  Diday,  is  the 
least  serious,  indicating  a  "  less  confirmed  diathesis."  Ecthyma  is  the  most 
serious,  on  account  of  the  reduced  state  of  the  system  with  which  it  is  usually 
associated.  Syphilitic  papulae  and  squamae  are  rare  in  infants,  but  cases  have 
been  observed.  Onychia  occasionally  occurs,  though  less  frequently  than  in 
syphilis  of  the  adult. 

In  an  interesting  lecture  on  hereditary  syphilis  Dr.  Miller  remarks  that 
polymorphism  of  its  cutaneous  eruptions  characterizes  hereditary  syphilis. 
In  1000  cases  of  the  inherited  disease  the  local  afiections  referable  to  syphilis, 
and  seated  upon  or  in  immediate  relation  with  the  cutaneous  and  mucous  sur- 
faces, were  as  follows  :  ^ 

Papules 74  per  cent,  of  the  cases. 

Ehagades  of  the  lips  and  anus 70    "      "  "  " 

Ehinitis 58    "      "  "  " 

Ulcers  of  hard  palate 62    "      "  "  " 

Erythematous  eruptions 45    "      "  "         " 

^  Pacific  Med.  Surg.  Jour.,  1888. 


VISCERAL  LESIONS.  257 

Lymphadenitis  chronica 20  per  cent,  of  the  cases. 

Ulcers  of  tongue  (glossitis  ulcerosa) 27  "  "  "  " 

Bullous  eruptions  (pemphigus) 25  "  "  "  " 

Onychia  and  paronychia 23  "  "  "  " 

Laryngitis • 17  "  "  "  " 

Pseudo-paralysis  of  extremities 7  "  "  "  " 

Ulcers  ...._._._ 4  "  " 

Ulcerative  gingivitis 4  "  "  "  " 

Visceral  Lesions. — The  visceral  lesions  which  result  from  the  syphilis 
of  infancy  and  childhood  are  suppuration  in  the  thymus  gland ;  gummy 
tumors  in  certain  organs,  most  frequently  the  lungs  and  liver;  increase  of 
the  connective  tissue  of  the  liver,  known  as  syphilitic  cirrhosis ;  partial  peri- 
hepatitis, with  depressions  resembling  cicatrices  on  the  surface  of  the  liver ; 
periostitis,  with  thickening  of  the  bone  ;  and  exostosis. 

Suppurative  inflammation  in  the  thymus  gland  is  not  common  or  has  not 
been  frequently  observed.  AVhen  it  is  present  the  gland  sometimes  presents 
its  normal  appearance  externally,  and  the  abscess  is  only  discovered  by  incis- 
ions. Gummy  tumors  are  white  and  spheroidal ;  some  are  as  small  or  smaller 
than  a  pin's  head,  while  others  are  as  large  as  a  pea  or  even  a  hazel-nut.  I 
have  seen  a  considerable  number  of  them  not  as  large  as  a  pin's  head  in  the 
liver  of  an  infant.  Gummy  tumors,  according  to  Lebert,  consist  ''  of  loose 
fibrous  tissue  made  up  of  pale,  elastic  fibres,  enclosing  in  their  large  inter- 
spaces a  homogeneous  granular  substance,  the  elements  of  which  are  less  adhe- 
rent to  each  other  than  in  deposits  of  true  tubercle."  Lebert  also,  with  other 
microscopists,  discovered  round  granular  cells  in  these  tumors.  According  to 
Robin,  gummy  tumors  "are  made  up  of  rounded  nuclei  belonging  to  fibro- 
plastic cells,  or  cytoblustions  ;  of  a  finely  granular,  semi-transparent,  and  amor- 
phous substance  ;  and,  finally,  of  isolated  fibres  of  cellular  tissue,  a  small 
number  of  elastic  fibres,  and  a  few  capillary  blood-vessels." 

Constitutional  syphilis  is  one  of  the  principal  causes  of  waxy  degenera- 
tion, and  the  spleen  and  liver  of  infants  may  be  enlarged  from  this  cause. 
Dr.  Samuel  Gee  has  expressed  the  opinion  that  in  half  the  cases  of  hereditary 
syphilis  the  spleen  is  enlarged  {London  Lancet^  April  13,  1867). 

Infiltration  of  the  liver  by  fibrous  substance  was  first  noticed  by  Giibler. 
It  is  not  common  in  the  infant.  A  specimen,  showing  this  lesion,  was  pre- 
sented to  the  London  Pathological  Society  in  1866  by  Dr.  Samuel  AVilks. 
The  following  remarks  by  Dr.  Wilks  convey  a  good  idea  of  the  appearance 
and  state  of  the  liver  in  syphilitic  cirrhosis :  "  Having  dissected  the  bodies 
of  several  infants  who  have  died  of  congenital  syphilis,  I  have  found  fatty 
livers  and  an  inflammation  of  the  capsule,  but  in  only  two  have  I  discovered 
adventitious  products  of  a  fibrous  character.  The  present  example,  however, 
corresponds  in  every  particular  with  the  disease  described  by  Giibler.  It 
must  be  distinguished  (at  least  as  far  as  the  naked-eye  appearance  reaches) 
from  syphilitic  disease  of  adults,  of  which  many  specimens  have  been  before 
the  society.  In  these  the  organ  is  cicatrized  on  the  surface  and  contains  dis- 
tinct nodules  of  fibrous  tissue  ;  while  in  the  disease  of  children,  as  in  the 
present  specimen,  the  whole  organ  is  infiltrated  by  a  new  material,  and  it 
consequently  becomes,  as  described  by  Giibler,  hypertrophied,  globular,  and 
hard,  resistant  to  pressure,  and  even  when  torn  by  the  fingers  its  surface 
receives  no  indentation  from  them  ;  it  is  also  elastic,  and  when  cut  creaks 
slightly  under  the  scalpel.  This  was  the  form  of  disease  in  the  present 
specimen.  It  came  from  a  syphilitic  child  a  month  old,  in  wl)om  the  liver 
could  be  felt  enlarged  during  life,  and  when  removed  weighed  a  pound  and  a 
half.  It  was  smooth  on  the  surface,  and  so  hard  that  it  resembled  rather  a 
fibrous  tumor  than  a  liver.  It  is  seen  that  the  liver  in  the  syphilitic  child  is 
17 


258 


SYPHILIS. 


liable  to  three  distinct  pathological  processes — namely,  gummy  tumors,  cir- 
rhosis or  fibroid  degeneration,  and  waxy  degeneration." 

Syphilitic  perihepatitis  and  periostitis  are  more  rare  in  infancy  and  child- 
hood than  in  adult  life,  but  they  occasionally  occur.  The  late  Sir  James  Y. 
Simpson  considered  peritonitis  in  the  foetus  one  of  the  results  of  syphilis,  and 
a  cause  of  its  death. 

Osseous  Lesions. — Within  the  last  few  years  important  discoveries  have 
been  made  in  regard  to  the  elfect  of  syphilis  upon  the  nutrition  of  the  bones 
in  children.  In  1870,  Dr.  Wegner  of  Berlin  published  his  observations  of  the 
state  of  the  skeleton  in  twelve  syphilitic  children  who  were  either  stillborn 
or  who  died  within  a  few  days  or  weeks  after  birth.  He  found  clear  proof 
that  the  syphilitic  dyscrasia  frequently  disturbs  the  nutrition  and  produces 
anatomical  changes  in  the  skeleton  of  the  foetus.  The  following  are  the 
lesions  clearly  referable  to  syphilis  which  he  observed  :  Periostitis  of  long 
bones,  including  the  ribs ;  softening,  separation,  and  sometimes  crepitation  at 
the  point  of  union  of  diaphysis  and  epiphysis ;  chalky  concretions  and  infil- 
trations along  the  line  of  ossification  ;  fatty  degeneration  of  marrow ;  irreg- 
ular formation  and  distribution  of  spongy  substance  in  the  epiphysis.  These 
lesions  were  not  all  observed  in  each  case,  but  they  occurred  with  such  fre- 
quency that  there  could  be  no  doubt  that  they  were  due  to  the  syphilitic  taint 
of  system.  Confirmatory  observations  also  in  twelve  cases  have  since  been 
made  by  Waldeyer  and  Kobner.^ 

Again,  there  is  a  syphilitic  lesion  of  the  bone  in  children  which  is  not 
usually  present  or  has  not  usually  been  observed  at  birth,  but  is  developed 
in  the  first  weeks  or  months  of  infancy.  The  lesion  alluded  to  is  a  circum- 
scribed enlargement  of  one  or  more  bones.  This  has  been  most  frequently 
observed  upon  the  long  bones,  including  the  clavicle  and  ribs,  but  in  certain 

Fig.  26. 


children  it  occurs  upon  other  bones  in  addition.     In  some  cases  it  is  one  of 
the  first  manifestations  of  hereditary  syphilis,  occurring  even  sooner  than  the 

^  See  elaborate  paper  by  R.  W.  Taylor,  M.  D.,  New  York  Journal  of  Obstetrics,  etc., 
July,  1874. 


PROGNOSTS.  259 

coryza,  while  in  others  several  months  elapse  before  it  appears.  In  one  case 
reported  by  Dr.  Bulkley  ^  of  this  city  it  was  first  seen  only  a  few  days  after 
birth,  being  perhaps  congenital ;  while  in  another  case,  in  which  the  enlarge- 
ment was  upon  certain  phalanges,  and  which  is  represented  in  the  accompany- 
ing figure,  it  appeared  at  the  age  of  twelve  months.  When  it  occurs  upon  a 
phalangeal  bone  it  is  designated  dactylitis  st/philitica. 

The  enlargement,  if  upon  a  long  bone,  ordinarily  begins  at  or  near  the 
point  of  union  of  the  diaphysis  with  the  epiphysis.  It  is  located  upon  the 
extremity  of  the  shaft  which  it  encircles,  and  it  extends  over  a  part  or  nearly 
the  whole  of  the  epiphysis.  It  has  an  elevation  of  perhaps  one-half  or  three- 
quarters  of  an  inch  in  typical  cases :  its  surface  is  smooth  or  slightly  undu- 
lating, and  the  skin  over  it,  though  distended,  has  its  normal  appearance  and 
is  easily  movable,  unless  ulcerations  have  occurred. 

These  enlai'gements,  which  result  from  the  specific  inflammation  occurring 
in  the  periosteum  and  the  bone,  may  resolve  under  proper  treatment ;  but  if 
neglected  and  the  antihygienic  conditions  are  bad,  degenerative  changes  may 
occur,  ending  in  ulceration  and  destruction  of  the  diseased  part  to  a  greater 
or  less  extent. 

Though  these  bone-enlargements,  whenever  observed,  should  excite 
suspicions  of  syphilis  as  the  cause,  enlargements  which  present  the  same 
general  appearance  do  occur  from  other  causes.  Such  a  case  was  observed 
by  me  in  the  children's  class  in  the  Out-door  Department  of  Bellvue,  and  Dr. 
Bulkley  details  another  case  in  his  paper.  In  the  case  observed  by  me  the 
inflammation  and  enlargement  seemed  to  be  strumous.  Baumler  says : 
"  Dactylitis  syphilitica  does  not  always  originate  in  the  bone  ;  similar  appear- 
ances may  be  produced  through  gummous  formation  in  the  sheaths  of  the 
tendons  and  in  the  fibrous  structure  of  the  finger  ;"  and  again,  "  Its  outward 
appearance  may  be  produced  also  by  tuberculosis,  enchondroma,  or  sarcoma 
of  the  bone-marrow  "  (art.  "  Syphilis,"  Ziemssens  Encycl.^. 

Mr.  J.  Hutchinson  of  London  has  called  attention  to  the  fact  that  hered- 
itary syphilis,  having  perhaps  been  manifested  by  the  usual  symptoms  during 
infancy  and  then    becoming  latent,  may  give 
rise  to  new  symptoms  after  the  fourth  year.  Fig.  27. 

The  most  noticeable  of  these  symptoms  is   a  f\  i#Nlfit\  /w'W'^ 

dwarfing  of  the  permanent  incisor  teeth,  which  B^immk^K^mil  ir 
are  rounded  and  peg-like  and  their  enamel 
notched  at  the  free  ends  of  the  teeth.  On 
account  of  the  small  size  and  shape  of  the 
teeth  there  are  interspaces  between  them. 
This  abnormal  development  is  most  marked 
in  the  central  incisors  of  the  upper  jaw,  and  in  certain  cases  it  is  limited  to 
them,  and  it  never  appears  in  the  other  incisors  unless  it  does  also  in  them. 
Another  symptom,  which  only  appears  in  hereditary  sj^philis,  is  an  interstitial 
keratitis  occurring  on  both  sides  and  attended  by  the  deposition  of  fibrin  in 
the  substance  of  the  cornea.  In  a  few  weeks  the  inflammation  declines,  but 
a  slight  opacity  of  the  cornea  remains.  The  cerebral  nerves  may  become 
afiected,  usually  a  single  pair — if  the  auditory,  deafness  resulting ;  if  the 
optic,  dimness  of  sight.  Occasionally  there  are  other  manifestations  of 
syphilis  in  this  period,  as  enlargement  of  spleen  and  liver  and  nodes  upon 
the  long  bones. 

Prognosis. — This  depends  in  great  part  on  the  general  condition  of  the 
patient.  If  there  be  much  emaciation  and  the  symptoms  indicate  a  deeply- 
seated  cachexia,  a  considerable  proportion  of  the  patients  perish.  On  the 
other  hand,  if  the  general  health  be  not  greatly  impaired,  although  the  local 

'  "  Eare  Cases  of  Congenital  Syphilis,"  New  York  lied.  Journal,  May,  1874. 


260  SYPHILIS. 

affections  are  pretty  severe,  the  prognosis  witli  correct  treatment  is  good.  The 
younger  the  infant  when  the  symptoms  of  syphilis  appear,  the  more  unfav- 
orable, as  a  rule,  is  the  prognosis. 

Treatment. — Parents  who  beget  syphilitic  children  ought,  from  a  due 
regard  for  their  offspring,  to  make  use  of  antisyphilitic  remedies,  although 
they  present  in  their  persons  no  evidences  of  syphilitic  taint.  A  good  pre- 
scription for  the  parents  is  one-sixtieth  of  a  grain  of  corrosive  sublimate  in 
the  compound  tincture  of  bark,  given  twice  or  three  times  daily  for  several 
months.  If  the  father  have  had  syphilis,  both  parents  should  be  subjected  to 
this  treatment,  and  it  may  be  continued,  at  least  on  the  part  of  the  mother, 
during  the  first  months  of  her  gestation.  So  small  a  dose  of  the  mercurial 
does  not,  in  my  opinion,  materially  increase  the  liability  to  miscarry.  There 
is  much  more  danger  of  miscarrying  from  allowing  the  syphilitic  taint  to 
remain  uncontrolled.  Some  prefer  the  use  of  mercurial  ointment  in  the 
treatment  of  pregnant  women  having  syphilis,  in  the  belief  that  it  is  less  likely 
to  produce  abortion.  It  is  used  for  this  purpose  in  the  proportion  of  one 
drachm  to  the  ounce.  It  is  equally  effectual  in  the  eradication  of  the  syph- 
ilitic taint  with  the  small  dose  of  corrosive  sublimate  recommended  above  for 
internal  administration  ;  but  it  is  impossible  to  determine  the  quantity  of 
mercury  which  enters  the  circulation  when  inunction  is  employed  and  saliva- 
tion is  more  likely  to  occur.  The  following  is,  however,  probably  the  best 
prescription  for  the  treatment  of  parents  infected  by  the  syphilitic  virus  It 
should  be  given  several  months  : 

R.  Hydrarg.  biniodidi,  gr.  j; 

Liq.  potassii  arsenit.,  5J  I 

Tine,  belladonnse,  .^ij ; 

Potassii  iodidi,  ^ss ; 

Aquae,  q.  s.  ad  3iv.     M. 

Dose :  One  teaspoonful  three  times  daily  after  the  meals. 

Or 

R.  Vini,  |yj; 

Pepsini  puri  in  lamellis,  3ij  ; 

Potassii  iodidi,  3ij  > 

Liq.  potassii  arsenit.,  ^ij  ; 

Hydrarg.  biniodidi,  gr.  j  ; 

Qui.  et  ferri  citratis,  3y  > 

Syr.  simplic,  gij ; 

01.  anisi,  gtt.  iij.     Misce. 
Dose :  One  dessertspoonful  three  times  daily. 

The  nutrition  of  the  infant  that  has  unfortunately  inherited  the  syphilitic 
taint  requires  special  attention.  Besides  exhibiting  the  characteristic  symp- 
toms of  the  disease,  it  usually  suffers  from  innutrition,  and  sometimes  passes 
into  a  state  of  decided  marasmus.  The  mother  who  has  given  birth  to  a 
syphilitic  infant  should,  if  possible,  wet-nurse  it.  Even  if  she  never  has 
exhibited  any  symptoms  of  the  disease  in  her  own  person,  she  cannot  contract 
syphilis  from  her  infant.  Colles  wrote  as  follows  in  1837 :  "  One  fact  well 
deserving  our  attention  is  this :  that  a  child  born  of  a  mother  who  is  with- 
out obvious  venereal  symptoms,  and  which,  without  being  exposed  to  any 
infection  subsequent  to  its  birth,  shows  this  disease  when  a  few  weeks  old, — 
this  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it  or  merely 
handle  and  dress  it;  and  yet  this  child  is  never  known  to  infect  its  own 
mother,  even  though  she  suckle  it  while  it  has  venereal  ulcers  of  the  lips  and 
tongue."  This  remarkable  law  relating  to  the  immunity  of  mothers  has  been 
fully  accepted  by  all  subsequent  syphilographers.     On  the  other  hand,  a  wet- 


TREATMENT.  201 

nurse  employed  to  suckle  a  syphilitic  infant  is  very  liable  to  contract  the  dis- 
ease, through  her  nipples,  from  the  infected  lips  of  the  infant.  If  a  wet-nurse 
be  employed  for  such  an  infant,  she  should  be  aware  of  the  risk  she  incurs, 
and  should  protect  herself  by  the  use  of  an  artificial  nipple.  At  the  same 
time,  the  infant  should  be  placed  fully  under  antisyphilitic  treatment.  Artificial 
feeding,  though  usually  disastrous,  is  preferable  to  the  propagation  of  the  dis- 
ease to  a  healthy  wet-nurse. 

Syphilis  in  the  infant  requires  mercurial  treatment  as  in  the  adult.  Mer- 
cury may  be  employed  internally  or  by  inunction.  Some  prefer  inunction  in 
the  treatment  of  ordinary  cases  in  the  manner  recommended  by  Sir  Benjamin 
Brodie.  "  I  have  spread,"  says  he,  "  mercurial  ointment,  made  in  the  propor- 
tion of  a  drachm  to  an  ounce,  over  a  flannel  roller,  and  bound  it  round  the 
child  once  a  day.  The  child  kicks  about,  and,  the  cuticle  being  thin,  the 
mercury  is  absorbed.  It  does  not  either  gripe  or  purge,  nor  does  it  make  the 
gums  sore,  but  it  cures  the  disease.  I  have  adopted  this  practice  in  a  great 
many  cases  with  the  most  signal  success."  The  oleate  of  mercury,  10  per 
cent.,  is  a  better  preparation  for  inunction.  Five  drops  may  be  rubbed  in 
three  times  daily.  Trousseau,  on  the  other  hand,  discountenances  the  use 
of  inunction,  since  mercurial  ointment  applied  to  the  skin  produces  irritation 
and  increases  the  sufiering  and  restlessness  of  the  child.  He  prefers  the  fol- 
lowing solution,  which  is  known  as  Van  Swieten's,  for  internal  treatment : 

R.  Hydrarg.  bichlorid.,  Ipart; 

Aquse,  950  parts ; 

Spts.  rectific,  100  parts.     Misce. 

Dose:  One  or  at  most  two  grammes  (15.434  to  30.868  grains),  in  milk,  daily. 

In  order  to  avoid  the  risk  of  establishing  a  diarrhoea,  and  to  leave  the 
stomach  free  for  the  employment  of  other  medicines,  as  cod-liver  oil  and  the 
iodide  of  iron,  I  prefer  and  commonly  prescribe  for  infants  inunction  with  the 
mercurial  ointment  diluted  with  eight  times  its  quantity  of  lard,  cold  cream, 
or  vaseline.  It  should  not  be  applied  as  a  plaster,  but  a  quantity  of  the  size 
of  a  large  chestnut  should  be  rubbed  three  times  daily  upon  the  neck  or  breast 
of  an  infant  of  three  or  four  months.  For  children  over  the  age  of  eight  or  ten 
months,  Van  Swieten's  or  one  of  the  following  formulae  may  be  employed : 

R.  Hydrarg.  cum.  creta,  gr.  iij-yj ; 

Sach.  alb.,  9j.     Misce. 

Divid.  in  chart.  No.  xii.     One  powder  three  times  daily. 

R.  Hydrarg.  clilor.  corros.,  gr.  ss-j  ; 

Syr.  sarsae  com  p.,  _^ij  ; 

Aquee,  5viij.     Misce. 
Dose  :  One  teaspoonful  three  times  daily. 

R.  Hyd.  chlor.  corros.,  gr.  ss ; 

Potas.  iodid.,  rzS ; 

J^  em  et  ammon.  citrat.,  Zj  ; 

Syr.  simplic,  ^vj.     Misce. 

Dose:  One  teaspoonful  three  times  daily  for  a  child  of  three  to  five  years. 

R.  Hyd.  chlor.  corros.,  gr- j  ; 

Potas.  iodid.,  ^ij  ; 

Syrup,  simplic, 

Aquae,  da.  ^ij.     Misce. 

Dose :  Six  drops  three  times  daily  for  a  child  of  three  months. 

Prof.  A.  Jacobi  recommends,  in  the  treatment  of  syphilis  of  the  newly- 


262  SYPHILIS. 

born,  one-twentieth  of  a  grain  of  calomel,  to  be  given  three  times  daily.  An 
important  advantage  of  its  use  is  the  rapidity  and  certainty  of  its  action. 

Mercury,  in  whatever  way  employed,  should  not  be  discontinued  entirely 
till  several  weeks  after  the  syphilitic  symptoms  have  disappeared  ;  it  is  proper 
to  continue  it  for  a  time,  in  diminished  quantity  and  fewer  doses,  after  the 
health  seems  fully  restored. 

When  the  mercurial  is  omitted  tonics  are  often  required.  The  prepa- 
rations of  cinchona  are  useful  in  certain  cases,  as  are  also  those  of  iron.  If 
the  patient  remain  feeble  and  pallid,  presenting  evidences  of  struma,  cod-liver 
oil  and  syrup  of  the  iodide  of  iron  will  be  found  beneficial,  continued  for  some 
weeks  or  months  after  the  mercury  is  discontinued.  Attention  should  always 
be  given  to  cleanliness  and  the  hygienic  management  of  the  patient.  In  some 
instances  direct  treatment  of  the  local  afiections  is  serviceable.  To  aid  in  the 
cure  of  syphilitic  coryza  the  following  ointment  should  be  applied  within  the 
nostrils  by  a  nasal  sponge  three  times  daily : 

R.  Ung.  hydrarg.  nitratis,  gij  ; 

Ung.  zinci  oxidi,  §ij,     Misce. 

Recently  I  have  been  in  the  habit  of  employing  Squibb's  oleate  of  mer- 
cury, 2  per  cent.,  for  syphilitic  coryza  of  infants,  and  the  effect  has  been 
satisfactory.  It  may  also  be  employed  by  cutaneous  inunction  in  the  treat- 
ment of  the  general  disease. 

Condylomata  or  mucous  patches  seated  upon  the  cutaneous  surface  should 
be  dusted  with  calomel.  At  my  clinique  in  April,  1871,  a  child  two  years 
and  ten  months  old  was  presented,  with  a  large  condylomatous  outgrowth 
near  the  anus.  The  history  of  the  child  showed  that  in  all  probability  the 
disease  had  been  contracted  within  a  year  from  syphilitic  children  in  one  of 
the  public  institutions.  Within  three  weeks  this  affection  disappeared  by 
dusting  upon  it  calomel  once  daily,  with  appropriate  internal  treatment. 

The  infant  should  be  kept  clean  by  bathing  it  in  tepid  water  twice  daily, 
and  excoriations  upon  its  lips  or  mucous  patches  should  be  bathed  before  the 
nursing  with  some  mild  disinfectant  solution,  as  boracic  acid.  The  best  pos- 
sible hygienic  conditions  should  be  provided  for  the  infant,  since  cachexia 
is  commonly  present.  It  should  be  taken  outdoor  frequently  in  suitable 
weather,  and  its  removal  from  the  city  to  the  country,  especially  in  hot 
weather,  may  be  advisable.  The  cachexia  which  remains  after  the  disap- 
pearance of  the  syphilitic  manifestations  requires  the  use  of  tonics,  as  cod- 
liver  oil  and  syrup  of  the  iodide  of  iron. 

Syphilitic  symptoms  may  reappear  during  childhood.  The  exanthemata 
rarely  appear  at  this  age  when  the  proper  treatment  has  been  employed  in 
infancy,  but  condylomata  and  gummy  tumors  may,  and  they  require  a  return 
to  the  mercurial  treatment.  If  the  bones  are  affected  the  iodide  of  potassium 
is  the  proper  remedy.  It  causes  the  disappearance  of  the  periosteal  pains 
and  swelling,  and  manifest  improvement  in  the  symptoms  generally. 


SECTION  II. 
ERUPTIVE    FEVERS. 


CHAPTER    I. 

MEASLES. 


The  disease  known  in  the  vernacular  as  measles  has  also  the  names 
rubeola  and  morbilli.  It  is  a  common  exanthematic  affection  occurring  at 
any  age,  but  most  frequently  in  childhood.  It  affects  once  the  majority  of 
mankind.  Writers  recognize  three  stages  of  measles  :  first,  that  of  invasion, 
which  ends  with  the  appearance  of  the  eruption ;  secondly,  the  eruptive 
stage ;  and,  thirdly,  the  stage  of  decline  or  desquamation. 

Etiology. — Micrococci  have  been  found  in  the  blood  of  rubeolar  patients 
by  Coze  and  Feltz.  Keating  also  discovered  them  during  an  epidemic  of 
malignant  measles  (Fhila.  Med.  Times,  Aug.  12,  1882),  and  Ransome,  Braid- 
wood,  and  Vacher  found  them  in  the  breath  of  patients  as  well  as  in  their 
tissues  (Brit.  Med.  Jour.,  Jan.  21,  1882).  It  seems  probable  that  they  are 
the  specific  principle  ;  if  so,  they  remain  dormant  in  the  system  about  twelve 
days,  which  is  the  incubative  period.  Additional  observations  are  required 
in  order  to  determine  positively  whether  this  micrococcus  be  the  causal  agent 
in  measles,  or  whether  it  may  not  be  some  other  microbe. 

Symptoms. — This  disease  commences  with  such  symptoms  as  usually 
occur  in  mild  but  pretty  general  inflammation  of  the  air-passages — to  wit, 
cough,  fever,  anorexia,  and  thirst.  The  eyes  present  a  suffused,  moderately 
injected,  and  brilliant  appearance,  and  the  buccal  and  faucial  surfaces  are 
injected.  The  Schneiderian  membrane  and  that  lining  the  larynx,  trachea, 
and  bronchial  tubes  participate  in  the  increased  vascularity.  The  cough  at 
first  is  dry,  and  sometimes  distinctly  croupy.  Catarrhal  or  false  croup, 
indeed,  is  not  infrequent  in  the  initial  period  of  measles.  The  cough  is 
attended  with  slight  acceleration  of  respiration  and  by  little  or  no  pain  in 
the  respiratory  movements.  If  auscultation  be  practised  at  this  early  stage, 
we  observe  the  vesicular  murmur,  somewhat  harsh  in  character,  and  some- 
times sonorous  and  sibilant  rales.  A  little  later  rales  of  a  moist  character 
appear. 

The  patient,  if  old  enough,  commonly  complains  of  headache  and  of  dull 
pain  in  the  epigastric  region  or  the  centre  of  the  sternum,  due  to  the  bron- 
chitis. With  these  local  symptoms  febrile  reaction  occurs.  The  tempera- 
ture rises  to  about  102°  or  103°,  as  indicated  b}^  the  thermometer  in  the 
axilla.  The  pulse  numbers  from  110  to  130  per  minute.  The  febrile  move- 
ment is  greater  than  in  primary  tracheo-bi'onchitis.  except  when   the   bron- 

263 


264  MEASLES. 

chitis  extends  to  the  bronchioles,  but  it  is  less  than  in  most  cases  of  scarlet 
fever. 

The  fever  in  the  premonitory  stage  of  measles  after  the  first  day  is  not 
uniform.  It  is  attended  by  remissions  and  exacerbations,  the  former  occur- 
ring in  the  first  part  of  the  day,  the  latter  in  the  evening.  Sometimes  two 
exacerbations  occur  in  the  day.  The  face  is  flushed  and  somewhat  swollen, 
especially  during  the  times  of  increase  in  the  fever,  and  the  child  is  drowsy 
or  restless.  Vomiting,  so  common  a  symptom  in  the  commencement  of  scar- 
let fever,  occasionally  occurs  in  measles.  While  in  scarlet  fever  this  takes 
place  in  the  first  twenty-four  hours,  in  measles  it  takes  place  with  about 
equal  frequency  at  any  period  previously  to  the  eruption.  It  was  present 
during  the  first  stage,  sometimes  almost  as  late  as  the  eruptive  period,  in 
13,  and  was  absent  in  23  cases  in  which  I  preserved  records  in  reference 
to  this  symptom. 

The  duration  of  the  first  stage  varies  in  difierent  cases.  It  is  usually 
from  two  to  five  days,  with  an  average  of  about  four.  Occasionally  it  is 
more  protracted  on  account  of  some  disturbance  in  the  economy,  either  from 
exposure  to  cold  or  other  cause,  which  prevents  the  necessary  afflux  of  blood 
toward  the  surface  and  retards  the  eruption.  In  18  cases  in  my  practice 
in  which  the  duration  of  the  cough  previously  to  the  appearance  of  the  rash 
was  accurately  ascertained,  the  time  varied  from  one  to  five  days,  with  an 
average  of  three  and  one-third ;  in  10  other  cases  it  had  continued,  the 
parents  stated,  about  a  week ;  and  in  5,  from  from  one  to  two  weeks  pre- 
viously to  the  eruption. 

The  eruption  commences,  when  the  disease  pursues  its  normal  course, 
upon  the  forehead  and  neck,  then  the  face,  and  gradually  extends  downward, 
occupying  from  twenty-four  to  thirty-six  hours  in  passing  over  the  trunk 
and  limbs.  It  appears  first  as  indistinct  red  points,  not  more  than  a  line  in 
diameter,  which  increase  in  size  and  become  more  distinct.  Their  borders 
are  uneven  or  irregular  or  they  are  finely  notched ;  their  general  shape  is, 
however,  circular,  except  as  two  or  more  unite,  when  they  may  assume  any  form. 
The  crescentic  form  which  writers  describe  is  due  to  the  union  of  two  points 
of  eruption.  The  largest  of  these  spots,  when  there  is  no  coalescence,  do 
not  exceed  a  quarter  of  an  inch  in  diameter,  and  many  are  much  smaller. 
Frequently  in  plethoric  children,  if  there  be  much  fever,  there  is  continuous 
redness  over  several  inches  of  surface.  The  eruption  is  then  confluent. 
This  form  is  often  observed  upon  the  parts  of  the  surface  where  the  capil- 
lary circulation  is  most  active  when  it  is  discrete  elsewhere.  In  some  of 
these  cases  diagnosis  of  measles  from  scarlet  fever  is  attended  with 
difficulty. 

The  rubeolous  eruption  is  slightly  elevated,  the  elevation  not  being 
appreciable  to  the  sight,  but  it  can  be  ascertained  by  passing  the  flnger  over 
the  skin,  when  roughness  is  felt  at  the  point  of  eruption.  Sometimes  the 
elevation,  especially  in  the  commencement  of  the  efflorescence,  is  not  appre- 
ciable, even  to  the  touch.  The  eruption  is  broad  and  flat,  never  acuminate, 
never  changing  its  form  to  the  vesicular  or  pustular.  It  disappears  by  pres- 
sure, and  immediately  reappears  when  the  pressure  is  removed.  It  has  been 
compared  in  appearance  to  flea-bites.  Small,  pointed,  papular,  vesicular,  or 
pustular  eruptions  are  sometimes  seen  in  connection  with  those  of  measles, 
but  they  are  accidental,  occurring  in  other  states  of  the  system,  as  well  as  in 
measles,  if  there  be  the  same  augmented  temperature. 

In  the  commencement  of  the  eruptive  period  the  severity  of  the  consti- 
tutional and  local  symptoms  increases.  The  pulse  and  temperature  corre- 
spond with  the  character  which  they  presented  during  the  exacerbations  of 
the  first  stage.     The  features  are  slightly  swollen ;  the  eyes  still  watery  and 


SYMPTOMS.  265 

sensitive  to  light;  the  conjunctiva,  ocular  and  palpebral,  and  the  mucous 
membrane  of  the  cavity  of  the  mouth  and  of  the  air-passages,  continue 
injected.  The  tongue  is  covered  with  a  moist  thin  fur,  and  its  papillae  are 
prominent,  though  less  so  than  in  scarlet  fever.  The  cough  continues  fre- 
quent, and  is  seldom  attended  with  much  expectoration  in  uncomplicated 
cases ;  often  there  is  no  expectoration  whatever.  The  appetite  is  lost,  but 
drinks  are  readily  taken  on  account  of  the  thirst.  Diarrhoea  sometimes 
occurs  on  the  first  day  of  the  eruption,  but  it  lasts  only  a  few  hours,  and, 
if  the  disease  pursue  its  usual  course,  abates  of  itself.  With  the  exception 
of  this  the  bowels  are  regular  or  a  little  constipated  during  the  eruptive 
period. 

On  the  second  day  of  the  eruption,  or  sixth  of  the  fever,  the  symptoms 
begin  to  abate.  The  pulse  is  less  accelerated  and  the  temperature  dimin- 
ishes ;  the  cough  is  less  frequent  and  is  easier,  and  the  flushed  and  swollen 
appearance  of  the  face  declines.  By  the  close  of  the  third  or  on  the  fourth 
day  the  rash  has  disappeared  in  the  order  in  which  it  extended  over  the  body. 
There  only  remain  faint  maculae,  which  in  the  course  of  a  day  or  two  fade 
completely. 

With  the  disappearance  of  the  rash  the  fever  nearly  or  quite  ceases,  but 
a  slight  and  painless  cough  continues  for  several  days. 

Occasionally  the  eruption  presents  a  livid  appearance  ;  this  is  the  rubeola 
nigra  of  writers.  From  cases  which  I  have  ob.served  it  is  my  opinion  that 
this  should  not  be  con.sidered  a  distinct  species  in  the  vast  majority  of 
patients,  but  that  the  dark  color  is  due  to  internal  inflammation,  usually 
capillary  bronchitis  or  pneumonia,  which  prevents  full  decarbonization  of  the 
blood.  Rarely,  rubeola  nigra  is  due  to  the  vitiated  state  of  the  blood  or  the 
malignant  nature  of  the  disea.se.  The  course  of  the  eruption  in  this  form  of 
measles  is  somewhat  diff"erent ;  it  continues  longer,  fades  more  slowly,  and 
does  not  disappear  so  readily  on  pressure.  Traces  of  it  are  observed  a  week 
or  more  after  its  first  appearance  ;  it  is  likely  to  be  fatal.  Measles  may  pre- 
sent this  form  from  the  beginning,  or,  commencing  as  vulgaris,  it  may  pass 
into  rubeola  nigra. 

Measles  may  be  irregular  in  form,  but  aberrations  are  less  frequent  than 
in  scarlet  fever.  Writers  describe  measles  without  catarrh,  and,  on  the  other 
hand,  with  catarrh,  but  without  the  rash.  But  po.sitive  diagnosis  in  such 
cases  must  be  difficult.  It  is  probable  that  simple  catarrh  and  roseola  have 
sometimes  been  mistaken  for  the  two  forms  of  irregularity  mentioned ;  but 
when  a  child  in  a  family  of  children  aff"ected  with  measles  presents  all  the 
symptoms  of  that  disease  except  the  catarrh  or  except  the  eruption,  the  diag- 
nosis of  irregular  measles  would,  as  a  rule,  be  correct. 

Occasionally  the  stage  of  invasion  is  very  short  or  even  absent.  In  one 
case  the  parents  informed  me  that  the  catarrhal  symptoms  began  on  the  day 
when  the  eruption  appeared.  Convulsions  sometimes  occur  at  the  commence- 
ment of  measles,  as  well  as  during  its  progress.  A  single  convulsive  attack 
at  the  commencement  is  usually  not  dangerous  ;  when  repeated  it  is  more 
serious ;  it  is  also  more  serious  when  it  occurs  in  the  course  of  measles. 
In  certain  patients  the  eruption  appears  in  an  irregular  and  partial  manner, 
occurring  perhaps  at  a  late  period,  and  indistinctly,  upon  the  trunk  alone 
or  upon  the  trunk  and  partially  upon  the  legs.  In  many  cases  of  deferred 
or  partial  eruption  there  is  internal  congestion  or  inflammation  of  some  part, 
which  causes  withdrawal  of  blood  from  the  surface,  and  thus  prevents  the 
normal  development  of  the  rash. 

When  the  eruption  disappears  the  third  stage  commences,  that  of  des- 
quamation. It  is  characterized  by  a  scanty  furfuraceous  exfoliation  of  the 
epidermis.     The  desquamation  is  seldom  as  great  as  in  scarlet  fever,  and  it 


266  MEASLES. 

occurs  most  where  the  eruption  has  been  thickest  and  the  epidermis  most 
inflamed.  Exfoliation  occurs  between  the  fourth  and  seventh  days  after 
the  commencement  of  the  eruption,  the  eighth  and  the  eleventh  of  the 
disease.  Frequently  it  does  not  take  place,  or  is  so  slight  as  not  to  be 
observed. 

With  the  disappearance  of  the  rash  the  symptoms  rapidly  abate.  The 
pulse  becomes  more  natural,  the  temperature  is  reduced,  the  digestive  organs 
return  to  their  normal  state,  and  convalescence  is  established.  The  cough 
continues  several  days  after  the  other  symptoms  abate,  but  it  is  less  and  less 
frequent,  and  is  not  painful. 

Complications. — The  complications  of  this  disease  are  important.  Much 
of  the  success  of  the  physician  in  the  management  of  measles  depends  upon 
a  correct  diagnosis  and  understanding  of  them.  The  most  frequent  of  these 
complications  are  bronchitis  and  broncho-pneumonia.  Slight  bronchitis  is 
uniformly  present  in  measles,  but  if  it  increase  so  as  to  cause  embarrassment 
of  respiration  and  become  a  source  of  danger,  it  is  properly  a  complication. 
This  complication,  as  well  as  pneumonia,  may  occur  at  any  period  of  measles, 
but  it  commences  most  frequently  in  the  first  stage.  Occurring  in  the  first 
stage,  it  may  prevent  the  regular  appearance  of  the  rash ;  if  in  the  second 
stage,  it  often  causes  retrocession  of  it. 

When  bronchitis  becomes  really  serious  it  usually  has  invaded  the  minute 
bronchial  tubes.  This  disease,  designated  capillary  bronchitis  or  suff"ocative 
catarrh,  I  have  elsewhere  described.  The  clinical  history  of  fatal  bronchitis 
as  a  complication  of  measles  is  as  follows  :  The  respiration,  at  first  not  notably 
altered,  becomes  by  degrees  accelerated  and  the  patient  more  and  more  fret- 
ful. The  pulse,  instead  of  becoming  less  accelerated,  as  after  the  first  days 
of  simple  measles,  is  daily  more  rapid  and  the  respiration  more  frequent  and 
labored.  The  dyspnoea  gradually  increases,  the  inframammary  region  is 
depressed  during  each  inspiration,  and  the  subcrepitant  rale  is  heard  on  both 
sides  of  the  chest.  There  is  probably  collapse  or  inflammation  of  some  of 
the  lobules.  Finally,  the  prolabia  and  fingers  become  livid,  and  death  occurs 
from  apnoea.  Capillary  bronchitis,  occurring  as  a  complication  and  continuing 
as  a  sequel  of  measles,  usually  becomes  a  broncho-pneumonia.  A  large  pro- 
portion of  those  afiiected  under  the  age  of  three  years  die.  The  anatomical 
characters  of  fatal  bronchitis  occurring  in  connection  with  measles  we  have 
had  frequent  opportunities  to  inspect  in  the  Foundling  Asylum  and  Infant 
Asylum.  In  some  cases  there  have  been  evidences  of  continuous  inflamma- 
tion from  the  epiglottis  downward,  ending  in  lobular  or  broncho-pneumonia. 
Broncho-pneumonia  as  a  complication  does  not  difier  materially  from  the 
idiopathic  inflammation,  except  that  it  is  more  protracted  and  fatal. 

The  next  most  frequent  serious  complication  of  measles  is  entero-colitis. 
This  may  commence  at  any  period  during  the  course  of  the  disease.  If  the 
colon  be  more  especially  the  seat  of  inflammation,  the  evacuations  contain 
mucus  and  blood,  unless  in  young  children,  in  whom  the  stools,  even  in 
severe  colitis,  commonly  have  a  green  color.  The  anatomical  character  of 
this  complication  varies  in  difl"erent  cases,  like  the  idiopathic  form  of  inflam- 
mation. Sometimes  there  is  simple  arborescence  of  the  intestinal  mucous 
membrane,  with  tumefaction  of  its  follicles ;  in  other  cases,  in  addition  to 
increased  vascularity,  the  mucous  coat  is  softened  and  thickened ;  and  in 
others  still,  especially  if  the  inflammatory  action  has  been  protracted,  ulcer- 
ation occurs,  for  the  most  part  in  the  site  of  the  solitary  glands.  Excep- 
tionally, in  fatal  cases  of  measles  attended  with  diarrhoea,  no  vascularity  is 
observed  after  death,  although  the  intestines  may  be  thickened  and  softened. 
In  such  cases  the  diarrhoea  was  probably  inflammatory,  the  injection  of  the 
vessels  having  disappeared  after  death. 


COMPLICATIONS.  267 

Severe  and  obstinate  diarrhoeal  affections  occurring  with  measles  usually 
commence  as  the  primary  disease  is  about  declining.  They  then  become 
sequelae,  ending  fatally  in  many  instances,  especially  in  the  summer  months, 
several  days  or  perhaps  .weeks  after  the  disappearance  of  the  eruption. 
Diarrhoeal  attacks  occurring  in  or  previously  to  the  eruptive  stage  are,  as 
a  rule,  mild  and  easily  relieved. 

In  some  grave  cases  measles  have  a  tendency  from  the  first  to  affect  the 
internal  organs  more  than  the  surface.  Bronchitis,  pneumonia,  and  entero- 
colitis may  coexist  with  indistinctness  of  the  eruption  on  the  skin.  Such 
complications  render  a  fatal  result  highly  probable. 

Eclampsia  is  also  an  occasional  very  dangerous  complication.  It  some- 
times occurs  very  suddenly  and  unexpectedly.  A  child  of  five  years,  in  my 
practice,  apparently  progressing  favorably  with  measles,  was  allowed  to  sit  at 
dinner  with  the  family  ;  suddenly  and  without  premonition  eclampsia  occurred, 
the  rash  receded,  and  notwithstanding  vigorous  treatment  death  resulted  in 
a  few  hours.  Rapidly-developed  cerebral  congestion  seemed  to  be  present. 
To  prevent  such  a  complication  the  patient  should  remain  quiet  in  bed  dur- 
ing the  eruptive  stage. 

Another  very  fatal  complication  and  sequel  is  pseudo-membranous  laryn- 
gitis, commencing  when  rubeola  is  beginning  to  decline  ;  but  it  is  less  frequent 
than  pneumonia  or  entero-colitis.  In  catarrhal  or  false  croup — which,  as  has 
been  previously  stated,  is  not  infrequent  at  the  commencement  of  measles — 
the  cough  has  a  loud,  ringing  character.  In  membranous  laryngitis,  on  the 
other  hand,  it  is  hoarse  or  harsh  and  less  distinct,  on  account  of  the  presence 
of  the  pseudo-membrane  in  the  larynx.  This  form  of  laryngitis,  always  a 
grave  disease,  is  more  serious  when  it  occurs  as  a  complication  of  measles  than 
when  it  is  idiopathic,  not  only  because  the  blood  is  vitiated  and  the  system 
reduced  by  the  primary  affection,  but  because  the  inflammation  of  the  mucous 
surface  is  in  general  more  extensive,  as  is  also  the  pseudo-membrane.  This 
membrane  in  the  croup  of  measles  often  extends  so  far  down  the  air-passages 
that  neither  intubation  nor  tracheotomy  can  produce  any  decided  ameliora- 
tion of  symptoms.  This  complication,  though  always  grave,  is  not,  however, 
necessarily  fatal.  I  have  known  cases  recover  by  inhalation  of  solvent  sprays 
when  for  days  there  had  been  dyspncea  and  other  evidences  of  a  pretty  firm 
pseudo-membrane.  True  croup  causes  continuation  of  the  fever,  which  had 
perhaps  begun  to  abate. 

Diphtheria,  when  epidemic,  also  frequently  complicates  measles.  Much 
of  the  mortality  from  measles  in  this  city  since  the  year  1858  was  due  to 
this  cause.  In  cases  observed  by  myself  diphtheria  usually  began  while  the 
fauces  were  still  inflamed,  and  sometimes  before  the  eruption  had  begun  to  fade. 
The  pseudo-membranous  laryngitis  or  true  croup  mentioned  above  is,  in  most 
instances,  in  localities  where  diphtheria  prevails,  a  local  manifestation  of 
this  disease. 

These  are  the  most  common  complications  of  measles.  There  are  others 
of  less  frequent  occurrence,  among  which  may  be  mentioned  stomatitis,  pha- 
ryngitis, and  otitis  sufiiciently  severe  to  be  considered  complications.  Rarely, 
also,  purpura,  attended  by  hemorrhages  from  the  different  mucous  surfaces, 
occurs  in  connection  with  measles.  This  complication  is,  however,  more  fre- 
quent in  certain  other  constitutional  diseases,  as  scarlet  fever,  and  especially 
variola. 

It  is  seen  that  the  inflammations  which  occur  in  the  course  of  measles 
are  chiefly  of  the  mucous  surfaces.  In  scarlet  fever,  on  the  other  hand,  the 
inflammations  are  more  frequently  of  serous  surfaces. 

There  are  other  affections  originating  in  measles  which  are  rather  sequelae 
than  complications.     Gangrene  of  the  mouth  is  one  which,  as  stated  in  another 


268  MEASLES. 

part  of  this  book,  occurs  more  frequently  after  measles  than  any  other  disease. 
After  a  severe  epidemic  of  measles  in  the  New  York  Foundling  Asylum  in 
1874  three  cases  of  gangrenous  vulvitis  occurred  in  those  who  had  been 
affected.  Ophthalmia  commencing  in  measles  often  persists  for  weeks  or 
months.  It  may  give  rise  to  granulation  of  the  lids,  and  cases  have  been 
reported  of  violent  inflammation  of  a  purulent  character  producing  ulcera- 
tion of  the  cornea  and  destroying  vision.  The  ophthalmia  is  sometimes  very 
intractable.  Inflammation  of  the  Schneiderian  membrane,  commonly  present 
during  measles,  often  continues  as  a  sequel,  extending  back  as  far  as  the  Eusta- 
chian tube,  where  it  may  cause  swelling,  with  impairment  of  hearing,  and 
forward  to  the  lip,  where  it  may  produce  chronic  eczema.  Prof.  Moos  has 
described  the  lesions  which  occur  in  the  labyrinth  in  measles  when  the  ear 
is  affected.  Cells  and  coagulated  lymph  fill  the  semicircular  canals  and  the 
cochlea,  and  collect  in  the  lymphatics.  The  blood-vessels  in  the  Haversian 
canals  and  in  the  spiral  ligament  are  nearly  destroyed.  The  nerves  become 
gelatinous  and  atrophy;  the  muscular  fibres  undergo  waxy  degeneration. 
Notwithstanding  such  lesions,  permanent  deafness  is  rare  and  reparation 
seems  possible  (^Congress  at  Wiesbaden,  Sept.  22,  1887). 

Anatomical  Characters. — I  have  made  or  witnessed,  mainly  in  insti- 
tutions, a  considerable  number  of  post-mortem  examinations  of  those  who 
have  died  in  or  after  an  attack  of  measles.  In  all  there  were  lesions  due  to 
complications.  Indeed,  death  directly  from  measles  is  so  rare  that  few  have 
had  an  opportunity  of  studying  the  anatomical  charcters  apart  from  the  com- 
plications. In  those  who  have  died  without  any  obvious  coexisting  disease — 
and  these  cases  chiefly  occur  in  the  malignant  form — there  has  been  congestion 
of  the  internal  organs,  especially  marked  in  the  lungs,  and  sometimes  the  tis- 
sues appeared  softened.  The  blood  also  in  the  malignant  form  has  a  darker 
hue  than  natural,  and  ecchymotic  patches  have  been  observed  upon  the  mucous 
surfaces  and  elsewhere,  corresponding  in  character  with  the  petechise  under 
the  skin  which  sometimes  occur  in  this  form  of  measles.  In  cases  resulting 
fatally  from  bronchitis  or  pneumonia  the  bronchial  glands  are  commonly  tume- 
fied in  the  same  manner  as  the  mesenteric  glands  are  enlarged  in  enteritis  and 
the  glands  of  the  mesocolon  in  dysentery. 

Nature. — Rubeola,  like  the  other  exanthematic  fevers,  is  due  to  a  mate- 
ries  morbi,  probably  micrococci,  as  has  been  stated  above.  It  is  highly  con- 
tagious through  the  air.  It  has  been  inoculated  by  the  serum  from  vesicles 
which  sometimes  occur  in  connection  with  the  rubeolous  eruption,  and  also 
by  the  blood  from  a  patient.  Inoculation  does  not  appear  to  moderate  the 
disease,  and  as  measles,  when  contracted  in  the  ordinary  way,  is  not  in  itself 
dangerous,  but  dangerous  only  from  complications,  inoculation  is  not  per- 
formed except  as  a  matter  of  scientific  interest.  The  usual  mode  of  prop- 
agation is  through  the  air.  Measles  is  communicated  by  the  breath  and  prob- 
ably by  exhalations  from  the  surface.  Under  whatever  circumstances  it  occurs, 
the  specific  principle  has  been  communicated  from  some  infected  person.  We 
frequently  meet  cases,  as  one  in  a  sparsely-settled  district  that  has  come  to 
my  knowledge,  in  which  exposure  cannot  be  traced.  Yet  the  immunity  of 
certain  islands  for  centuries  till  infected  through  commerce  renders  the  doc- 
trine of  an  origin  de  novo  improbable. 

Twelve  to  fourteen  days  elapse  from  the  time  of  infection  to  the  com- 
mencement of  the  eruption.  In  cases  observed  in  the  children's  department 
of  Charity  Hospital  the  incubative  period  was  ascertained  to  be  about  twelve 
days.  In  those  who  have  been  inoculated  the  incubative  period  is  said  to  have 
been  about  one  week.  Rubeola  prevails  epidemically,  like  the  whole  class  of 
infectious  diseases,  and  in  different  epidemics  the  type  may  vary  as  well  as 
the  character  of  the  complications. 


TREATMENT.  269 

Diagnosis. — The  diagnosis  of  measles  previously  to  the  eruption  is  often 
difficult.  The  catarrhal  symptoms  then  predominate,  and  these  are  such  as 
may  occur  independently  of  any  constitutional  or  blood  disease.  The  first 
stage,  therefore,  is  not  infrequently  mistaken  for  coryza  or  mild  bronchitis. 
The  points  of  differential  diagnosis  are  the  suffused  appearance  of  the  eyes, 
the  greater  degree  of  fever  on  the  first  day  than  would  be  likely  to  arise 
from  so  moderate  an  amount  of  local  disease,  and  morning  remission  and 
evening  exacerbation  of  the  fever.  Measles  in  the  first  stage  has  been  mis- 
taken for  remittent  fever.  The  catarrhal  symptoms  should  prevent  such  an 
error. 

Sometimes  roseola  closely  resembles  measles  in  appearance,  but  the  rash 
•of  roseola  appears  within  a  few  hours  after  the  commencement  of  febrile 
symptoms,  and  almost  simultaneously  over  the  whole  body,  and  without 
those  local  symptoms  referable  to  the  mucous  surfaces  which  characterize 
measles. 

Variola  on  the  first  day  of  the  eruption  has  sometimes  been  diagnosti- 
cated measles.  I  recollect  once  being  called  to  an  infant  with  fatal  confluent 
smallpox  who  was  said  to  have  measles.  A  physician  a  few  days  previously, 
•observing  the  red  points  in  the  commencement  of  the  eruption,  had  made 
this  absurd  diagnosis,  and,  predicting  a  favorable  result,  had  not  thought  it 
necessary  to  repeat  his  visit.  In  case  of  doubt  it  is  the  part  of  prudence  to 
defer  making  a  positive  diagnosis.  A  few  hours  suffice  to  show  the  distinct- 
ive characters  of  rubeolous  and  variolous  eruptions.  But  the  anxiety  of 
friends  often  necessitates  the  expression  of  opinion.  The  absence  or  light- 
ness of  catarrhal  symptoms,  the  earlier  appearance  of  the  eruption,  and  its 
papular  feel  under  the  finger  in  smallpox,  enable  us  to  discriminate  between 
the  two  diseases  in  the  commencement  of  the  eruptive  stage.  Moreover,  the 
symptoms  in  the  initial  periods  are  different,  as  will  be  seen  in  our  description 
of  smallpox. 

Prognosis. — This  is  favorable,  provided  that  no  serious  complication 
arises.  With  internal  inflammatory  complication,  on  the  other  hand,  the  dis- 
ease becomes  much  more  grave.  A  large  proportion  thus  affected  die.  The 
prognosis  is  less  favorable  in  feeble  children  with  scanty  eruption  or  an 
eruption  appearing  at  a  late  period  and  irregularly.  Dyspnoea,  persistent  and 
^reat  acceleration  of  pulse,  and  coma  indicate  an  unfiivorable  ending.  Con- 
vulsions occur  much  more  rarely  in  the  course  of  measles  than  in  scarlet 
fever,  and  when  they  occur  after  the  initial  period  they  usually  end  in  coma 
and  death.  The  mortality  from  measles  varies  greatly  according  to  the 
severity  of  the  type,  but  more  according  to  the  season,  the  locality,  the  sur- 
roundings, and  the  care  which  the  patients  receive,  which  determine  the 
liability  to  complications.  Thus  in  the  cities  the  mortality  is  large  from 
measles  in  the  hot  months  among  infants,  who  at  this  time  are  very  liable  to 
gastro-intestinal  catarrh.  It  also  seems  to  be  larger  in  the  asylums  than  in 
family  practice.  In  epidemics  in  Boston  and  Pont  de  I'Arche  the  mortality 
was  5  per  cent,  of  the  cases,  in  Neufchatel,  Switzerland,  2  per  cent.,  and 
among  the  Sioux  Indians,  at  Crow  Creek  Agency,  Dakota,  6.66  per  cent. 
(Therapeutic  Gaz.,  July  16,  1888). 

Treatment. — Uncomplicated  rubeola  requires  little  medicinal  treatment 
except  to  palliate  symptoms.  The  child  should  be  kept  in  an  airy  apartment 
■at  a  uniform  temperature  of  about  70°.  A  temperature  so  elevated  as  to  be 
uncomfortable  to  the  nurse  is  injurious  to  the  patient.  But  while  the  pop- 
ular idea  is  erroneous  that  he  should  be  kept  in  a  heated  atmosphere,  it  is 
correct  that  currents  of  air  and  sudden  reduction  of  temperature  are  dan- 
gerous. A  violent  and  fatal  attack  of  croup  occurred  in  my  practice  in  a 
girl  of  fifteen  in  consequence  of  exposure  at  an  open  window  at  the  close  of 


270  MEASLES. 

the  eruptive  stage.  The  diet  should  he  mild,  and  for  the  most  part  liquid. 
The  patient,  indeed,  refuses  solid  food,  hut  on  account  of  the  thirst  takes 
liquids  more  readily.  Farinaceous  suhstances,  with  milk,  afford  sufficient 
nutriment  in  ordinary  cases.  If  the  previous  health  have  been  poor  and  the 
vital  powers  reduced,  or  if  there  be  a  complication,  more  sustaining  diet  is 
required.  Stimulation  by  wine  or  brandy  is  needed  in  these  cases.  During 
the  two  or  three  weeks  succeeding  an  attack  of  measles  care  should  be  taken 
to  avoid  exposure  to  cold  or  changes  of  temperature,  since  during  this  period 
there  is  great  liability  to  inflammations  of  the  mucous  surfaces. 

The  cough  ordinarily  requires  treatment,  inasmuch  as  the  suffering  of 
the  child  and  loss  of  sleep  are  largely  due  to  this  symptom.  Demulcent 
drinks,  as  flaxseed  tea,  infusion  of  slippery-elm  bark,  or  solution  of  gum 
Arabic,  are  useful,  to  which,  to  render  them  more  palatable,  lemon-juice  may 
be  added.  A  small  Dover's  powder  or  the  mistura  glycyrrhizaef  composita 
of  the  Pharmacopoeia,  given  occasionally,  relieves  the  severity  and  diminishes 
the  frequency  of  the  cough. 

As  the  chief  danger  in  measles  is  from  inflammation  of  the  respiratory 
organs,  local  treatment  directed  to  the  chest  is  important.  The  chest  should 
be  covered  with  cotton  wadding  or  in  cold  weather  even  oil-silk,  unless  in 
the  mildest  cases.  This  increases  the  amount  of  eruption  upon  the  surface 
underneath,  and,  I  believe,  tends  greatly  to  prevent  complication  by  capillary 
bronchitis  and  pneumonia.  If  the  eruption  be  tardy  in  its  appearance  or 
indistinct,  it  is  well  to  produce  moderate  counter-irritation  by  some  gentle 
irritant  underneath,  as  camphorated  oil,  to  which  in  older  children  a  little 
turpentine  may  be  added. 

Affections  which  complicate  measles  should  receive,  for  the  most  part, 
such  treatment  as  is  appropriate  for  them  when  idiopathic.  Secondary  dis- 
eases, however,  require  sustaining  measures  more  than  primary.  In  bronchial 
and  pulmonary  inflammations — which  if  they  occur  early  in  measles  prevent 
the  regular  appearance  of  the  eruption,  or  if  in  the  eruptive  stage  cause  its 
disappearance — prompt  counter-irritation  over  the  chest  by  sinapisms  or  other- 
wise is  required.  Trousseau  states  that  he  has  derived  benefit  in  these  cases- 
from  what  he  designates  urtication.  This  is  produced  by  stroking  the  chest 
two  or  three  times  daily  with  the  nettle  (  Urtica  dioica  or  Urtica  wens).  This 
causes  a  prompt  and  abundant  eruption,  and  with  a  less  amount  of  sufferings 
than  one  would  suppose.  The  fever  abates,  and  the  respiration  becomes 
more  natural  in  proportion  to  the  amount  of  nettlerash.  On  the  second  day 
the  effect  is  less  than  on  the  first,  and  after  three  or  four  days,  says  Trous- 
seau, no  further  irritation  results  from  the  nettle.  When  counter-irritation 
is  produced,  by  whatever  method,  the  chest  should  be  covered  with  a  warm 
and  soft  poultice,  as  the  ground  flaxseed ;  derivatives  to  the  extremities  are 
useful  in  such  cases.  In  capillary  bronchitis  and  pneumonia  stimulating 
expectorants  are  required,  as  carbonate  of  ammonium.  I  frequently  write 
the  following  prescription.  It  is  useful  both  as  an  expectorant  and  cardiac 
stimulant.  ■  Given  in  milk  or  after  food  is  taken,  it  does  not  produce  gastritis,, 
as  it  often  does  in  a  more  concentrated  form  : 

R.  Ammon.  carbonat.,  gr.  xvj-.^ss; 

Aquae  purse,  ^ij. 

Give  one  teaspoonful  in  three  or  four  of  milk  every  hour  or  two. 

Chloride  of  ammonium  is  also  a  good  remedy  in  these  cases,  employed  in- 
double  the  dose  of  the  carbonate. 

Quinia  to  reduce  the  fever  and  digitalis  or  strophanthus  or  camphor  as  a 


ETIOLOGY.  271 

heart  tonic  are  also  very  useful  in  these  inflammations,  given  alone  or  alter- 
nately with  the  above. 

The  cases  of  gangrenous  vulvitis  alluded  to  above  were  treated  with  a  flax- 
seed poultice,  and  iodoform  dusted  over  the  surface  each  day  or  second  day, 
with  a  satisfactory  result.  As  regards  the  treatment  of  other  complications 
the  appropriate  measures  are  detailed  elsewhere. 


CHAPTER    II. 
SCARLET  FEVER. 

It  is  supposed  by  some  who  have  studied  the  history  of  scarlet  fever  that 
it  is  of  ancient  origin,  but  the  descriptions  of  diseases  left  us  by  the  old  writers, 
and  by  those  in  the  Christian  era  until  after  the  Middle  Ages,  are  so  obscure 
or  difi'er  so  widely  in  the  statements  made  from  the  symptoms  of  scarlet  fever 
as  it  occurs  in  modern  times  that  the  impartial  critic  fails  to  find  any  clear 
evidence  of  its  occurrence  prior  to  the  last  four  or  five  centuries. 

The  first  clear  and  undoubted  portrayal  of  this  disease  is  found  in  the 
medical  literature  of  the  sixteenth  century.  Sydenham  and  his  contemporaries 
in  the  seventeenth  century  witnessed  epidemics  of  it  and  studied  its  nature 
more  thoroughly,  and  consequently  acquired  a  more  accurate  knowledge  of  it 
than  that  possessed  by  their  predecessors.  It  was  in  this  century  that  measles 
and  scarlet  fever  were  differentiated.  During  the  last  two  hundred  years 
scarlatina  has  been  the  subject  of  monographs  too  numerous  to  mention.  It 
has  long  been  regarded  as  one  of  the  most  important  maladies  of  childhood, 
on  account  of  its  frequency  and  the  great  mortality  that  attends  it,  so  that 
numerous  cases  and  many  epidemics  are  every  year  related  in  the  medical 
journals.  By  this  vast  accumulation  of  observations  and  the  patient  and 
thorough  use  of  the  microscope  our  knowledge  of  scarlet  fever  has  become 
full  and  accurate. 

As  with  most  of  the  infectious  maladies,  scarlet  fever  was  introduced  into 
the  Western  Hemisphere  by  European  navigators.  It  was  brought  to  North 
America  about  the  year  1735.  Tardily  it  spread  to  South  America,  where  it 
appeared  in  1829,  and  more  recently  it  has  been  established  in  Australia. 
It  entered  Iceland  in  1827  and  Greenland  in  1847. 

Etiology. — As  yet,  observers  do  not  agree  in  regard  to  the  parasite 
which  is  supposed  to  sustain  a  causal  relation  to  scarlet  fever.  Klebs  states 
that  it  is  highly  probable  that  both  measles  and  scarlet  fever  are  produced  by 
micrococci,  and  he  has  sketched  the  design  and  described  the  development  of 
a  microbe  which  he  designates  the  Monas  scarlatinosum. 

The  London  Medical  Times  and,  Gazette  for  Jan.  28,  1882,  contains  an 
account  of  the  supposed  discovery  of  the  scarlatinous  microbe  by  Eklund  of 
Stockholm,  an  authority  in  the  microscopic  examination  of  parasites.  He 
says  that  scarlet  fever  is  rarely  absent  from  the  Swedish  capital  and  from 
the  barracks  and  dwellings  on  the  isle  of  Skeppsholm.  In  the  urine  of  scar- 
latinous patients  he  has  constantly  found  a  prodigious  number  of  discoid  cor- 
puscles, oval  or  round,  their  diameter  being  less  than  y^Vcr  millimetre,  and 
from  -ji-jj-  to  -Jq-  that  of  a  red  blood-cell.  They  are  colorless  or  yellowi.sh-white, 
surrounded  by  a  distinct  cell-wall,  each  containing  a  well-defined  nucleus  of  a 
deeper  hue.  Sometimes  one,  sometimes  more,  of  them  are  seen  in  the  field 
of  the  microscope.     They  exhibit  rotatory  or  oscillatory  movements,  especially 


272  SCARLET  FEVER. 

observed  when  a  drop  of  water  is  added  to  the  fluid.  They  multiply,  as 
Eklund  has  frequently  seen,  by  fission — first  in  the  microbes,  next  in  the 
nucleus,  and  lastly  in  the  cell-wall.  He  cannot  say  whether  they  develop 
into  a  mycelium.  At  any  rate,  the  development  of  fine  filaments  seems  to 
be  exceptional.  He  has  never  seen  them  adhere  in  moniliform  chains  nor 
massed  as  zoogloea.  He  considers  them  to  be  veritable  schizomycetes,  and 
proposes  the   name  Plox  scindens. 

Eklund  asserts  that  he  has  found  these  organisms  in  vast  numbers  in  the 
soil-  and  ground-water  of  the  isle  of  Skeppsholm,  in  the  mud  of  the  trenches 
dug  for  the  water-mains,  and  in  the  greenish  mould  upon  the  walls  of  the  old 
barracks,  where  scarlet  fever  was  most  rife.  He  states  that  scarlet  fever  has 
occurred  in  children  after  drinking  milk  mixed  with  the  ground-water  of  the 
island,  and  he  observed  a  case  which  followed  immersion  in  one  of  the  trenches 
of  the  island  and  the  drying  of  the  clothes  in  a  small  room.  In  another 
instance  scarlet  fever  broke  out  in  a  block  immediately  after  exposure  of  the 
ground-water  by  excavations.  It  is  evident  that  the  discovery  of  this  microbe 
tinder  such  circumstances  does  not  prove  that  it  is  the  cause  of  the  disease. 
This  can  only  be  determined  by  inoculation  or  by  experiments  which  furnish 
the  conditions  of  scientific  exactness.  In  1886,  Dr.  Edington  of  Edinburgh 
isolated  a  diplococcus  and  a  bacillus  from  the  blood  and  epidermis  of  scarlat- 
inous patients.  He  states  that  inoculation  of  the  bacillus  in  rabbits  caused 
erythema,  followed  by  desquamation.  But  these  observations,  as  detailed  in 
the  Lancet,  show  possible  sources  of  error,  and  have  therefore  attracted  but 
little  attention. 

Dr.  E.  0.  Shakespeare  describes  the  bacillus  scarlatinas  of  Edington  as 
"rods  measuring  0.4  m.  in  thickness  and  1.2  m.  to  1.4  m.  in  length,  most 
usually  forming  excessively  long-pointed  and  curved  leptothrix  filaments, 
motile  ;"  and  he  remarks,  "  it  is  pretty  well  proven  that  this  bacillus  scarlatinas 
is  the  specific  cause  of  scarlet  fever."  ^ 

Whatever  may  be  the  micro-organism  which  causes  scarlet  fever,  its  mode 
of  action  and  effects  have  been  ascertained  by  clinical  observations.  Without 
doubt,  it  commonly  enters  the  system  by  the  breath,  but  it  probably  may 
enter  in  the  ingesta  and  it  infects  the  blood.  That  it  resides  in  the  blood  has 
been  ascertained  by  inoculation  with  this  liquid,  by  which  scarlet  fever  has 
been  reproduced  in  its  typical  form.  From  the  blood  it  enters  the  tissues 
and  secretions.  Hence  handkerchiefs  or  linen  containing  the  saliva  or  mucus 
of  a  patient,  the  epidermic  scales  shed  abundantly  in  the  desquamative  period, 
and  probably  also  the  urinary  and  fecal  evacuations,  contain  the  poison,  so  as 
to  be  highly  infectious.  Even  the  discharge  of  a  scarlatinous  otorrhoea  is 
thought  by  some  to  be  contagious  for   a  considerable  time. 

Scarlatina  is  communicable  not  only  by  direct  exposure  to  a  patient,  but 
also  by  exposure  to  objects  which  happen  to  be  in  his  room  during  his  illness, 
and  to  which  the  poison  becomes  attached,  such  as  clothing,  books,  and  toys ; 
small  packages,  as  we  have  stated  above,  sometimes  convey  and  disseminate 
the  contagious  principle. 

In  England  observations  have  been  made  which  show  that  scarlatina  has 
been  communicated  by  infected  milk.  The  disease  occurred  in  the  family  of 
a  milkman,  and  the  milk,  before  it  was  distributed,  remained  for  a  time  in  a 
kitchen  which  had  been  occupied  by  the  patients.  This  milk  was  taken  by 
twelve  families,  and  in  six  of  these  scarlatina  occurred  almost  simulta- 
neously at  a  time  when  few  cases  were  occurring  in  the  locality.  There  had 
been  no  direct  exposure  to  the  carrier  of  the  milk  nor  to  members  of  the 
affected  family  (Taylor).  In  another  instance  a  woman  and  her  son  had 
scarlet  fever  while  they  were  serving  milk  to  several  families,  and  the  disease 
1  Annual  of  Med.  Sci,  vol.  v.,  1888. 


ETIOLOGY.  273 

appeared  in  all  these  families  except  one,  which  consisted  of  old  people  (Bell). 
It  is  known  that  milk  absorbs  volatile  substances  so  as  to  be  flavored  by  them, 
as  is  shown  in  the  experiment  of  placing  it  in  an  open  vessel  in  a  box  with  a 
pineapple  ;  and  it  may  in  a  similar  manner  become  infected  by  the  specific 
principle  of  scarlet  fever,  or  it  may  be  infected  by  detached  particles  of  epi- 
dermis ;  which  is  not  improbable  when  one  convalescing  from  scarlet  fever  is 
allowed  to  milk  the  cows  or  prepare  the  milk  for  distribution.  In  1885  an 
epidemic  of  scarlet  fever  in  London  was  traced  to  the  milk-supply  coming 
from  a  certain  dairy  in  Hendon.  The  health  officer  of  Hendon  discovered  a 
contagious  disease  in  the  cows  of  this  dairy  communicable  to  healthy  cows 
by  inoculation  from  the  teats,  and  also  communicable  to  man.  The  symp- 
toms in  the  cow  were  fever,  cough,  sore  throat,  discharge  from  nostrils  and 
eyes.  Communicated  to  man,  the  disease  produced  malaise,  and  in  four  or 
five  days  a  vesicle.  Crookshank  believes  that  the  Hendon  disease  was  the 
Jennerian  cowpox,  and  the  symptoms  certainly  bore  a  closer  resemblance  to 
cowpox  than  to  scarlet  fever.  Probably,  therefore,  the  scarlet  fever  in  Lon- 
don originated  from  some  other  source  (^Loiulon  Lancet). 

The  scarlatinous  virus  surpasses  that  of  any  other  eruptive  fever  except 
smallpox  in  its  tenacious  attachment  to  objects  and  its  portability  to  distant 
localities.  Hence  in  the  literature  of  the  disease  are  the  records  of  many 
cases  in  which  the  poison  was  conveyed  long  distances,  retaining  its  virulence 
to  the  full  extent  and  causing  an  outbreak  of  the  malady  in  the  localities  to 
which  it  was  carried.  In  New  York,  so  frequently  has  scarlet  fevor  as  well 
as  measles  and  diphtheria  been  contracted  from  the  persons  or  clothing  of 
well  children  who  come  from  infected  houses,  that  the  Health  Board  now 
exclude  from  the  public  schools  all  children  who  come  from  such  houses,  even 
though  they  live  on  separate  floors  from  those  occupied  by  the  sick.  In  one 
instance  that  came  under  my  notice  a  washerwoman  whose  child  had  scarlet 
fever  communicated  the  disease  to  an  infant  in  the  household  where  she  was 
employed,  by  placing  her  shawl  over  the  cradle  in  which  it  was  lying.  A 
physician  of  my  acquaintance  went  from  a  scarlet-fever  patient  to  a  family 
several  streets  distant,  and  took  one  of  the  children  upon  his  lap.  After 
the  usual  incubative  period  this  child  sickened  with  a  fatal  form  of  the  mal- 
ady, and  the  remaining  children  of  the  hou.sehold  were  in  time  affected.  In 
New  York  scarlet  fever  has  seemed  to  me  to  be  not  infrequently  communi- 
cated through  school-books,  which,  profusely  illustrated  by  pictures  and  ren- 
dered attractive  to  the  young,  are  often  allowed  to  lie  upon  the  bed  of  a  scar- 
latinous patient,  and  be  handled  by  him  during  convalescence  or  even  during 
the  course  of  the  fever  if  it  be  mild.  The  young  librarian  of  the  circulating 
library  of  a  Sunday-.school,  whose  pupils  came  largely  from  the  tenement- 
houses,  was  occupied  a  considerable  part  of  a  day  in  covering  and  arranging 
the  books.  After  about  the  usual  incubative  period  of  scarlet  fever  he  sick- 
ened with  the  disease.  His  two  sisters  were  immediately  removed  to  a  rural 
township  three  hundred  miles  away,  and  to  an  isolated  house  where  scarlatina 
had  never  occurred.  About  one  month  after  his  recovery,  and  after  his  room 
had  been  disinfected  by  burning  sulphur  and  his  bedclothes  and  linen  had 
been  thoroughly  washed,  and  all  articles  suspected  to  hold  the  poison  had 
been  either  disinfected  or  destroyed,  the  brother  visited  his  sisters  in  the 
country.  Three  weeks  subsequently  to  his  arrival  one  of  the.se  sisters  sick- 
ened with  scarlet  fever,  and  a  week  later  the  other  also.  It  seems  that  the 
exposure  must  have  occurred  several  days  after  his  arrival  in  the  country 
from  some  books  or  other  infected  article  in  his  possession.  About  two 
months  elapsed  after  the  last  case  ;  the  family  had  returned  to  the  city,  the 
infected  room  in  the  country-house  had  been  thoroughly  fumigated  by  burn- 
ing sulphur  from  morning  till  evening,  when  a  little  girl  from  an  inland  city 
18 


274  SCARLET  FEVER. 

remained  a  few  days  in  this  liouse,  and  probably  often  entered  the  room  where 
the  young  ladies  had  been  sick.  In  a  few  days  she  also  sickened  with  a  fatal 
form  of  scarlatina.  Such  histories  and  experiences  are  not  infrequent.  They 
are  common  during  epidemics  of  scarlet  fever.  They  indicate  an  extraordi- 
nary attachment  of  the  scarlatinous  poison  to  objects,  and  show  that  it  is  not 
gaseous  nor  readily  volatilized. 

A  striking  example  of  this  fixity  of  the  poison  occurred  in  the  practice 
of  the  late  Kearney  Rogers,  formerly  a  prominent  and  much-esteemed  sur- 
geon of  New  York  City.  Six  children  in  a  family  had  scarlet  fever.  Three 
and  a  half  months  subsequently  another  child,  living  at  a  distance,  was 
allowed  to  return  home  and  occupy  the  apartment  in  which  the  sickness  had 
occurred.  One  week  subsequently  to  the  date  of  the  return  this  child  sick- 
ened with  the  same  malady.  Elliotson  states  that  a  patient  with  scarlet  fever 
was  admitted  into  one  of  the  wards  of  St.  Thomas's  Hospital,  and  for  two 
years  subsequently  young  persons  who  were  admitted  into  the  ward  were  apt 
to  take  the  disease.  Richardson  of  London  relates  the  following  experiences 
of  a  family  whom  he  attended  in  the  rural  district :  "  At  a  short  distance 
from  one  of  our  villages  there  was  situated  on  a  slight  eminence  a  small 
clump  of  laborers'  cottages,  with  the  thatch  peering  down  on  the  beds  of  the 
sleepers.  A  man  and  his  wife  lived  in  one  of  these  cottages  with  four 
lovely  children.  The  poison  of  scarlet  fever  entered  the  poor  man's  door, 
and  struck  down  one  of  the  flock."  The  remaining  children  were  now 
removed  some  miles  away,  and  after  several  weeks  one  of  them  was  allowed 
to  return.  Within  twenty-four  hours  he  also  took  the  disease,  and  quickly 
died.  The  walls  of  the  cottage  were  now  thoroughly  cleaned  and  white- 
washed, the  floors  scoured,  and  all  the  wearing  apparel  either  destroyed  or 
washed.  Four  months  elapsed  after  the  last  sickness  when  one  of  the 
remaining  children  returned.  "  He  reached  his  father's  cottage  early  in  the 
morning ;  he  seemed  dull  the  next  day,  and  at  midnight  I  was  sent  for,  to 
find  him  also  the  subject  of  scarlet  fever.  The  disease  again  assumed  the 
malignant  type,  and  this  child  died."  Richardson  believes  that  the  contagion 
was  attached  to  the  thatch,  which  could  not  be  thoroughly  disinfected.  The 
fact  of  this  remarkable  long-continued  attachment  of  the  poison  to  objects, 
indicating  by  this  fixity  that  it  is  a  solid,  is  consonant  with  the  theory  that 
it  is  an  organism. 

Incubative  Period. — The  duration  of  the  incubative  period  varies  in 
different  cases.  It  is  sometimes  less  than  twenty-four  hours,  as  in  the  above 
case  reported  by  Richardson  ;  in  the  following  well-known  case,  observed  by 
Trousseau,  it  was  one  day  :  A  girl  arrived  in  Paris  from  Pau,  where  there 
was  no  scarlet  fever,  and  occupied  the  same  apartment  with  her  sister,  who 
was  sick  with  this  disease.  Twenty-four  hours  after  her  arrival  she  was  also 
attacked  with  the  same  malady. 

Russeberger  attended  a  child  who  was  exposed  at  noon  to  scarlet  fever, 
and  took  the  disease  on  the  following  night.  B.  W.  Richardson  (^Clinical 
Essays,  1861,  vol.  i.  p.  94)  gives  his  own  experience.  He  had  applied  his 
ear  to  the  chest  of  a  patient  sufiering  from  scarlet  fever,  and  was  conscious 
of  a  peculiar  odor  emitted  from  the  patient.  He  was  immediately  nauseated 
and  chilly,  and  from  that  moment  he  dated  the  beginning  of  an  attack  of 
scarlet  fever.  In  the  Transactions  of  the  Clinical  Society  of  London,  vol. 
ix.,  1878,  the  late  Charles  Murchison  gives  the  statistics  of  75  cases  showing 
the  incubative  period,  as  follows  : 

In    4  cases  it  was  not  more  than 24  hours. 

"     2     "         "  "         "         30     " 

"     3     "         "  "         "         36     " 


CONTAGIOUSNESS.  275 

In    4  cases  it  was  not  more  than 40  hours. 

"     1     "         "  "         "  41     " 

"     4     "         '•  "         "  58     " 

"     1     "         "  " '       "  54     " 

"     1     "         "  "         "  2J  days. 

"  31  eases  it  was  within  (time  not  accurately  ascertained)    ...    4       " 

"     2  cases  the  incubation  did  not  exceed 4J     " 

"  17     "  "  "      "         "       5"     " 

"     2     "  "  "      "         "       6       " 

In  3  cases  Murchison  believes  that  the  incubation  was  precisely  fixed  at 
thirty-six  hours,  three  clays,  and  four  and  a  half  days. 

Watson  says  that  a  man  reached  Devonshire  at  mid-day  to  see  his  daugh- 
ter, who  had  scarlet  fever.  Two  days  later  he  was  also  attacked.  Eehn  saw 
a  child  who  was  attacked  two  days  after  its  grandmother  returned  from  a 
case  of  scarlet  fever ;  and  Zengerle,  a  girl  of  ten  years,  residing  at  Wangen, 
where  there  was  no  scarlet  fever,  who  took  the  disease  two  days  after  her 
mother  had  returned  from  visiting  a  family  affected  with  it.  Loochner  states 
that  a  boy  aged  four  and  a  half  years  was  attacked  one  and  a  half  days  after 
admission  into  the  infected  wards  of  a  hospital.  Armistead,  in  his  annual 
report  on  the  health  of  the  Newmarket  rural  district,  states  that  three  chil- 
dren, coming  from  a  different  part  of  the  district,  visited  Wesley,  and  stayed 
next  door  to  a  child  who  had  had  scarlet  fever  six  weeks  previously,  and  who 
was  allowed  to  play  with  these  children  on  the  evening  of  August  13th  and 
morning  of  the  14th.  The  family  then  returned  home,  and  on  the  18th, 
four  days  after  the  exposure,  all  three  children  sickened  with  scarlet  fever 
(^British  Medical  Journal,  September  30,  1882). 

Ordinarily,  therefore,  the  incubative  period,  though  varying  in  different 
cases,  is  within  six  days.  Many  cases,  however,  occur  in  which  it  seems  to 
be  longer.  Thus,  in  my  practice  scarlet  fever  appeared  in  a  family  on  April 
26,  1882.  The  patient  was  immediately  removed  to  the  third  floor  and  the 
other  children  to  the  basement.  All  communication  between  the  infected 
room  and  the  basement  was  forbidden,  but  on  May  8th,  twelve  days  after 
the  separation,  one  of  these  children  sickened  with  the  disease.  Many 
observers,  among  whom  may  be  mentioned  Niemeyer  and  Copland,  believe 
that  the  incubative  period  may  be  longer  than  one  week,  but  on  account  of 
the  subtlety  of  the  poison  and  the  many  modes  of  transmission,  it  is  possi- 
ble that  in  the  instances  of  an  apparently  long  incubative  period  there  were 
other  and  unsuspected  exposures.  When  scarlet  fever  has  been  communi- 
cated by  inoculation,  as  in  the  experiments  of  Rostan  and  others,  the  incu- 
bative period  has  been  about  seven  days,  but  Grerhardt  states  that  a  man  was 
attacked  four  days  after  an  abscess  was  opened  by  a  knife  used  upon  a  scar- 
latinous patient.  This  variation  in  the  incubative  period,  which  also  occurs 
in  some  other  infectious  diseases,  as  diphtheria,  is  probably  due  mostly  to 
individual  differences,  some  being  more  susceptible  than  others ;  but  it  may 
be  due  partly  to  those  obscure  meteorological  conditions  which  we  desig- 
nate the  epidemic  influence.  Probably,  as  a  rule,  when  the  disease  is 
quickly  developed  after  exposure  the  attack  is  more  sevei'e  than  when 
several  days  elapse. 

Contagiousness. — The  area  of  the  contagiousness  of  scarlet  fever  is 
small :  it  apparently  embraces  only  a  few  feet.  Therefore,  close  proximity 
is  the  necessary  condition  of  its  propagation.  Hence  many  who  are  exposed, 
particularly  of  those  who  are  remotely  exposed,  do  not  contract  the  disease. 
There  is  also  an  idiosyncrasy  in  some  children,  so  that  they  resist  infection 
even  when  repeatedly  and  closely  exposed.  In  the  Neio  York  Medical  Record 
for  March  23,  1878,  C.  E.  Billington  states  that  of  90  children  in  26  families 


276  SCARLET  FEVER. 

who  were  exposed  to  scarlet  fever,  43  contracted  the  disease  and  47  escaped ; 
whereas,  as  is  well  known,  comparatively  few  unprotected  children  escape 
pertussis,  variola,  varicella,  or  measles  if  exposed  to  either  of  these  diseases. 
By  strict  isolation,  therefore,  the  spread  of  scarlet  fever  is  more  easilv  pre- 
vented than  that  of  most  other  acute  infectious  maladies.  In  the  New  York 
Foundling  Asylum  for  a  number  of  years  children  with  scarlet  fever  were 
isolated  in  a  small  room  attached  to  one  of  the  wards.  The  door  between 
the  two  rooms  was  closed,  and  not  opened  during  the  continuance  of  the 
sickness.  Entrance  into  the  small  room  was  through  another  door,  and  a 
nurse  was  assigned  to  the  scarlet-fever  cases,  with  strict  directions  that  she 
should  not  mingle  with  the  other  children.  These  simple  precautions  were 
found  sufficient  in  the  various  epidemics  of  scarlet  fever  which  occurred  in 
the  city  to  prevent  the  spread  of  the  malady  through  this  institution ; 
whereas,  similar  measures  were  much  less  eflfectual  in  arresting  the  spread 
of  measles  and  pertussis.  Consequently,  an  outbreak  of  scarlet  fever  in  this 
institution  was  usually  limited  to  a  few  cases,  while  the  extension  of  measles 
and  pertussis  was  arrested  with  difficulty  till  a  more  efficient  quarantine  was 
established. 

Variations  in  Type. — The  type  of  scarlet  fever  varies  greatly  in  different 
epidemics,  and  frequently  also  in  cases  which  occur  in  the  same  epidemic, 
even  in  the  same  family.  One  child  may  have  scarlatina  so  mildly  that  little 
treatment  is  required  and  convalescence  soon  begins,  while  another  has  the 
malignant  form,  and  soon  succumbs,  notwithstanding  the  prompt  employment 
of  the  most  efficient  and  appropriate  measures.  Ordinarily,  however,  if  the 
first  case  in  a  family  be  very  severe,  subsequent  cases  will  present  a  similar 
type ;  but  there  are  notable  exceptions.  This  variation  in  type  in  different 
years  and  different  epidemics  is  probably  not  equalled  in  any  other  infectious 
malady.  Consecutive  epidemics  may  present  this  variation,  or  the  same  type 
may  continue  for  a  series  of  years,  and  then,  from  some  unknown  cause, 
change  to  one  milder  or  more  severe.  In  England,  during  Sydenham's  life, 
scarlet  fever  was  so  mild  that  he  regarded  it  as  a  trivial  affection,  requiring 
little  attention,  like  rotheln  of  the  present  time ;  but  after  the  death  of 
Sydenham,  Morton  and  his  contemporaries  in  London  found,  to  their  sorrow, 
that  the  type  of  scarlet  fever  was  very  different  from  that  described  by 
Sydenham's  pen.  The  late  Dr.  Graves  of  Dublin  and  his  contemporaries 
treated  a  mild  type  of  scarlet  fever  with  a  very  small  percentage  of  deaths 
— much  less  than  that  during  the  preceding  generation — and  they  attributed 
their  success  to  their  greater  knowledge  and  moi'e  appropriate  use  of  remedies 
than  their  ancestors  possessed  and  employed.  By  and  by  the  type  changed, 
the  mortality  of  former  years  was  restored,  and  they  discovered  that  their 
previous  success  in  saving  life  had  been  due  not  to  their  skill,  but  to  the  mild 
form  of  the  malady.  A  distinguished  physician  of  New  York  treated  more 
than  fifty  cases  of  scarlet  fever  in  one  of  the  institutions  without  a  single 
death.  A  few  months  afterward  the  type  of  the  malady  changed,  and  his 
own  son  perished  from  it. 

Surgical  Scarlatina. 

After  surgical  operations,  and  sometimes  in  surgical  cases  not  requiring 
operative  measures,  a  scarlatinous  efflorescence  occasionally  appears  upon  the 
whole  or  nearly  the  whole  body,  and  remains  for  several  days.  The  follow- 
ing were  cases  of  the  kind  alluded  to.  They  occurred  in  Guy's  Hospital,  and 
were  published  by  H.  G.  Howse  in  Gm/R  Ho^'pltal  Reports  for  1879:  On 
March  15,  1878,  Jacobson  performed  osteotomy  upon  a  child  suffering  from 
extreme  rachitis.     The  operation  was  followed  by  a  moderate  febrile  move- 


SURGICAL  SCARLATINA.  211 

ment  (100°  to  101°),  and  after  three  days  by  the  appearance  of  an  efflores- 
cence, with  sore  throat  and  the  strawberry  tongue.  The  osteotomy  had  been 
performed  under  carbolic-acid  spray  and  with  all  the  details  of  antiseptic 
surgery.  The  rash  soon  faded,  the  temperature  fell,  and  the  child,  tempo- 
rarily separated  from  the  other  patients  from  the  suspicion  that  the  disease 
was  scarlet  fever,  was  brought  back  to  the  ward.  The  subsequent  history 
confirmed  the  diagnosis  of  scarlet  fever,  for  the  skin  desquamated,  and  on 
April  1st  abundant  albumen  was  found  in  the  urine.  The  case  terminated 
favorably.  Three  months  previously  the  same  operation  had  been  performed 
on  the  other  leg,  with  no  unfavorable  symptoms.  On  April  5th,  three  weeks 
after  the  osteotomy,  a  lipoma  was  removed  from  another  patient  aged  twenty- 
one  years.  The  following  day  the  temperature  rose  to  101°,  and  remained 
at  that  till  April»8th,  when  it  suddenly  increased  to  103°,  and  a  rose-rash 
occurred  over  the  body,  with  sore  throat.  On  April  9th,  Howse  excised  the 
elbow-joint  of  a  girl  of  sixteen  years  having  pulpy  disease.  On  the  10th 
her  temperature  began  to  increase,  and  on  the  11th  reached  105.8°.  Toward 
evening  a  roseoloid  eruption  appeared  over  her  body,  and  she  was  isolated. 
On  April  12th,  Dr.  H.  excised  a  fibroid  bursa  patellae  from  a  woman  of  twenty- 
nine  years.  On  the  following  day  her  temperature  was  99°,  but  on  the  14th 
it  rose  to  100°,  and  on  the  evening  of  the  15th  she  had  rigors  and  headache. 
On  the  morning  of  the  16th  the  temperature  was  102.5°,  and  a  roseoloid 
eruption  occurred  over  the  face  and  chest.  The  surgeons  now  perceived  that 
an  epidemic  of  the  so-called  surgical  scarlatina  was  occurring,  so  as  to  justify 
the  postponement  of  other  operations. 

In  the  same  volume  of  Guy's  Hospital  Reports,  James  F.  Goodhart  gives 
the  histories  of  nearly  thirty  cases  of  this  disease  occurring  during  a  series 
of  years  in  the  same  hospital.  The  patients  were  chiefly  children,  having  the 
most  diverse  surgical  ailments,  among  which  may  be  mentioned  hip  disease 
and  abscess,  genu  valgum  without  operation,  necrosis  of  femur,  hydrocele 
with  explorative  operation,  a  scald,  a  sinus  over  the  great  trochanter,  spinal 
disease  with  abscess,  tenotomy  for  club-foot,  and  vesical  calculus  with  opera- 
tion. The  most  common  disease  was  caries  or  necrosis  with  abscess.  In 
cases  operated  on  the  intervals  between  the  operations  and  the  occurrence  of 
the  efflorescence  varied  from  two  days  to  more  than  two  weeks.  Goodhart, 
after  a  careful  examination  of  these  cases,  came  to  the  conclusion  that  they 
were  for  the  most  part  examples  of  true  scarlet  fever,  especially  as  a  consid- 
erable proportion  of  them  occurred  in  groups,  and  there  was  a  known  exposure 
of  some  of  the  patients  to  children  admitted  into  the  hospital  with  the  sequelae 
of  scarlet  fever. 

In  the  British  Med.  Jour,  for  Jan.,  1879,  George  May,  Jr.,  reported  a  case 
of  efflorescence  in  surgical  practice  which  appears  to  have  been  scarlatinous. 
A  child  was  operated  on  for  the  radical  cure  of  hernia  on  Dec.  4th.  Toward 
the  close  of  the  same  day  he  became  restless,  vomited,  and  his  pulse  on  the 
following  day  rose  to  136.  Forty-eight  hours  after  the  operation  a  rash 
appeared  on  the  chest  and  arms,  the  abdomen  became  tense  and  painful,  and 
on  the  following  day  he  died.  The  poison,  however,  in  this  case  may  have 
been  septic. 

Hillier  remarks  (Diseases  of  Children)  :  "  In  the  hospital  for  sick  children, 
of  the  children  who  contract  scarlatina  a  very  large  proportion  have  been  the 
subjects  of  a  surgical  operation  within  a  week  before  the  rash  appears."  Gee 
says  (Reynolds's  System  of  Medicine)  :  "  It  has  been  doubted  by  some  whether 
the  scarlatiniform  rash  which  sometimes  follows  operations  is  really  scarlatinal. 
The  eruption  appears  from  the  second  to  the  sixth  day  after  the  operation, 
and,  in  the  cases  which  have  caused  the  doubt,  is  very  fugitive  and  the 
first  and  only  symptom.     Yet  that  the  disease  really  is  scarlet  fever  would 


278  SCARLET  FEVER. 

seem  to  be  proved  by  the  following  observations  :  first,  that  the  disease  occurs 
in  epidemics ;  secondly,  that  in  a  given  epidemic  a  severe  case  occasionally 
relieves  the  monotonous  recurrence  of  the  very  mild  form  ;  thirdly,  that  a 
precisely  similar  scarlatinilla  attacks  in  the  same  epidemic  patients  who  have 
not  been  subjected  to  operation  and  who  have  no  open  sores;  and  lastly,  by 
way  of  a  veritable  experimentum  crucis,  that,  however  freely  the  patients  are 
exposed  to  ordinary  scarlet-fever  contagion  afterward,  they  do  not  contract 
that  disease."  Paget  and  other  distinguished  London  surgeons  who  have 
observed  this  complication  of  surgical  cases  believe  that  the  patients  have 
been  previously  exposed  to  the  scarlatinous  poison,  and  that  the  surgical  dis- 
eases or  operations  furnish  favorable  conditions  for  the  occurrence  of  scarlet 
fever,  so  that  the  exposure,  which  probably  would  have  been  without  result 
in  ordinary  health,  causes  an  outbreak  of  the  malady.  ^ 

Those  who  have  reported  cases  of  this  form  of  efflorescence  have  for  the 
most  part  neglected  to  state  whether  the  patients  had  had  scarlet  fever  pre- 
viously, knowledge  of  which  would  have  aided  in  the  diagnosis ;  but  from  an 
examination  of  the  histories  of  cases,  especially  those  published  in  the  London 
journals  in  the  last  four  or  five  years,  there  can,  I  think,  be  little  doubt  that 
surgical  maladies  of  a  certain  kind,  especially  traumatism,  do  produce  a  state 
of  system  which  predisposes  to  scarlet  fever,  so  that  this  class  of  patients  are 
especially  liable  to  contract  it.  Therefore,  in  my  opinion,  a  considerable  pro- 
portion of  reported  cases  of  surgical  scarlatina  are  genuine,  but  in  a  consider- 
able number,  perhaps  an  equal  number,  of  such  cases  the  histories  and  symp- 
toms indicated  a  septic  rather  than  scarlatinous  efilorescence,  and  in  not  a  few 
instances,  when  consultations  have  been  held,  opinions  differed,  some  diagnos- 
ticating scarlet  fever,  others  septicaemia.  In  some  of  the  cases  I  find  it  stated 
that  the  fauces  presented  the  normal  appearance.  Now,  faucial  redness  is  so 
generally  present  in  scarlet  fever,  antedating  that  of  the  skin  and  coexisting 
with  it,  that  its  absence  is  strong  evidence  that  the  disease  is  not  scarlatinous. 
Moreover,  when,  as  was  true  of  certain  of  the  reported  cases,  the  rash  appeared 
irregularly  upon  the  surface,  and  faded  away  in  two  or  three  days  with  the 
abatement  of  the  fever,  and  the  conditions  of  septic  absorption  were  present, 
the  efHorescence  was  probably  septicaemic. 

The  following  were  apparently  cases  of  septicjemic  efflorescence :  A  child 
aged  five  years  (Brit.  Med.  Jour.,  Feb.  15,  1879)  had  inflammation  of  the 
lymphatic  glands  in  the  groin,  which  suppurated.  At  the  time  when  the 
abscess  was  fully  formed  a  rash  appeared  over  the  entire  body.  It  consisted 
of  numerous  red  points,  but  was  paler  than  that  of  ordinary  scarlet  fever ; 
temperature  never  above  99°  ;  no  sore  throat  nor  desquamation  of  cuticle. 
No  child  exposed  to  her  took  scarlet  fever,  and  her  sickness  could  not  be 
traced  to  infection.  In  the  British  Med.  Jour.,  Jan.  4,  1879,  L.  Braxton 
Hicks  states  that  his  son,  attending  school  at  Reading,  was  seized  with  a 
severe  attack  of  pyrexia,  accompanied  on  the  second  day  by  delirium  and  the 
occurrence  of  a  rash  like  scarlet  fever  over  the  entire  surface.  He  had  no 
decided  redness  of  the  fauces,  though  it  was  perhaps  slightly  flushed.  The 
right  buttock  was  swollen  from  inflammation,  and  a  large,  deep-seated  abscess 
formed  near  the  tuberosity  of  the  ischium.  When  the  delirium  abated  the 
boy  said  that  he  was  standing  the  day  before  the  fever  began  with  his  legs 
far  apart,  when  a  schoolfellow  stretched  them  farther  by  suddenly  pulling  on 
one  of  them.  The  rash,  which  was  nearly  universal,  lasted  three  days,  and 
was  not  followed  by  desquamation.  No  case  of  scarlet  fever  occurred  in  the 
school  before  or  afterward.  In  the  same  volume  of  the  British  Medical  Jour- 
nal. Surgeon  Frolliott,  of  the  East  India  Service,  relates  the  case  of  a  private, 
aged  twenty-three  years,  and  three  years  in  India,  who,  when  on  duty  in  the 
Punjab,  was  injured  by  the  explosion  of  an  Afghan  powder-magazine.      The 


OBSTETRICAL  SCARLATINA.  279 

accident  occurred  Dec.  21, 1878.  On  Dec.  25th  a  bright  scarlet  rash  appeared 
upon  the  abdomen  and  spread  over  the  entire  body.  The  following  day  the 
eruption  was  very  vivid,  like  a  boiled  lobster,  and  it  lasted  five  days.  The 
temperature,  which  in  tlie  beginning  had  been  101°,  abated  to  the  normal 
after  the  rash  appeared.  No  soreness  of  throat  nor  redness  of  the  buccal  sur- 
face occurred,  but  the  epidermis  des([uaniated,  even  from  the  palms  of  the 
hands  and  soles  of  the  feet.  Now,  the  febrile  movement  of  scarlet  fever  does 
not  cease  while  the  efflorescence  is  distinct.  It  does  not  even  diminish  when 
the  eruption  appears,  while  in  the  above  case  it  fell  to  the  normal — a  common 
occurrence  in  septic£emia,  even  when  the  blood-poisoning  is  profound.  More- 
over, scarlet  fever  is  so  rare  in  India  that  Frolliott,  after  twelve  years'  service, 
had  only  heard  of  one  case  among  Europeans  and  natives.  The  surgeons 
who  consulted  over  the  case  of  this  private  disagreed  in  opinion,  some  regard- 
ing the  disease  as  septicoemic,  others  as  scarlatinous.  But  a  better  knowledge 
of  the  clinical  history  of  scarlet  fever  on  the  part  of  these  army  surgeons 
would,  I  think,  have  removed  all  doubt  as  to  the  diagnosis. 

It  is  the  opinion  of  some  reputable  surgeons  that  the  exposure  of  trau- 
matic patients  to  the  scarlatinous  poison  sometimes  aggravates  the  inflamma- 
tion of  wounds,  causing  them  to  assume  an  unhealthy  appearance,  even  though 
no  scarlatina  be  produced.  The  late  Dr.  Solly  made  the  remark,  "  Whenever 
a  case  of  surgery  in  private  practice  takes  on  a  highly  phlegmonous  appear- 
ance, I  am  always  sure  to  find  break  out,  in  the  inmates  of  the  house,  either 
■erysipelas  or  scarlet  fever"  (^British  Med.  Jour.,  Feb.  15,  1879).  We  will 
see  that  the  scarlatinous  poison  sometimes  causes  pharyngitis  or  nephritis 
without  producing  the  general  disease.  In  a  similar  manner  it  seems  that  it 
may  aggravate  open  wounds,  intensifying  the  inflammation  in  them,  while 
there  is  no  efflorescence  or  other  symptom  to  show  that  scarlatina  itself  is 
present.     The  poison  appears  to  act  entirely  locally  in  such  cases. 

Paget,  in  his  Clinical  Lectures,  says :  "  I  think  it  not  improbable  that  in 
some  cases  results  occurring  with  obscure  symptoms  within  two  or  three  days 
after  operations  have  been  due  to  the  scarlet-fever  poison,  hindered  in  some 
way  from  its  usual  progress."  Playfair,  in  his  remarks  on  the  puerperal  state, 
adds  :  "  Mr.  Spencer  Wells  informs  me  that  he  has  seen  cases  of  surgical 
pyemia  which  he  had  reason  to  believe  originated  in  the  scarlatinal  poison  ; 
and  his  well-known  success  as  an  ovariotomist  is  no  doubt,  in  a  great  meas- 
ure, to  be  attributed  to  his  extreme  care  in  seeing  that  no  one  likely  to  come 
in  contact  with  his  patients  has  been  exposed  to  any  such  source  of  infec- 
tion." Opinions  like  these,  held  by  such  prominent  members  of  the  profes- 
sion and  sustained  by  many  observations,  should  certainly  induce  physicians 
to  prevent,  as  far  as  possible,  exposure  of  their  surgical  patients,  especially 
if  they  have  sores  or  wounds,  whether  by  traumatism  or  scalpel,  to  the  scar- 
latinal poison. 

Obstetrical  Scarlatina. 

Women  during  convalescence  after  childbirth  are  very  liable  to  contract 
scarlet  fever.  In  the  New  York  Infant  Asylum,  which  has  maternity  wards, 
a  woman  was  admitted  from  a  house  in  which  scarlet  fever  was  prevailing, 
and  assigned  to  a  cot  next  that  occupied  by  one  of  the  waiting-women,  who 
was  confined  soon  afterward.  Her  labor  was  favorable,  but  three  days  after- 
ward she  took  scarlet  fever,  and  another  lying-in  patient  contracted  it  from  her. 
The  sore  throat  and  desquamation  were  characteristic.  It  has  come  to  my 
knowledge  that  a  physician  of  New  York,  in  whose  family  scarlet  fever  was 
occui-ring,  attended  three  women  in  succession  in  their  confinement,  and  all 
contracted  scarlet  fever,  which  presented  the  characteristic  symptoms,  and  two 
of  them  died.     Experienced  and  cautious  physicians  of  New  York,  aware  of 


280  SCARLET  FEVER. 

the  danger,  do  not  go  directly  from  a  scarlatinous  patient  to  an  obstetrical 
case,  but  avoid  the  risk  by  intermediate  visits  to  other  patients  or  by  remain- 
ing for  a  time  in  the  open  air.  As  an  additional  precaution,  I  never  attend 
a  case  of  midwifery  without  first  soaking  my  fingers  in  a  solution  of  corrosive 
sublimate. 

Playfair,  remarking  on  this  subject,  says  :  "  There  is  good  reason  to  believe 
that  the  contagium  of  zymotic  diseases  may  produce  a  form  of  disease  indis- 
tinguishable from  ordinary  puerperal  septicaemia,  and  presenting  none  of  the 
characteristic  features  of  the  specific  complaint  from  which  the  contagium  was. 
derived.  This  is  admitted  to  be  a  fact  by  the  majority  of  our  most  eminent 
British  obstetricians,  although  it  does  not  seem  to  be  allowed  by  continental 
authorities,  and  it  is  strongly  controverted  by  some  writers  in  this  country. 
It  is  certainly  difiicult  to  reconcile  this  with  the  theory  of  septicaemia,  and 
we  are  not  in  a  position  to  give  a  satisfactory  explanation  of  it.  I  believe^ 
however,  that  the  evidence  in  favor  of  the  possibility  of  puerperal  septicaemia 
originating  in  this  way  is  too  strong  to  be  assailable.  The  scarlatinal  poison 
is  that  regarding  which  the  greatest  number  of  observations  has  been  made. 
Numerous  cases  of  this  kind  are  to  be  found  scattered  through  our  obstetric 
literature,  but  the  largest  number  are  to  be  met  with  in  a  paper  by  Braxton 
Hicks.  Out  of  68  cases  of  puerperal  disease  seen  in  consultation,  no  less  than 
37  were  distinctly  traceable  to  the  scarlatinal  poison.  Of  these,  20  had  the 
characteristic  rash  of  the  disease,  but  the  remaining  17,  although  the  history 
clearly  proved  exposure  to  the  contagium  of  scarlet  fever,  showed  none  of  its 
usual  symptoms,  and  were  not  to  be  distinguished  from  ordinary  typical  cases, 
of  the  so-called  puerperal  fever.  On  the  theory  that  it  is  impossible  for  the 
specific  contagious  diseases  to  be  modified  by  the  puerperal  state,  we  have  to 
admit  that  one  physician  met  with  17  cases  of  puerperal  septicaemia  in  which, 
by  a  mere  coincidence,  the  contagion  of  scarlet  fever  had  been  traced,  and 
that  the  disease  nevertheless  originated  from  some  other  source — an  hypothesis 
so  improbable  that  its  mere  mention  carries  its  own  refutation." 

Parturition,  like  traumatism,  furnishes  in  an  eminent  degree  the  conditions 
in  which  septic  poisoning  occurs,  and  the  efflorescence  which  often  accompa- 
nies septicaemia  bears,  as  we  have  seen,  a  very  close  resemblance  to  that  of 
scarlet  fever.  Hence  in  many  instances  the  same  difficulty  is  present  in  mak- 
ing a  difierential  diagnosis  between  septic  and  scarlatinous  blood-poisoning  in 
obstetrical  cases  which  occurs  in  surgical  practice.  But,  according  to  my 
observations,  an  efflorescence  occurring  during  the  week  following  parturi- 
tion is  in  most  instances  septic.  It  is  only  in  exceptional  cases  that  it  is 
scarlatinous.  But  if,  as  Playfair  believes,  the  scarlatinal  poison  sometimes 
produces  in  parturient  women  a  puerperal  fever  in  which  the  characteristic 
scarlatinal  symptoms  are  lacking,  and  which,  in  the  present  state  of  our 
knowledge,  is  not  distinguishable  from  ordinary  septic  fever,  certainly  the 
scarlatinous  virus  sustains  a  more  frequent  causal  relation  to  childbed  fever 
than  has  been  heretofore  supposed. 

Age. — Infants  under  the  age  of  six  months  do  not  ordinarily  contract 
scarlet  fever,  although  fully  exposed,  and  those  under  four  months  nearly 
possess  immunity.  Still,  this  disease  has  been  observed  in  new-born  infants, 
contracted,  apparently,  through  the  placental  circulation.  Tourtual  states 
that  a  woman  waited  upon  her  own  husband  and  child,  both  of  whom  had 
scarlet  fever,  during  the  eighth  and  ninth  months  of  her  pregnancy  till  near 
her  confinement.  Though  she  had  no  symptoms  of  scarlet  fever,  her  infant 
had  unusual  redness  of  the  skin  and  buccal  surface  and  difficulty  of  swallow- 
ing up  to  the  fifth  day.  On  the  ninth  day  desquamation  began,  and  at  a 
later  stage  the  nails  of  the  fingers  and  toes  separated.  A  case  having  a  his- 
tory in  some  respects  similar  is  related  by  Megnert,  but  the  symptoms  were 


CLINICAL   FACTS  REGARDING  SCARLET  FEVER.  281 

anomalous  for  scarlet  fever,  and  the  disease  may  have  been  ordinary  septic 
fever.  On  the  other  hand,  in  one  instance  in  my  practice  a  mother  had  scarlet 
fever,  beginning  about  the  third  day  after  her  confinement,  and  although  she 
suckled  her  infant  and  it  was  constantly  in  bed  with  her,  it  had  no  symptoms 
of  scarlet  fever,  but  became  affected  immediately  afterward  by  a  severe 
form  of  eczema,  probably  from  the  altered  quality  of  the  milk  ;  and  in  two 
instances  observed  by  Murchison  new-born  infants  remained  healthy,  although 
their  mothers  suffered  from  scarlet  fever. 

After  the  age  of  six  months  the  liability  to  scarlet  fever  increases  till  the 
close  of  infancy,  children  between  the  ages  of  six  months  and  one  year  being 
less  liable  to  contract  the  malady  than  during  the  second  year,  and  those  in 
the  second  year  being  less  liable  to  it  than  those  in  the  third  year.  Murchison 
collected  the  statistics  of  deaths  from  scarlet  fever  in  England  and  Wales 
during  a  series  of  years  ending  with  1861.  The  number  of  deaths  aggregated 
148,829,  and  the  percentage  of  deaths  at  different  ages  was  as  follows  : 

Deaths    under    1  year 6.7    per  cent. 

"       between  1  and    2  years 14.09       " 

2  and    3     "       16.00 

3  and    4     "       15.13       " 

"  "         4  and    5     "       11.9 

"  "         5  and  10  "  25.9 

"  '•       10  and  15  "  5.8  " 

"       15  and  25  "  2.6  " 

"  "       25  and  35  "  0.8  " 

"     over  the  age  of  35  "  0.8  " 

x\mong  the  deaths  were  10  cases  above  the  age  of  85  years,  so  that  scarlet 
fever,  though  especially  a  disease  of  childhood,  may  occur  in  any  decade  of 
life  ;  but  old  age.  like  early  infancy,  almost  possesses  immunity  from  it. 

I  have  preserved  the  records  of  the  ages  of  145  consecutive  cases  occurring 
in  private  practice.  If  we  add  to  these  58  cases  observed  by  Prof.  Octerlony 
{Amer.  Jam:  of  Med.  Sci.,  July,  1882),  we  have  the  statistics  of  the  ages  of 
203  eases,  which  are  embraced  in  the  following  table : 

Under  1  year 3 

From  1  to    2  years 25 

"      2  to    3     "      43 

"     3  to    5     " 57 

"     5  tolO     " 53 

"    10  to  15     " 13 

"    15  to  20     " 3 

"    20  to  30    " 4 

"    30  to  40    " 2 

Total 203 

Clinical  Facts  regarding  Scarlet  Fever. 

As  a  rule,  scarlet  fever  occurs  but  once,  one  attack  conferring  immunity 
from  the  disease  for  life ;  but  there  are  exceptions.  In  1860,  I  attended  a 
child  with  fatal  scarlet  fever  who  three  years  previously,  it  was  stated,  had 
passed  through  a  first  attack  with  all  the  characteristic  symptoms.  The  fol- 
lowing case  occurred  in  a  family  attended  by  the  late  Dr.  Herzog :  R ,  a 

boy  of  six  years,  had  scarlet  fever  in  a  mild  form  in  January  and  February, 
1875,  followed  by  moderate  desquamation.  In  July  of  the  same  year  he  was 
kicked  by  a  horse  in  the  street,  receiving  a  deep  scalp-wound  which  required 
stitching.  Three  days  afterward  he  had.  to  appearance,  a  second  attack 
of  scarlet  fever,  attended  by  high  febrile  movement  and  followed  also  by 


282  SCARLET  FEVER. 

desquamation.  It  was  believed  by  Dr.  H.  to  be  a  genuine  case,  and  was  so 
treated.  I  am  not  able  to  state  as  regards  the  presence  of  soreness  of  the 
throat,  and  doubt  arises  whether  the  second  attack  may  not  have  been  septi- 
csemic.  In  April,  1876,  a  third  attack  occurred,  which  I  saw  from  the  begin- 
ning. It  was  accompanied  by  all  the  characteristic  symptoms — injection 
of  the  fauces,  an  efflorescence  continuing  the  usual  time,  followed  by  des- 
quamation and  albuminuria,  the  latter  remaining  several  weeks.  Richardson 
states  that  three  distinct  attacks  occurred  in  his  own  person,  and  a  student 
attending  the  lecture  at  which  this  was  mentioned  informed  the  doctor  that 
he  also  had  scarlet  fever  three  times. 

Sometimes  a  second  attack  occurs  so  soon  after  the  first  that  it  has  been 
described  as  a  relapse.  The  following  was  a  case  in  point  in  the  practice  of 
Godneff  (Meditz.  Vestnik.,  No.  iv.,  iV.  Y.  Med.  Rec,  April  30,  1881)  :  A  youth 
of  seventeen  years  contracted  scarlet  fever  while  taking  care  of  a  child.  It 
began  with  a  chill,  and  he  had  the  usual  efflorescence,  sore  throat,  and  tume- 
faction of  the  cervical  glands.  An  exudation  appeared  upon  his  tonsils  and 
uvula,  and  his  temperature  reached  104°.  The  urine  contained  a  trace  of 
albumen  ;  the  rash  in  due  time  faded  ;  and  the  epidermis  exfoliated.  On  the 
fifteenth  day,  when  he  was  about  ready  to  leave  the  hospital,  he  again  had  a 
chill,  followed  by  fever.  The  temperature  reached  105.2°,  the  rash  reap- 
peared over  the  entire  surface  except  the  face,  diphtheritic  exudations 
occurred  upon  the  fauces,  and  the  urine,  the  quantity  of  which  was  dimin- 
ished, again  became  albuminous.  The  second  efflorescence  faded  on  the 
twenty-fourth  day,  and  on  the  twenty-seventh  exfoliation  began.  Hillier 
says :  "  I  have  seen  a  young  woman  in  the  fever  hospital  suffering  from  a 
second  attack  of  scarlatina,  the  first  attack  having  occurred  five  weeks  pre- 
viously. She  had  quite  recovered  from  her  first  illness,  and  was  acting  as 
nurse.  In  both  seizures  the  rash,  the  sore  throat,  and  other  symptoms  were 
•characteristic.  The  relapse  or  recurrence  was  less  severe  than  the  primary 
disease."  Cases  of  a  fourth  attack,  or  even  of  a  greater  number,  have 
been  reported.  The  first  seizure  is  sometimes  milder,  but  in  other  instances 
is  more  severe,  than  those  which  follow. 

Exposure  to  the  scarlatinous  poison  not  infrequently  produces  pharyngitis 
without  the  occurrence  of  scarlatina,  and  the  inflammation  is  usually  severe, 
accompanied  by  pain  in  swallowing  and  marked  febrile  movement.  This 
phlegmasia  is  distinguished  from  scarlet  fever  by  its  shorter  duration  and  the 
absence  of  the  efflorescence.  It  occurs  in  adults  as  well  as  in  children,  and 
in  those  who  have  had,  as  well  as  in  those  who  have  not  had,  scarlatina.  So 
far  as  I  have  observed,  it  is  very  seldom  accompanied  or  followed  by  any  of 
the  complications  or  sequelas  so  common  in  and  after  scarlet  fever.  It  can- 
not be  distinguished  from  ordinary  pharyngitis  except  in  the  manner  in  which 
it  occurs,  and  one  attack  does  not  pi-eclude  another.  The  late  Greorge  B. 
Wood  made  the  remark  that  he  never  attended  a  case  of  scarlet  fever  with- 
out suffering  from  sore  throat.  The  following  were  examples  of  this  form 
of  pharyngitis  :  On  Jan.  17,  1882,  I  was  called  to  a  boy  of  three  years  with 
severe  scarlet  fever,  ushered  in  by  convulsions.  On  the  following  day  his 
sister,  aged  seven  and  three-fourths  years,  whom  I  had  attended  a  year  pre- 
Yiously  during  a  severe  attack  of  scarlatina,  and  who  had  been  almost  con- 
stantly with  the  brother,  became  very  ill,  with  a  temperature  of  103.5°. 
Examination  revealed  severe  inflammation  of  the  fauces,  without  pseudo- 
membrane  or  any  other, exudation  except  muco-pus.  On  Jan.  19th  an  older 
brother,  nine  years,  whom  I  had  attended  in  scarlet  fever  three  years  pre- 
viously, was  affected  in  the  same  way,  his  temperature  being  104°  and  his 
respiration  guttural  and  noisy,  especially  during  sleep,  in  consequence  of  the 
great  amount  of  faucial  swelling.     At  times  he  was  delirious.     The  inflam- 


SYMPTOMS.  283 

mation  in  both  cases  began  to  abate  about  tlie  third  day,  and  had  disappeared 
by  the  close  of  the  week.  That  the  contagium  of  scarlet  fever  may  be 
received  into  the  system  and  cause  pharyngitis  while  the  patient  has  immu- 
nity from  scarlet  fever  through  a  previous  attack,  and  that  this  inflammation 
may  occur  any  number  of  times,  as  in  the  case  of  Dr.  Wood,  are  remarkable 
facts. 

Now  and  then  cases  occur  which  appear  to  show  that  the  scarlatinous 
poison  may  affect  the  kidneys,  producing  nephritis,  while  there  is  no  other 
manifestation  of  its  influence.  Thus  in  my  practice  a  lady  of  about  forty- 
five  years  constantly  attended  her  son,  sleeping  by  his  side,  during  an  attack 
of  scarlet  fever.  Her  health  had  previously  been  good.  When  the  boy  was 
■convalescent,  as  her  appetite  failed  and  she  was  indisposed,  a  careful  exam- 
ination revealed  the  fact  that  she  had  albuminuria,  although  she  had  had  no' 
sore  throat  or  other  symptoms  of  scarlet  fever.  After  several  weeks  of 
treatment  her  disease  was  removed,  and  she  has  remained  well  since.  In  the 
British  Med.  Jour,  for  Nov.  29,  1879,  it  is  stated  that  in  a  family  four  girls 
were  found  to  be  suffering  from  desquamative  nephritis.  One  of  them  had 
xecently  had  scarlet  fever,  but  the  other  three  had  presented  no  symptoms 
whatever  of  this  disease.  Such  cases,  although  probably  rare,  appear  to 
show  that,  as  the  scarlatinous  poison  may  produce  inflammation  of  the  fauces 
without  the  occurrence  of  scarlet  fever,  so  it  may  cause  nephritis  without 
producing  the  general  disease,  or  apparently  disturbing  the  functions  or 
■changing  the  state  of  other  parts,  except  the  kidneys. 

Symptoms. —  Ordinary  Form. — Scarlet  fever  usually  begins  abruptly, 
so  that  the  exact  time  of  its  commencement  can  be  fixed.  If  any  premoni- 
tory symptoms  occur,  they  are  slight,  so  as  scarcely  to  attract  attention,  as 
languor  or  the  appearance  of  fatigue.  A  dusky  aspect  of  the  surface  may 
occasionally  be  observed  during  the  few  hours  preceding  the  attack.  In 
some  children  the  first  symptom  is  chilliness,  and  occasionally  a  distinct 
chill  occurs.  In  the  adult  a  chill  is  ordinarily  the  first  symptom.  With  or 
without  the  initial  chilliness  fever  occurs,  of  variable  intensity  according  to 
the  severity  of  the  type,  and  accompanied  by  such  symptoms  as  usually 
arise  in  a  febrile  state  of  system,  as  cephalalgia,  anorexia,  and  thirst.  The 
pulse  rises  to  110,  120,  or  more  per  minute,  the  temperature  to  102°,  103°, 
or  104°  ;  the  skin  is  hot,  face  flushed,  and  the  eyes  bright.  Even  in  cases 
that  are  not  malignant  or  grave,  and  that  give  indications  of  a  favorable 
result,  there  is  often  more  or  less  stupor,  with  transient  delirium  and  sudden 
starting  or  twitching  of  the  extremities,  showing  that  the  cerebro-spinal  axis 
is  involved. 

Vomiting  is  a  common  symptom  in  the  beginning  of  scarlet  fever,  occur- 
ring before  the  appearance  of  the  efflorescence.  It  therefore  has  diagnostic 
value  when  the  nature  of  the  case  is  still  doubtful.  In  some  patients  it  is 
an  initial  symptom,  but  in  others  some  hours  have  elapsed  when  it  occurs. 
I  recorded  its  presence  or  absence  in  214  patients,  with  the  following  result : 
present  in  162  patients,  absent  in  52.  In  severe  forms  of  the  disease  it  is 
rarely  absent,  and  if  it  do  not  occur  it  is  probable  that  the  case  will  be  mild, 
requiring  little  treatment  and  having  a  favorable  termination.  In  epidemics 
of  unusual  mildness  the  number  of  cases  without  vomiting  may  be  in  excess 
of  those  in  which  this  symptom  occurs.  It  appears  to  be  due  to  functional 
disturbance  of  the  cerebro-spinal  system,  and  may  therefore  be  properly 
regarded  as  a  nervous  symptom.  In  severe  cases  the  vomiting  is  usually 
repeated,  not  only  on  the  first  but  on  subsequent  days,  and  we  shall  see  that 
in  cases  of  great  gravity,  in  which  a  fatal  termination  is  not  improbable,  per- 
sistent vomiting,  by  which  the  food  and  stimulants  so  urgently  requii'ed  are 
rejected,   interferes  seriously  with    successful    treatment.      In    a  few  cases 


284  SCABLET  FEVER. 

embraced  in  my  statistics  nausea  without  vomiting  was  recorded.  The  bowels 
in  ordinary  scarlatina  act  regularly  or  are  slightly  constipated.  Diarrhoea, 
which  so  commonly  accompanies  the  persistent  vomiting  in  malignant  cases, 
if  it  occur  in  this  form  of  the  malady  is  slight  and  transient  and  due  to  acci- 
dental causes.  The  food,  if  it  be  given  in  the  liquid  form  and  cool,  is  usually 
taken  readily  on  account  of  the  thirst,  except  when  deglutition  is  rendered 
painful  by  the  pharyngitis. 

The  symptoms  pertaining  to  the  nervous  system  vary  according  to  the 
severity  of  the  disease  and  the  temperament  of  the  patient.  Many  children 
during  the  progress  of  the  common  form  of  scarlet  fever  present  a  dull  or 
apathetic  appearance.  They  lie  much  of  the  time  with  their  eyes  closed  ; 
.others  are  more  restless,  and  not  a  few,  if  the  fever  be  considerable,  have 
occasional  twitchings  of  the  limbs  and  more  or  less  headache.  Eclampsia 
sometimes  occurs  on  the  first  day,  especially  in  those  predisposed  to  it,  even 
when  the  subsequent  course  of  the  disease  is  mild  and  favorable.  This  com- 
plication, very  grave  and  usually  fatal  when  it  occurs  at  a  later  stage,  is  in 
most  instances,  when  it  takes  place  on  the  first  day,  readily  controlled  by 
proper  remedies  and  with  little  detriment  to  the  patient.  But  if  it  be  attended 
by  high  elevation  of  temperature  and  marked  drowsiness,  approaching  the 
comatose  state,  it  is  very  serious  upon  the  first  as  well  as  upon  the  subsequent 
days.  Nervous  symptoms  occurring  in  the  beginning  of  scarlet  fever,  when 
it  has  the  ordinary  favorable  type,  begin  to  abate  in  three  or  four  days,  but 
if  they  supervene  at  a  later  date,  and  especially  in  the  declining  stage,  they 
possess  more  gravity,  since  they  then  not  infrequently  result  from  and  indi- 
cate renal  complication. 

Early  in  the  disease,  nearly  as  soon  as  the  commencement  of  the  fever^ 
the  faueial  and  buccal  surfaces  become  inflamed,  as  shown  by  redness,  swell- 
ing, and  tenderness.  The  physician  summoned  in  the  beginning  of  an  attack 
will  already,  at  his  first  visit,  observe  hypergemia  of  the  fauces,  with  points 
of  deeper  injection  than  over  the  general  faueial  surface,  and  soon  the  buccal 
surface  also  participates.  The  inflammation  at  first  produces  preternatural 
dryness,  and  this  is  followed  by  a  viscid  secretion.  The  papillae  of  the  tongue 
enlarge  and  become  prominent,  giving  rise  to  the  appearance  known  as  straw- 
berry tongue  which  is  so  common  in  scarlet  fever.  This  state  of  the  buccal 
and  faueial  membrane  continues  throughout  the  disease.  A  thin  fur  appears 
upon  the  tongue  on  the  first  day,  and  it  increases  on  the  second  and  third 
days,  after  which  it  is  usually  detached,  exposing  the  surface  of  the  organ, 
which  has  a  deep-red  hue,  but  in  not  a  few  patients  the  fur  remains  or  is 
reproduced  as  soon  as  shed.  Except  in  the  mildest  cases  the  Schneiderian 
membrane  also  participates  in  the  inflammation  as  the  disease  advances,  so 
that  a  thin,  irritating  discharge  containing  leucocytes  or  pus-cells  flows  from 
the  nostrils.  The  skin  is  hot  and  dry  and  cutaneous  transpiration  is  nearly 
checked.  The  respiratory  system  is  rarely  involved  in  any  notable  manner 
unless  there  be  a  complication.  Many  have  no  cough  whatever,  while  others 
have  a  slight  cough,  due  to  the  fact  that  the  inflammation  of  a  catarrhal  form 
has  extended  from  the  fauces  to  the  surface  of  the  glottis.  Slight  accelera- 
tion of  respiration,  corresponding  with  the  degree  of  fever,  may  also  be 
observed.  The  kidneys  commonly  act  regularly  and  normally  during  the 
first  days,  any  serious  impairment  of  their  functions  being  rare  before  the 
close  of  the  first  week. 

When  the  symptoms  described  above  have  continued  from  six  to  eighteen 
hours  the  efflorescence  appears.  It  is  first  observed  about  the  ears,  neck,  and 
shoulders  in  reddish  patches  fading  into  the  normal  hue.  These  patches 
extend  and  unite,  and  in  the  course  of  a  few  hours  the  trunk  and  upper 
extremities,  and  finally  the  legs,  are  covered.     The  scarlatinous  rash  usually, 


SYMPTOMS.  285 

when  fully  developed,  resembles  that  produced  by  external  heat  or  the  appli- 
cation of  a  sinapism.  It  has  been  likened  to  the  appearance  of  a  boiled  lob- 
ster, but  there  are  numerous  minute  points  of  a  deeper  or  duskier  hue  than 
the  surface  generally.  In  many  patients  the  rash  appears,  especially  over 
the  abdomen  and  lower  extremities,  as  minute,  thickly-set  points,  with  the 
skin  of  normal  appearance  between  them.  Henoch  of  Berlin  says  of  scarlet 
fever :  ''  In  general,  the  moderate  grades  of  eruption  prevail,  the  skin,  when 
seen  from  a  distance,  presenting  a  diffuse,  more  or  less  scarlet  redness,  while 
on  closer  inspection  it  is  found  that  this  redness  is  composed  of  innumerable 
red  points  closely  situated  together,  and  separated  from  one  another  by  very 
small  paler  portions  of  skin.  The  dark-red  points  appear  to  correspond  to 
the  hair-follicles."  On  passing  the  finger  over  the  efflorescence  no  distinct 
prominences  are  observed,  but  a  sensation  of  roughness  is  sometimes  imparted 
from  engorgement  of  the  cutaneous  papillae.  The  rash  disappears  on  pres- 
sure, but  it  immediately  reappears  when  the  pressure  is  removed.  Its  slow 
return  is  evidence  of  sluggish  circulation,  and  it  indicates  a  grave  and  dan- 
gerous form  of  the  malady.  The  color  is  then  usually  a  dusky  instead  of  a 
bright  red.  The  efflorescence  is  most  marked  in  dependent  parts,  as  along 
the  back,  over  the  chest  and  abdomen,  and  in  the  flexures  of  the  joints. 
Parts  pressed  upon  by  the  bedclothes,  which  confine  and  intensify  the  heat, 
present  a  deeper  coloration  than  other  portions  of  the  surface.  Often,  espe- 
cially in  mild  cases,  the  rash  is  absent  from  portions  of  the  surface  where  it 
■commonly  appears,  while  it  presents  its  typical  character  elsewhere.  Tardy 
and  incomplete  establishment  of  the  rash  when  the  symptoms  indicate  an 
attack  of  ordinary  or  more  than  ordinary  severity  is  commonly  due  to  some 
perturbating  cause,  especially  diarrhoea.  In  the  London  Lancet  for  Aug.  16, 
187U,  cases  are  related  of  supposed  scarlet  fever  without  the  rash — cases  in 
which  pharyngitis  and  stomatitis  with  the  strawberry  tongue  occurred,  with- 
out efflorescence  upon  the  skin  ;  but  it  is  to  be  remembered,  as  stated  above, 
that  the  inflammations  which  commonly  attend  or  follow  scarlet  fever,  par- 
ticularly the  pharyngitis  and  nephritis,  not  infrequently  occur  in  those  who 
have  already  had  scarlatina,  and  occur  more  than  once  from  fresh  exposure 
to  scarlatina  patients.  These  inflammations,  occurring  under  such  circum- 
stances, appear  to  be  purely  local  maladies,  produced  by  the  scarlatinous 
virus  ;  and  it  seems  to  me  a  question  whether,  in  the  so-called  scarlatina 
without  efflorescence,  the  inflammations  which  are  present,  and  which  un- 
doubtedly have  a  scarlatinous  origin,  are  not  local  in  their  nature,  instead  of 
being  local  manifestations  of  the  constitutional  disease.  The  burning  and 
itching  sensation  produced  by  the  rash  increases  the  restlessness  of  the 
patient,   and   is   sometimes   the   most  annoying   of  the   symptoms. 

The  temperature  in  the  common  favorable  forms  of  scarlet  fever  usually 
varies  from  101°  in  the  mildest  cases  to  103°  or  104°  in  those  more  severe. 
If  it  attain  105°  or  over,  the  case  is  properly  designated  grave  or  severe. 
The  febrile  movement  ordinarily  fluctuates  but  little  from  day  to  day  till  the 
fourth  or  fifth  day,  when,  if  the  case  be  favorable  and  no  complication  occur, 
it  begins  to  decline.  The  temperature  is  as  high  in  the  beginning  of  the 
attack  as  subsequently. 

The  symptoms  pertaining  to  the  digestive  system  during  the  initial  period 
of  scarlet  fever  have  been  sufficiently  described.  The  subsequent  symptoms 
referable  to  this  system  do  not  diff"er  materially  from  those  present  in  the 
beginning,  except  the  absence  of  vomiting.  The  lips  are  dry  and  often 
cracked.  The  inflammation  of  the  mouth  and  throat  continues,  with  ano- 
rexia and  thirst.  With  the  decline  of  the  disease  the  appetite  gradually 
returns,  but  it  is  not  till  the  close  of  the  second  week  that  it  is  fully 
restored.      Great    and    continued    disturbance    of   the    digestive    apparatus, 


286  SCARLET  FEVER. 

seriously  interfering  with  the  nutrition,  pertains  to  the  malignant  forms  of 
scarlet  fever. 

The  urine  is  high-colored,  and  in  robust  children  during  the  first  days  of 
scarlet  fever  it  frequently  deposits  urates  on  cooling.  Gee,  who  has  carefully 
investigated  the  state  of  the  urine  in  scarlet  fever,  says  that  the  quantity  of 
water  is  diminished  and  the  urea  is  not  necessarily  increased  during  the  pyrexia ; 
that  the  chloride  of  sodium  is  diminished  till  the  fourth,  fifth,  or  sixth  day  ; 
and  that  the  phosphoric  acid  is  diminished  during  the  climax  of  the  pyrexia, 
though  not  in  the  first  three  or  four  days.  In  one  case  he  made  a  daily  esti- 
mation of  the  amount  of  uric  acid,  and  found  it  greatly  diminished  on  the 
second  and  third  days,  normal  on  the  fourth,  and  much  increased  on  the  fifth. 
He  believes  that  similar  variations  are  common  in  the  quantity  of  the  prod- 
ucts excreted  in  the  urine.  Bile  may  also  appear  in  the  urine,  coincident 
with  a  yellow  tinge  of  the  conjunctiva.^ 

The  duration  of  scarlet  fever  varies  in  diflferent  cases.  If  the  attack  be 
very  mild,  with  little  efflorescence,  the  febrile  movement  may  decline  by  the 
fourth  or  fifth  day  ;  but  if  the  disease  be  severe,  little  or  no  amelioration  of 
symptoms  may  occur  before  the  twelfth  or  fourteenth  day,  even  when  no  com- 
plication has  occurred  to  increase  the  temperature  or  cause  aggravation  of 
symptoms.  Octerlony,  who  estimated  the  duration  of  scarlet  fever  from  the 
commencement  of  febrile  symptoms  to  "  the  disappearance  of  fever,  with 
marked  improvement  in  leading  symptoms,"  .  ,  .  .  "  found  that  the  average 
duration  of  the  disease  in  forty  cases  was  six  and  one-sixth  days.  The 
minimum  duration  in  a  very  slightly  marked  case  was  three  days :  the  maxi- 
mum duration  was  fourteen  days."  In  general,  prolongation  of  fever  beyond 
the  usual  time  is  due  to  some  complication — more  frequently  to  unusually 
severe  pharyngitis,  with  accompanying  cellulitis,  than  to  any  other  cause. 

The  malady  whose  commencement  was  so  abrupt  declines  gradually.  In 
ordinary  cases,  by  the  close  of  the  first  week  or  in  the  beginning  of  the 
second  the  rash  becomes  less  and  less  distinct,  and  finally  disappears,  as  do 
also  the  redness  and  swelling  of  the  buccal  and  faucial  surfaces.  The  engorge- 
ment of  the  tonsils  and  of  the  papillas  of  the  tongue  subsides,  the  appetite 
returns,  the  countenance  brightens  and  becomes  natural,  and  the  child,  who 
during  the  height  of  the  fever  scarcely  noticed  objects  or  noticed  them  with 
indiff"erence  or  even  repugnance,  can  be  amused  as  before  his  sickness. 

Desquamation  succeeds.  This  begins  at  about  the  sixth  day,  and  is  not 
completed  till  the  tenth  or  twelfth  day,  often  not  till  the  close  of  the  third 
or  in  the  fourth  week.  The  amount  of  desquamation  corresponds  with  the 
intensity  and  duration  of  the  efflorescence,  or  rather  of  the  dermatitis  which 
produces  the  efflorescence.  If  the  efflorescence  have  been  slight  and  partial, 
it  will  be  slight,  perhaps  scarcely  appreciable,  but  if  the  rash  have  been  gen- 
eral, full,  and  protracted,  exfoliation  occurs  upon  every  part.  It  begins  about 
the  face  and  neck,  and  within  a  day  or  two  appears  upon  other  parts.  Where 
the  skin  is  thin  the  epidermis  as  it  is  detached  presents  a  furfuraceous  appear- 
ance ;  where  it  is  thick,  as  upon  the  palms  of  the  hands  or  soles  of  the  feet, 
it  separates  in  layers  of  considerable  thickness. 

Such  is  a  brief  description  of  scarlet  fever  when  it  pursues  its  normal 
course  without  any  disturbing  element,  but  there  is  no  other  disease  in  which 
complications  and  sequelae  so  frequently  occur.  The  liability  to  them  renders 
the  prognosis  in  every  case  doubtful.  They  largely  increase  the  percentage 
of  deaths.     They  occur  both  in  mild  and  severe  forms  of  scarlatina. 

The  difference  in  type  in  different  cases  and  epidemics  has  already  been 
alluded  to.  Scarlet  fever  is  sometimes  so  mild  and  its  symptoms  so  slight  that 
the  diagnosis  is  necessarily  uncertain.     In  the  spring  of  1866,  I  was  called 

^  Article  on  Scarlatina  in  Reynolds's  System  of  MecUcive. 


SYMPTOMS.  287 

to  an  infant  thirteen  months  old  who  had  slight  pharyngitis  and  an  indistinct 
rash  over  a  part  of  tlie  surface.  In  two  days  the  eruption  had  disappeared, 
and  the  health  within  a  day  or  two  was  apparently  fully  restored.  Diagnosis 
would  have  been  doubtful'  except  for  sequelae  which  clearly  indicated  the 
scarlatinous  nature  of  the  attack.  In  another  instance  two  children  pa.ssed 
through  the  entire  course  of  scarlet  fever,  playing  every  day  in  the  street. 
Although  the  intelligent  grandmother  saw  the  rash  upon  them,  its  nature  was 
not  suspected,  as  it  was  midsummer  and  cases  of  prickly  heat  common,  till 
nearly  two  weeks  afterward,  when  one  of  the  children  had  nephritis  and 
anasarca,  ending  fatally.  In  cases  so  mild  as  these  the  heat  of  the  surface 
is  but  slightly  increased,  the  pulse  but  little  accelerated,  and  the  rash  usually 
does  not  occupy  so  much  of  the  surface  as  in  ordinary  cases;  the  appetite  is 
not  lost,  though  diminished,  and  the  thirst  is  moderate. 

Between  scarlet  fever  so  mild  that  it  terminates  in  four  or  five  days,  and 
that  of  the  grave  or  malignant  type  presently  to  be  described,  all  grades  of 
severity  exist.  Scarlet  fever  occurs  in  all  forms  from  mild  to  severe,  but 
certain  symptoms  characterize  grave  or  malignant  cases — symptoms  which 
are  absent  or  much  less  prominent  in  ordinary  scarlet  fever.  Therefore  the 
grouping  of  cases  accoi'ding  to  the  type  is  proper,  and  it  facilitates  the  study- 
ing of  the  disease. 

Grave  Form  (malignant  scarlet  fever). — This  form  of  the  disease  is  in 
some  epidemics  common,  while  in  others  it  is  rare.  The  symptoms  which 
characterize  it  are  severe  from  the  beginning,  those  of  the  nervous  system 
predominating  at  first,  such  as  intense  cephalalgia,  restlessness  or  stupor, 
sudden  twitching  of  the  muscles,  and  perhaps  delirium  or  even  convulsions. 
Many  pass  rapidly  into  coma  and  die  within  two  or  three  days,  succumbing 
to  the  intensity  of  the  scarlatinous  poison  while  the  malady  is  still  in  its 
commencement.  The  rash  is  dusky.  It  disappears  by  pressure,  and  returns 
slowly  when  the  pressure  is  removed,  showing  extreme  sluggishness  of  the 
capillary  circulation.  Some  patients  are  very  drowsy,  lying  in  a  semi-comatose 
state  except  when  aroused,  and  if  aroused  are  very  restless.  Others  are  con- 
stantly restless.  If  placed  in  one  position  on  the  bed,  they  throw  themselves 
in  another  in  a  half-conscious  or  unconscious  state.  They  do  not  speak,  or 
they  mutter  like  those  affected  by  the  graver  forms  of  typhus,  calling  the 
names  of  playmates  or  talking  incoherently  about  things  which  interested 
them  when  well.  The  theremometer  placed  in  the  axilla  is  found  to  rise 
above  103°,  which  is  a  safe  average,  to  105°  or  even  107°,  and  the  heat  of 
the  surface  is  pungent  except  when  the  case  approaches  a  fatal  termination, 
when  the  extremities,  ears,  and  nose  may  be  cool  while  the  trunk  and  head 
are  extremely  hot.  The  pulse  from  the  first  is  rapid,  ranging  from  130  as 
the  minimum  in  a  malignant  case  to  a  frequency  which  can  scarcely  be 
counted.  A  very  frequent  pulse  is  nearly  always  feeble  and  compressible. 
Irritability  of  the  stomach  is  one  of  the  most  common  symptoms  in  grave 
cases,  so  that  many  patients  immediately  reject  the  nutriment  and  stimulants 
which  are  so  urgently  required  to  sustain  the  vital  powers.  The  vomiting, 
therefore,  if  frequent  and  severe,  greatly  increases  the  danger,  and  in  not  a 
few  instances  this  symptom  is  associated  with  diarrhoea,  which  also  tends  to 
increase  the  prostration. 

Severe  and  dangerous  nervous  symptoms,  due  to  the  intensity  or  activity 
of  the  scarlatinous  poison,  occur  chiefly  within  the  first  three  or  four  days. 
Grinding  the  teeth,  sudden  muscular  twitching,  delirium,  convulsions,  and 
profound  stupor  occur  for  the  most  part  within  this  time.  Afterward  the 
danger  is  mainly  from  exhaustion,  unless  in  the  second  week  or  subsequently, 
when  nervous  symptoms  may  arise  from  uraemia. 

Those  who  survive  the  onset  of  malignant  scarlet  fever  often  have  in  the 


288  SCARLET  FEVER. 

course  of  a  few  days  severe  pharyngitis,  with  extension  of  the  inflammation 
to  the  lymphatic  glands  and  connective  tissue  around  the  angle  of  the  jaw. 
These  inflammations  cause  more  or  less  external  swelling.  The  faucial  tur- 
gescence  around  the  entrance  of  the  larynx,  with  the  accompanying  secre- 
tions of  viscid  mucus  or  muco-pus,  often  causes  noisy  respiration,  and  many 
at  this  stage  of  the  attack  breathe  with  the  mouth  constantly  open  to  facili- 
tate the  ingress  of  air. 

Ordinarily,  no  discharge  occurs  at  first  from  the  nasal  surface,  but  as  the 
disease  continues,  if  the  type  remain  severe,  defluxion  of  thin  muco-pus  takes 
place  from  the  Schneiderian  surface,  which  excoriates  the  cheek.  The  lips 
also  are  frequently  sore  and  swollen. 

In  malignant  cases  the  disease  is  more  protracted  than  when  the  type  is 
mild.  Thus  in  a  recent  case  in  my  practice  the  rash  was  still  distinct  at  the 
close  of  the  second  week,  though  the  temperature  had  fallen  from  105°  to 
102°,  and  some  desquamation  had  appeared.  Long  continuance  of  the  febrile 
movement  is,  however,  oftener  attributable  to  some  inflammatory  complica- 
tion than  to  the  primary  disease. 

In  all  epidemics  of  a  severe  type  cases  now  and  then  occur  in  which  the 
poison  is  so  intense,  or  it  acts  with  such  frightful  energy,  that  death  occurs 
even  within  the  first  day.  The  patient  is  overpowered  at  the  outset  of  the 
disease  by  the  virulence  of  the  specific  principle,  perishing  in  coma,  preceded 
perhaps  by  convulsions.  The  autopsy  in  such  cases  reveals  hyperaemia  of 
the  brain  and  cranial  sinuses,  blood  of  a  dark -red  color,  capillary  hemorrhages 
in  various  parts,  a  flabby  heart,  and  perhaps  some  engorgement  of  the  spleen 
and  kidneys. 

Usually,  malignant  scarlet  fever  exhibits  its  severe  type  from  the  first,  but 
cases  sometimes  occur  which  seem  mild  and  favorable  for  a  few  days,  when 
severe  symptoms  suddenly  supervene.  This  change  from  a  mild  to  a  danger- 
ous disease  is,  however,  most  frequently,  I  think,  due  to  some  complication. 

Irregular  Forms. — Deviation  from  the  normal  type  in  scarlet  fever  is 
usually  due  to  some  perturbating  cause,  which  is  often  a  pre-existing  or 
coexisting  disease  or  a  disordered  state  of  system  through  causes  distinct 
from  scarlatina.  Thus,  a  little  girl  in  my  practice  had  the  symptoms  of 
scarlet  fever,  such  as  febrile  movement  and  inflammation  of  the  buccal  and 
faucial  surfaces,  nearly  a  week  before  the  scarlatinous  eruption  appeared. 
During  this  time  the  patient  had  an  intestinal  catarrh,  with  diarrhoea,  which 
declined  when  the  rash  occurred.  This  intestinal  disease  was  the  apparent 
cause  of  the  irregularity  in  the  malady.  If  scarlatina  occur  during  a  severe 
attack  of  entero-colitis  attended  by  purging,  the  defluxion  from  the  intestinal 
surface  may  be  such  that  no  efflorescence  appears.  Severe  scarlet  fever  itself 
sometimes  appears  to  cause  gastro-intestinal  catarrh,  so  as  to  produce  an  afllux 
of  blood  toward  the  intestinal  tract  and  away  from  the  skin.  Practitioners 
occasionally  meet  cases  like  the  following,  which  I  recall  to  mind :  In  a  fam- 
ily where  scarlatina  was  prevailing  a  little  child  early  after  the  commencement 
of  the  symptoms  which  seemed  to  be  plainly  referable  to  this  exanthem  was 
seized  with  vomiting  and  purging,  which  continued  till  death  occurred  on 
the  third  day.  No  efflorescence  appeared  on  the  skin,  but  the  symptoms 
indicated  the  presence  of  severe  intestinal  catarrh,  complicating  and  masking 
scarlatina.  We  are  aided  in  the  diagnosis  of  such  cases  by  observing  the 
faucial  redness,  and  we  may  discover  a  faint  efflorescence  upon  parts  of 
the  surface,  as  about  the  groin  or  in  the  flexures  of  the  joints.  In  another 
instance  an  infant  in  the  warm  months,  having  protracted  entero-colitis,  the 
usual  summer  epidemic  of  the  cities,  had  the  characteristic  symptoms  of  scar- 
let fever,  which  was  present  in  the  family,  but  the  diarrhoea  continued  and 
no  rash  appeared. 


COMPLICATIONS  AND  SEqiJELM.  289 

In  one  who  is  much  reduced  by  an  antecedent  disease,  especially  if,  like 
the  intestinal  catarrh  mentioned  above,  it  produces  a  decided  afflux  of  blood 
away  from  the  surface  and  toward  the  interior  of  the  body,  the  eruption  is 
commonly  tardy  in  its  appearance,  indistinct,  or  wholly  absent.  On  the  other 
hand,  some  maladies  occurring  in  connection  with  this  exanthem  do  not  change 
its  symptoms,  but  themselves  undergo  modification,  l^ertussis  may  be  cited 
as  an  example,  the  cough  of  which  is  sometimes  modified  by  an  intercurrent 
attack  of  scarlet  fever,  the  symptoms  of  the  latter  disease  undergoing  little 
change. 

Scarlet  fever  may  also  be  irregular  without  any  apparent  perturbating 
cause.  In  1867,  I  attended  a  young  lady  whose  previous  health  had  been 
good,  and  whose  brother  was  sick  at  the  time  with  scarlet  fever.  She  had 
marked  elevation  of  temperature,  with  severe  pharyngitis,  and,  though  her  sur- 
face was  repeatedly  examined,  no  efflorescence  was  seen.  Two  weeks  subse- 
quently she  was  affected  with  severe  nephritis,  anasarca,  effusion  into  at  least 
one  of  the  pleural  cavities,  cedema  of  the  lungs,  and,  according  to  my  diagno- 
sis, hydro-pericardium,  the  case  ending  fatally.  Rilliet  and  Barthez  state  that 
a  second  attack  of  scarlet  fever  is  more  likely  to  be  irregular  than  the  first. 
Probably  this  opinion  is  correct,  especially  if  only  a  short  time  have  elapsed 
between  the  two  seizures.  Still,  as  we  have  already  stated,  both  seizures  may 
be  typical,  and  the  second  more  severe  than  the  first. 

It  would  be  impossible  to  make  a  clear  and  positive  diagnosis  of  certain 
cases  of  irregular  scarlet  fever,  in  which  cerebral,  pulmonary,  or  gastro-intes- 
tinal  symptoms  predominate,  were  it  not  for  the  fact  that  they  occur  in  con- 
nection with  other  cases  of  scarlet  fever  or  are  followed  by  sequelae  which 
evidently  have  a  scarlatinous  origin. 

Occasionally,  the  eruption,  if  it  be  intense  or  if  a  certain  condition  of  sys- 
tem be  present  in  the  patient,  is  accompanied  by  more  or  less  extravasation 
of  blood-corpuscles  from  the  capillaries,  usually  in  points,  so  that  the  redness 
does  not  entirely  disappear  on  pressure.  In  rare  instances  certain  of  the 
exanthematic  fevers  present  an  extreme  hemorrhagic  character,  so  as  to  be 
beyond  the  reach  of  remedies  and  of  necessity  speedily  fatal.  Hemorrhagic 
cases  of  this  severe  form  are  probably  more  common  in  variola  than  in  the 
other  fevers,  but  I  have  met  a  notable  case  in  what  was  diagnosticated  scar- 
latina. In  June,  1881,  a  man  in  his  thirty-second  year,  whose  previous  health 
had  not  been  good,  though  he  had  no  defined  ailment  and  had  been  able  to 
follow  his  occupation  of  harness-maker,  suddenly  became  very  ill,  with  great 
elevation  of  temperature  and  faucial  inflammation,  attended  by  marked  pros- 
tration. After  some  hours  an  intense  eruption  of  a  scarlatinous  appearance 
covered  nearly  the  entire  surface,  and  on  the  following  day  hemorrhages  began 
to  occur.  The  urine  contained  a  large  proportion  of  blood  ;  each  conjunctiva 
was  raised  by  hemorrhages  underneath  (ecchymosis),  so  that  its  natural  color 
was  lost,  the  eyelids  were  closed  with  difficulty,  and  blood  flowed  from  the 
nostrils,  gums,  and  under  the  skin,  forming  hemorrhagic  points  and  blotches. 
One  of  the  consulting  physicians,  perceiving  the  resemblance  to  hemorrhagic 
variola  as  described  by  Hebra,  suspected  that  we  had  a  case  of  this  formid- 
able malady  to  deal  with,  but  the  time  for  the  appearance  of  the  variolous 
eruption  passed  by  without  its  occurrence.  Death  took  place  on  the  fifth 
day.  The  temperature  during  the  sickness  remained  high,  though  the  record 
of  it  has  been  mislaid.  Fortunately,  such  severe  hemorrhagic  cases,  which 
are  necessarily  fatal,  are  rare. 

Complications  and  Sequelae. — Scarlet  fever,  if  its  type  be  severe,  is  in 
itself  dangerous  to  life.     Many,  as  we  have  seen,  perish  from  its  direct  effects 
when  it  produces  profound  blood-poisoning.      But,  while  the  ordinary  epi- 
demics of  this  malady  are  necessarily  attended  by  a  large  mortality  from  the 
19 


290  SCARLET  FEVER. 

virulence  and  depressing  effect  of  the  specific  principle,  unfortunately,  of  all 
the  diseases  of  modern  times,  scarlatina  ranks  first  as  regards  the  number  and 
gravity  of  its  complications  and  sequelae,  so  that  nearly  or  quite  as  many 
perish  from  these  as  from  the  direct  eff"ects  of  the  poison. 

Nervous  accidents  occur  chiefly  at  two  periods — to  wit,  in  the  first  days, 
when  they  are  due  to  the  severity  and  malignancy  of  the  malady  and  to  the 
impressible  nervous  temperament  of  the  child  ;  and  in  the  declining  stage  or 
after  the  termination  of  the  fever,  when  they  occur  from  uraemia.  If  the 
type  be  malignant,  delirium,  jactitation,  profound  stupor,  and  convulsions 
frequently  occur  on  the  first  and  second  days  ;  and  these  are  symptoms  which 
properly  excite  the  most  alarm  and  demand  all  the  resources  of  our  art,  since 
they  indicate  a  form  of  the  disease  which  frequently  ends  in  speedy  death. 
The  eyes  have  a  dull  or  wild  expression,  the  conjunctiva  is  suff'used,  the  heat 
of  surface  pungent,  the  pulse  rapid  and  compressible  or  feeble,  rising  above 
150,  even  to  200,  per  minute,  and  the  temperature  is  always  elevated  to  a 
degree  that  involves  danger,  the  thermometer  not  infrequently  indicating  105° 
or  106°.  But  this  severe  form  of  scarlet  fever,  attended  by  so  great  eleva- 
tion of  temperature,  is  much  less  dangerous  than  in  former  times,  even  though 
it  be  complicated  by  delirium  and  convulsions,  since  we  no  longer  hesitate  to 
reduce  bodily  heat,  when  excessive,  by  the  free  use  of  cold  baths,  and  have 
discovered  potent  agents  in  the  bromides  and  chloral  for  controlling  convul- 
sions. Nevertheless,  not  a  few  perish  in  the  commencement  of  scarlet  fever 
with  predominating  cerebral  symptoms,  as  delirium  or  eclampsia,  followed  by 
coma,  under  the  best  possible  treatment.  Sonaetimes  the  symptoms  have 
closely  simulated  those  of  acute  meningitis,  and  if  the  rash  have  been  delayed 
and  the  sore  throat  is  as  yet  slight,  the  physician  may  suspect  that  he  is  deal- 
ing with  this  disease ;  but  autopsies  in  such  cases  show  no  inflammatory 
lesions,  but  only  congestion  of  the  cerebral  and  meningeal  vessels. 

As  is  stated  in  a  preceding  page,  in  every  case  of  normal  scarlet  fever 
inflammation  of  the  faucial  surface  is  present,  as  indicated  by  redness,  tender- 
ness, and  increased  secretion  of  mucus  or  muco-pus.  It  precedes  the  efflores- 
cence on  the  skin,  and  is  announced  by  pain  in  swallowing  and  on  pressure 
with  the  fingers  behind  and  below  the  angles  of  the  jaw.  In  that  form  of 
scarlet  fever  which  has  been  designated  anginose  the  pharyngitis  is  severe, 
and  is  a  prominent  element  in  the  malady,  the  uvula,  the  pillars  of  the  fauces, 
and  the  faucial  surface  in  general  being  infiltrated  and  swollen.  Neverthe- 
less, this  inflammation,  with  the  accompanying  tumefaction,  is  properly  a 
part  of  the  disease,  rather  than  a  complication,  if  it  abate  with  the  subsidence 
of  the  scarlet  fever  or  begin  to  abate  soon  after,  and  if  it  produce  but  slight 
destructive  change  in  the  tissue  of  the  neck.  The  secretions  from  the  fauces 
may  be  foul  and  off"ensive  ;  even  superficial  ulcerations  or  gangrene  may  occur 
upon  the  faucial  surface,  causing  it  to  present  a  dark-brown  or  jagged  appear- 
ance, and  the  tissues  of  the  neck  may  be  infiltrated  to  a  certain  extent,  and 
we  designate  the  disease  a  form  of  scarlet  fever  under  the  title  anginose.  But 
when  this  condition  is  greatly  aggravated,  so  that  extensive  infiltration  and 
swelling  of  the  tissues  of  the  neck  occur,  with  an  amount  of  ulceration  or 
gangrene  which  in  itself  involves  danger,  continuing  after  the  primary  disease 
abates,  prolonging  the  fever  and  reducing  the  strength,  it  is  proper  to  regard 
the  state  of  the  throat  as  a  complication.  In  addition  to  the  pharyngitis, 
which  is  severe,  as  described  above,  the  sides  of  the  neck  around  the  angles 
of  the  jaw  become  swollen,  hard,  and  tender.  The  inflammation  has  been 
propagated  to  the  deeper  structures  of  the  neck.  Poisonous  substances,  the 
result  of  decomposition  or  vitiated  secretions,  traverse  the  lymphatic  vessels 
from  the  faucial  surface,  and,  being  intercepted  in  the  lymphatic  glands,  cause 
adenitis,  and  the  inflammation  extends  from  the  glands  to  the  adjacent  con- 


COMPLICATIONS  AND  SEQUELM  291 

nective  tissue,  which  becomes  hard,  tender,  swollen,  and  infiltrated  with 
inflammatory  products.  This  tumefaction  sometimes  begins  by  the  second  or 
third  day,  but  it  is  usually  about  the  close  of  the  first  week  or  in  the  begin- 
ning of  the  second  week  that  it  becomes  so  considerable  as  to  constitute  a 
source  of  danger  and  anxiety.  It  is  in  most  cases  bilateral,  though  one  side 
may  begin  to  swell  before  the  other  and  remain  larger  throughout. 

In  severe  cases  of  this  complication  the  tumefaction  extends  from  ear  to 
ear,  filling  up  the  space  below  and  around  the  angles  of  the  jaw  and  under 
the  chin.  Not  only  is  deglutition  difficult,  but  it  is  difficult  to  open  the 
mouth  sufficiently  to  inspect  the  fauces,  and  attempts  to  do  so  cause  much 
pain.  The  lymphatic  glands,  Avhich  lie  in  the  inflamed  area  and  participate 
in  the  inflammation,  are  greatly  enlarged  by  hyperplasia,  the  round  granular 
lymph-cells  multiplying  so  abundantly  that  the  glands  increase  to  many 
times  their  normal  size.  Most  of  the  tumefaction  is,  however,  due  to  exten- 
sion of  the  inflammation  to  the  connective  tissue  of  the  neck.  The  cellu- 
litis, which  resembles  that  occurring  in  other  conditions,  is  attended  by  dis- 
tension of  the  capillaries,  the  abundant  formation  of  young  round  cells,  and 
transudation  of  serum  (Billroth).  A  moderate  amount  of  tumefaction  may 
disappear  by  resolution,  but  if  it  be  considerable  it  seldom  abates  in  this 
way,  but  by  the  tedious  and  exhausting  process  of  suppuration  or  gangrene. 
If  the  swelling  at  its  most  prominent  point  present  a  reddish  hue,  all  hope 
of  producing  resolution  must  be  abandoned ;  it  cannot  be  effected  by  any 
medicine  or  appliance  within  the  resources  of  our  art.  The  abscess  which 
forms  is  likely  to  be  diffuse,  so  as  to  involve  danger  of  pyaemia,  unless  it  be 
soon  opened  and  properly  washed  out.  With  the  discharge  of  the  pus  the 
swelling  gi'adually  softens  and  declines.  In  other  cases  gangrene  results. 
The  vessels  in  the  inflamed  part  are  compressed  by  the  inflammatory  prod- 
ucts, so  that  they  no  longer  convey  the  blood  which  is  required  for  the  pur- 
pose of  nutrition.  It  is  a  law  of  the  economy  that  whenever  the  circulation 
ceases  the  tissues  which  receive  their  nutritive  supply  through  the  obstruct- 
ed vessels  lose  their  vitality.  Hence  gangrene  occurs  in  all  that  portion 
of  the  swelling  in  which  the  circulation  is  arrested.  The  skin  over  it  peels 
off,  the  dead  tissue  underneath  is  brown  or  dark,  and  soon,  if  life  be  pro- 
longed, the  slough  begins  to  separate.  The  prognosis  as  regards  this  com- 
plication depends  largely  on  the  size  of  the  slough.  If  it  be  large,  death 
will  probably  result,  since  the  strength  of  the  system  is  already  reduced  by 
the  primary  disease,  and  the  reparative  process  will  necessarily  be  slow, 
while  abundant  suppuration  tends  to  increase  the  exhaustion.  In  some 
of  the  worst  cases  of  cervical  gangrene  which  I  have  seen  the  slough  has 
laid  bare  the  muscles  and  vessels  of  the  neck,  producing  in  one  case  a  cavity 
or  excavation  sufficiently  large  to  admit  a  hen's  egg.  Often  the  slough 
extends  under  the  skin,  so  that  the  deepest  recesses,,  of  the  cavity  are  not 
visible,  and  occasionally,  in  cases  which  have  ended  fatally  in  my  practice, 
severe  hemorrhage  occurred  from  the  concealed  vessels.  If  the  ulcerative 
or  gangrenous  process  extends  so  deeply  into  the  tissues  of  the  neck  that 
hemorrhages  occur,  death  is  the  common  result ;  but  if  the  destructive  action 
be  of  moderate  extent  and  other  conditions  favorable,  we  may  expect  recov- 
ery thi'ough  cicatrization,  with  perhaps  some  deformity  by  contraction  of  the 
cicatrix. 

When  the  inflammation  of  the  connective  tissue  of  the  neck  is  extensive, 
involving  both  the  lateral  and  anterior  regions  of  the  neck,  the  patient  is  in 
a  perilous  state.  The  cellulitis,  when  extensive  and  accompanied  by  much 
swelling,  may  produce  oedema  of  the  glottis,  may  obstruct  respiration  by 
compressing  the  air-passages  or  the  laryngeal  nerves,  may  cause  compression 
of  the  jugular  veins,  and  thus  give  rise  to  dangerous  cerebral  symptoms,  or 


292  SCARLET  FEVER. 

may.  lay  bare  and  injure  important  muscles  and  nerves,  as  we  have  seen.  If 
the  ulceration  or  gangrene  be  extensive,  and  death  do  not  occur  by  hemor- 
rhage from  arterial  or  venous  twigs,  septic  poisoning  may  occur,  increasing 
still  more  the  fatal  nature  of  the  malady. 

Some  cases  of  this  complication  are  melancholy  in  the  extreme,  as 
one  related  by  Cremen,  in  which  ulceration  of  the  pharynx  occurred,  allow- 
ing the  escape  of  food  and  preventing  deglutition.  In  severe  scarlatinous 
pharyngitis  the  inflammation  sometimes  extends  along  the  Eustachian  tube, 
causing  its  occlusion.  This  accident  will  be  considered  when  we  treat  of 
otitis  media,  another  grave  complication.  It  often  also  extends  into  the  nares, 
causing  catarrh  of  the  Schneiderian  mucous  membrane,  with  discharge  of 
muco-pus  from  the  surface.  Not  infrequently  ulceration  or  gangrene  occurs 
in  the  faucial  surface,  producing  more  or  less  destruction  of  tissue  and  form- 
ing excavations,  while  the  cutaneous  surface  retains  its  integrity  and  is  not 
even  reddened.  The  following  case  shows  how  grave  the  complication  which 
we  are  now  considering  sometimes  is  when  the  external  surface  of  the  neck 
is  not  involved,  and  how  the  inflammation  by  extension  outward  from  the 
fauces  may  involve  the  middle  ear : 

Case  1. — Annie  K ,  aged  two  and  a  half  years,  an  inmate  of  the  New 

York  Foundling  Asylum,  was  well,  except  an  eczema  of  the  scalp,  until  the 
night  of  April  3,  1882,  when  she  was  attacked  with  vomiting  and  diarrhoea.  She 
was  feverish  and  drowsy,  and  at  2  p.  M.  on  the  4th  the  scarlatinous  efflorescence 
appeared  upon  her  neck,  body,  and  lower  extremities ;  tongue  coated ;  pharynx 
red;  temperature  (axillary)  103°;  pulse  160.  The  symptoms  and  aspect  indi- 
cated a  grave  form  of  the  malady,  and  the  usual  sustaining  treatment  was 
ordered.  On  April  5th  the  temperature  was  102°,  pulse  144,  tongue  less  coated, 
eruption  fading,  less  stupor,  no  albumen  in  urine.  April  6th,  morning  tempera- 
ture 102°,  pulse  160 ;  passed  a  restless  night ;  stools  thin  and  too  frequent ;  has 
grayish  patches  in  the  throat ;  p.  m.  temperature  103|-°,  pulse  150.  April  7th, 
the  diarrhoea  continues,  and  she  has  a  copious  muco-purulent  discharge  from  the 
nostrils ;  P.  M.  temperature  103|,  pulse  160.  April  10th,  the  temperature  has 
continued  at  about  103° ;  the  patient  is  very  sick,  with  a  constant  foul-smelling 
discharge  from  the  nostrils ;  breath  very  offensive ;  temperature  103.5°,  pulse  about 
180.  April  12th,  general  appearance  a  little  better,  but  the  posterior  surface  of 
the  fauces  is  completely  covered  by  a  thick  pseudo-membrane ;  had  four  loose 
stools  last  night ;  temperature  and  pulse  the  same  as  at  last  record ;  a  dark,  offen- 
sive, and  jagged  coating  over  the  fauces,  and  a  dark,  foul  discharge  from  the 
nostrils  as  before :  examination  of  the  chest  negative.  April  14th,  is  much 
prostrated  ;  temperature  104.5°,  pulse  rapid  and  weak  ;  respiration  noisy ;  dimin- 
ished resonance  over  lower  two-thirds  of  left  side  of  chest;  ulcers  upon  the 
mouth  and  tongue ;  fauces  red  and  ulcerated.  April  17th,  pulse  150,  tempera- 
ture 100.5° ;  general  appearance  somewhat  better,  but  the  diarrhoea  continues, 
and  patches  of  a  diphtheritic  character  have  appeared  upon  the  lijjs ;  moist 
r§,les  in  left  side  of  eldest.  The  symptoms  continued  nearly  the  same  until 
April  23d,  when  she  died.  A  dull  percussion  sound  and  distinct  bronchial  res- 
piration were  observed  in  the  left  scapular  region  during  the  last  days  of  her 
life. 

Autopsy  nine  hours  after  death  by  the  curator,  Dr.  W.  P.  Northrup  :  Body 
well  nourished  ;  the  tissues  have  a  jaundiced  hue  ;  lips  sore  ;  on  turning  the  head 
to  one  side  pus  runs  from  the  left  ear  and  dirty  muco-pus  from  the  mouth.  Brain 
normal ;  on  opening  the  petrous  portion  of  the  left  temporal  bone  the  middle  ear 
is  found  full  of  pus,  which  communicated  freely  with  the  external  ear  through  a 
perforated  membrana  tympani ;  the  Eustachian  tube  cannot  be  traced  in  the 
sloughy  tissue,  and  a  passage  filled  with  pus  extends  from  the  ear  to  the  fauces ; 
opposite  the  greater  cornua  of  the  hyoid  bone  are  two  deep  ulcers,  each  having 
about  the  diameter  of  a  ten-cent  piece,  with  sloughy  and  offensive  base  and  sides  ; 
the  left  ulcer  communicates  by  a  ragged  and  wide  sinus  with  a  dark  and  sloughy 
cavity  of  about  four  drachms  capacity  ;  this  cavity  is  located  in  the  neck  under 
the  angle  of  the  jaw,  apparently  occupying  the  site  of  a  disintegrated  gland,  and 


COMPLICATIONS  AND  SEQUELJE.  293 

it  opens  upon  the  .surface  of  the  fauces.  The  surface  of  the  larynx  has  a  dusky, 
dirty  apjiearance,  sprinkled  with  little  cheesy-looking  spots,  and  covered  l)y  a 
dirty,  foul-appearing  liquid,  as  if  some  of  the  ichorous  pus  had  escaped  into  it 
from  the  neck ;  about  one  and  a  half  inches  below  the  vocal  cords  there  is  an 
unmistakable  pseudo-membrane  ;  below  this,  near  the  bifurcation,  the  trachea 
has  a  bright-red  color,  as  if  a  pseudo-membrane  had  been  peeled  from  it,  leaving 
the  surface  raw.  The  detachment  of  a  pseudo-membrane  from  this  part,  if  it  did 
occur,  must  have  been  ante-mortem,  for  the  organ  had  been  carefully  handled  in 
making  the  autojisy.  Between  the  apex  of  the  left  lung  and  the  median  line  the 
tissues  of  the  neck,  dissected  upward,  are  found  indurated,  yellow„and  giving 
an  offensive  odor,  showing  that  the  cervical  cellulitis  had  extended  downward 
farther  than  usual.  The  bronchial  glands  have  undergone  hyperplasia,  being 
enlarged  and  hard.  The  right  lung  is  normal ;  about  one-half  of  the  left  lower 
lobe  is  consolidated,  and  when  cut  is  found  to  be  gangrenous  and  offensive.  The 
liver  is  apparently  somewhat  enlarged ;  spleen  normal  in  size ;  gastric  mucous 
membrane  has  a  congested  appearance  and  is  covered  with  mucus ;  mesenteric 
glands  enlarged,  pale,  and  firm ;  Peyer's  patches  swollen  and  pale;  at  lower  end 
of  ileum  some  pigmentation  of  these  glands ;  in  large  intestine  the  solitary 
glands  are  enlarged,  and  a  few  of  them  pigmented  ;  kidneys  pale,  cortex  thick- 
ened, and  markings  indistinct.  Microscopical  examination:  In  the  pia  mater 
perhaps  a  little  increase  of  cells;  meninges  of  brain  otherwise  normal.  The 
trachea  shows  well-marked  diphtheritic  inflammation ;  it  contains  a  film  of 
pseudo-membrane ;  evidences  of  inflammation  occur  also  upon  the  laryngeal 
surface,  though  less  marked  than  in  the  trachea.  The  solidified  portion  of  the 
lung  exhibits  the  ordinary  lesions  of  broncho-pneumonia,  with  some  interstitial 
change.  In  the  kidneys  we  find  parenchymatous  nephritis,  with  some  cell-growth 
in  the  Malpighian  bodies. 

The  above  case  has  been  related  at  length,  not  only  because  it  shows  how 
severe  and  destructive  the  inflammation  of  the  throat,  extending  into  the 
tissues  of  the  neck,  sometimes  is,  but  because  four  other  complications  or 
sequelce  were  also  present — to  wit,  otitis  media,  diphtheria,  nephritis,  and 
pneumonia.  We  see  how  formidable  a  disease  scarlet  fever  sometimes  is 
when  attended  by  the  inflammations  to  which  it  so  frequently  gives  rise,  for 
a  child  older  and  stronger  than  this,  if  thus  affected,  would  inevitably  have 
perished  with  the  best  possible  treatment. 

In  localities  where  diphtheria  is  endemic,  as  in  New  York  City  and  Paris, 
scarlet  fever  is  often  complicated  by  pseudo-membranous  inflammation  of  the 
fauces  and  air-passages.  In  severe  cases  the  Schneiderian  as  well  as  the 
faucial  surface  is  covered  with  pseudo-membrane,  so  that  it  can  be  readily 
seen  on  inspecting  the  anterior  nares.  Occasionally,  this  exudation  appears 
upon  the  laryngeal  and  tracheal  surfaces,  as  in  the  case  which  I  have  related 
above  and  in  others  presently  to  be  related,  causing  dangerous  embarrassment 
of  respiration.  This  complication  sometimes  begins  almost  at  the  commence- 
ment of  scarlet  fever,  but  in  most  instances  it  does  not  occur  before  the  third 
or  fourth  day,  and  it  sometimes  does  not  appear  till  in  the  declining  stage  of 
the  fever.  When  it  begins  it  intensifies  the  fever  and  produces  general 
aggravation  of  symptoms. 

The  elaborate  treatise  by  Sanne  of  Paris  on  diphtheria  contains  a  chapter 
entitled  "  Secondary  Diphtheria."  In  it  the  author  says,  what  all  who  are 
familiar  with  diphtheria  will  agree  to,  that  secondary  diphtheria  does  not 
differ  in  nature  from  the  primary  form,  and  that  it  exhibits  a  tendency  "  to 
occupy  the  organs  which  are  themselves  the  seat   of  the  more  pronounced 

local  determinations  of  the  primitive  malady Diphtheria  is  seen  in 

the  course  or  sequel  of  numerous  diseases.  Some  appear  to  have  a  special 
proclivity  for  engendering  diphtheria  ;  these  are  specific  maladies :  measles, 
scarlet  fever,  pertussis."  Sanne's  statistics  relating  to  the  seat  of  scarlatinous 
dinhtheritic  exudation  are  as  follows : 


294  SCARLET  FEVER. 

Fauces  alone  attacked 15  cases. 

Fauces  with  larynx  attacked 4  " 

Fauces  with  nasal  fossa  attacked 8  " 

Fauces  with  larynx  and  nasal  fossa  attacked 4  " 

Fauces  with  larynx  and  bronchi  attacked 1  " 

Fauces  with  nasal  fossa  and  lips  attacked 1  " 

Fauces  with  lips  and  skin  attacked 1  " 

Fauces  unaifected 3  " 

Diphtheria  generalized 2  " 

Larynx   only  affected 2  " 

Nasal  fossa 1  " 

^fhe  opinion  of  so  good  an  observer  as  Sanne,  that  when  in  scarlet  fever 
pseudo-membranous  exudation  appears  upon  the  mucous  surfaces  which  are 
the  seat  of  scarlatinous  inflammation,  diphtheria  has  supervened,  and  not  a 
croupous  form  of  scarlatinous  phlegmasia,  carries  with  it  great  weight. 

Nevertheless,  one  of  the  most  difficult  problems  which  we  have  to  deal 
with  in  certain  cases  is  to  distinguish  diphtheritic  from  non-diphtheritic 
inflammation  ;  and  I  see  no  reason  why  the  scarlatinous  inflammation  when 
intense  may  not  be  sometimes  membranous.  We  know  that  in  some  cases 
of  dysentery  a  fibrinous  exudation  occurs  upon  the  surface  of  the  colon  ; 
that  in  croupous  pneumonia  fibrin  exudes  into  the  bronchioles  and  alveoli  of 
the  lungs ;  and  that  physicians  in  localities  where  there  is  no  diphtheria  meet, 
though  at  long  intervals,  cases  which  they  designate  croupous  pharyngitis 
and  laryngitis ;  and  it  seems  probable  that  the  intense  inflammation  of 
anginose  scarlatina  sometimes  produces  the  same  exudation.  Moreover,  it  is 
very  difficult  to  distinguish  in  the  swollen  fauces  between  a  membranous 
exudation  and  ulceration  or  superficial  gangrene  so  common  in  malignant 
scarlet  fever.  The  grayish-white  surface,  jagged  and  foul,  may  be  the  one 
or  the  other,  an  exudation  or  a  sphacelus,  and  in  certain  instances  it  is  impos- 
sible to  discriminate  between  the  two  conditions  at  the  bedside. 

Diphtheria  complicating  scarlet  fever  occasionally  begins  nearly  simulta- 
neously with  the  latter.  Henoch  states  that  exceptionally  he  has  observed 
suspicious  patches  upon  the  fauces  before  the  appearance  of  the  scarlatinous 
eruption  upon  the  skin  ;  and  he  adds :  "  I  have  had  repeated  opportunities 
of  observing  this  unusual  beginning.  In  such  cases  we  must  ask  ourselves 
whether  the  first  afi'ection  was  really  connected  with  the  second,  or  whether 
the  former  was  a  true  primary  diphtheria  rapidly  followed  by  scarlatina. 
This  opinion  is  favored  by  the  fact  that  I  had  only  observed  such  cases  in 
the  hospital,  in  which  infection  with  various  forms  of  contagion  can  scarcely 
be  avoided." 

But  usually  it  is  not  till  the  third  or  fourth  day  of  scarlet  fever  that  this 
complication  begins.  The  patient  has  been  progressing  favorably  with  the 
fever  till  on  a  certain  day  a  marked  aggravation  of  symptoms  occurs.  A 
higher  temperature,  more  pungent  heat,  and  the  physiognomy  of  a  more 
serious  malady  are  present.  On  inspecting  the  fauces  to  discover  the  cause, 
we  observe  a  pellicle  forming  upon  the  tonsils  and  perhaps  other  portions  of 
the  faucial  surface.  Often  the  entire  aspect  of  the  case  changes  by  the 
occurrence  of  this  complication,  a  mild  case  of  scarlet  fever  becoming  grave 
and  fatal  in  consequence.  Thus  in  a  case  which  I  saw  with  Dr.  Hardy  of 
New  York  the  membranous  inflammation  of  diphtheria,  commencing  upon 
the  fauces  on  the  third  day  of  scarlet  fever,  extended  to  the  Schneiderian 
membrane,  and  thence  along  the  left  lachrymal  sac  to  the  eyelids,  producing 
redness  and  swelling  along  the  side  of  the  nose  and  upon  the  cheek  like  that 
of  erysipelas.  A  thick  diphtheritic  pellicle  occurred  upon  the  under  surface 
of  each  eyelid  on  the  left  side,  with  great  tumefaction  of  both  lids,  gangrene 
of  the  cornea,  and  destruction  of  the  eye.     The  case  soon  ended  fatally. 


COMPLICATIONS  AND  SEQUELAE.  295 

A  pellicular  exudation  sometimes  occurs  in  the  larynx  and  trachea  during 
the  course  of  scarlet  fever  as  a  thin  film,  rendering  tlie  respiration  noisy,  but 
the  development  of  a  thick  and  firm  pseudo-membrane,  so  as  to  imperil  the 
life  of  the  patient  from  the  stenosis  in  the  air-passages,  has  been  much  less 
frequent  in  n)y  practice  than  it  is  in  primary  diphtheria  and  in  diphtheria 
complicating  measles  or  pertussis.  The  following  were  cases  of  this  severe 
complication  occurring  in  a  recent  epidemic  in  the  New  York  Foundling 
Asylum.  In  these  cases  the  respiration  was  noisy,  but  the  obstruction  to 
breathing  was  apparently  due  to  infiltration  and  swelling  around  the  aper- 
ture of  the  glottis,  more  than  to  the  pseudo-membrane  which  the  autopsies 
showed  to  be  present  : 

Case  2. — A  child  aged  three  and  a  half  years,  who  previously  had  symptoms 
of  mild  catarrhal  croup,  with  moderate  redness  of  the  fauces,  sickened  with  scar- 
let fever  on  Oct.  1,  1882,  the  rash  being  profu.se  and  soon  covering  nearly  the 
entire  body.  The  axillary  temperature  was  103°,  pulse  140;  slight  stridor  in 
breathing  and  some  cough;  fauces  very  red,  but  free  from  membrane.  Oct.  2d, 
restless,  sleeping  but  little ;  has  vomited  four  times.  Oct.  3d,  temp.  103.5°,  pulse 
120  ;  fauces  much  swollen  ;  still  vomiting;  rash  abundant.  4  P.  M.,  temp.  104.3°, 
pulse  128  ;  tongue  clean  ;  some  discharge  from  nares;  urine  not  albuminous,  but 
its  quantity  diminished.  Oct.  4th,  aspect  that  of  very  severe  sickness;  profuse 
discharge  from  nostrils ;  fauces  of  a  deep-red  color,  and  a  pseudo-membrane  over 
tonsils  and  uvula ;  tumefaction  along  the  sides  of  the  neck ;  temp.  104°,  pulse 
140;  breathing  moderately  stridulous ;  urine  is  passed  more  freely  than  ye.ster- 
day ;  evening  temp.  105°.  Oct.  6,  croupy  symptoms  more  marked ;  tonsils  and 
uvula  greatly  swollen,  so  that  the  fauces  are  almost  occluded ;  temp.  103.5° ; 
breathing  difficult,  but  apparently  sufficient  oxygen  is  received ;  profuse  nasal 
discharge,  and  other  symptoms  as  before.  About  1.30  P.  M.  he  was  raised  to  take 
some  milk,  and  suddenly  became  asphyxiated.  His  face  was  dusky,  the  eyes 
protruded,  and  he  voided  urine  and  feces.  Dr.  Swift,  who  attended  the  child, 
and  to  whom  I  am  indebted  for  this  history,  immediately  performed  tracheotomy, 
which  gave  temporary  relief  by  the  exi^ulsion  of  a  considerable  quantity  of 
pseudo-membrane  through  the  opening.  On  the  following  day  the  respiration 
again  became  obstructed  at  some  point  below  the  canula,  so  that  it  could  not  be 
removed ;  the  features  grew  livid,  and  death  occurred  in  convulsions  twenty-six 
hours  after  the  tracheotomy. 

The  autopsy  was  made  by  Dr.  W.  P.  Northrup,  curator  of  the  asylum,  who 
found  the  pharynx  covered  by  a  membrane  which  was  traced  to  the  posterior 
nares ;  larynx,  trachea,  and  bronchial  tubes  as  far  as  the  third  divisions  covered 
with  membrane;  portions  of  the  tracheal  surface  denuded,  and  the  mucous  mem- 
brane underneath  of  a  bright-red  color  and  smooth. 

Case  3. — Katie,  aged  six  and  a  third  years,  was  returned  to  the  asylum  on 
Nov.  18th.  Three  days  later  (Nov.  21st)  she  had  sore  throat,  reddened  fauces, 
coated  tongue,  and  a  faint  ra,sh  upon  the  neck,  chest,  and  arms;  eyes  injected; 
temp.  102°.  In  the  afternoon  temp.  103° ;  eruption  still  faint.  koV.  22d,  temp. 
103.5°;  an  eruption  on  chest,  abdomen,  arms,  and  legs  in  patches.  Evening 
temp.  104° ;  voice  clear.  Nov.  23d,  temp.  103.5° ;  tongue  red ;  fauces  deeply 
reddened,  but  without  any  visible  pseudo-membrane ;  the  scarlatinous  eruption 
has  appeared  over  a  considerable  part  of  the  surface.  On  the  24th  a  pseudo- 
membrane  occurred  over  the  tonsils  and  adjacent  faucial  surface;  her  respira- 
tion became  labored,  and  death  took  place  from  dyspnoea  at  11  p.  M. 

Autopsy. — Naso-pharynx  covered  by  a  thick  fibro-purulent  membrane. 
Larynx  contains  a  well-marked  pseudo-membrane,  but  not  continuous.  Trachea 
covered  by  a  pseudo-membrane,  continuous  over  most  of  its  surface,  but  in  i>laces 
hroken  and  flaky.  Where  it  is  detached  the  mucous  membrane  is  seen  under- 
neath, dusky  and  deeply  injected.  At  the  root  of  the  lungs  the  pseudo-mem- 
brane can  be  traced  along  the  tubes  about  an  inch  in  all  directions.  Nothing 
noteworthy  in  the  other  lesions. 

In  another  case  of  scarlet  fever,  in  which  death  occurred  after  an  illness 
of  three  weeks  and  from  gradually  increasing  dyspnoea,  it  is  stated  in  the 


296  SCARLET  FEVER. 

records  of  the  autopsy  that  the  larynx  was  free  from  a  pseudo-membrane ; 
but  a  thin  film  extended  over  a  considerable  part  of  the  trachea. 

Coryza  frequently  commences  at  or  about  the  time  of  the  pharyngitis. 
The  inflammation  of  the  Schneiderian  membrane  is  continuous  posteriorly 
with  that  of  the  fauces,  and  is  announced  by  redness  and  swelling,  inability 
to  breathe  freely  through  the  nostrils,  and  an  irritating  ichorous  discharge. 
Simple  coryza  in  itself  involves  little  danger,  though  it  is  an  unpleasant  com- 
plication, and  in  the  nursing  infant  it  may  interfere  with  drawing  the  nipple. 
Diphtheritic  coryza,  on  the  other  hand,  which  is  frequently  present  when 
diphtheria  complicates  scarlet  fever,  involves  danger,  since  it  is  apt  to  cause 
ulcerations,  hemorrhages,  and  septic  poisoning.  When  the  local  symptoms 
are  unusually  severe  and  the  discharge  abundant,  it  is  probable  that  inflam- 
mation has  in  some  cases  extended  to  the  antrum  of  Highmore. 

Inflammation  of  the  middle  ear  is  another  unpleasant  and  not  infrequent 
complication.  The  statistics  of  different  aurists  collated  by  Dr.  C.  H.  May, 
and  presented  in  a  paper  on  scarlatinous  otitis  read  before  the  Paediatric  Sec- 
tion of  the  New  York  Academy  of  Medicine,  March  4,  1889,  show  that  about 
5  per  cent,  of  all  aural  alfections  result  from  scarlet  fever,  and  in  10  per  cent, 
of  the  cases  of  total  deafness  the  loss  of  hearing  is  from  this  disease.  It  is 
due  to  extension  of  the  catarrh  from  the  pharynx  along  the  Eustachian  tube 
to  the  tympanum.  In  a  considerable  proportion  of  cases  of  otitis  media  this 
tube  is  occluded  by  the  infiltration  and  swelling  of  its  mucous  membrane,  so 
that  the  muco-pus  escapes  with  difiiculty  or  is  retained.  Hence  severe  ear- 
ache, an  increase  of  the  febrile  movement,  and  outward  bulging  of  the  mem- 
brana  tympani  occur.  Sometimes  headache  or  other  cerebral  symptoms  arise, 
probably  from  the  fact  that  the  meningeal  artery,  which  supplies  the  meninges, 
is  connected  by  anastomosing  branches  with  the  tympanum.  In  one  of  the 
cases  related  above  it  will  be  recollected  that  the  ulceration  and  abscess 
extended  from  the  fauces  to  the  middle  ear,  the  entire  Eustachian  tube 
having  disappeared  in  the  ulcerative  process. 

Frequently,  the  otitis  escapes  detection,  its  symptoms  being  masked  or 
obscured  by  the  general  disease,  until  the  membrana  tympani  is  perforated 
and  otorrhcea  begins ;  but  by  careful  examination  the  nature  of  the  complica- 
tion can  usually  be  ascertained  before  the  ear  is  injured  to  this  extent,  for  a 
patient  too  young  to  speak  will  often  press  with  the  fingers  against  the  painful 
ear  or  lie  with  the  ear  pressed  upon  the  pillow,  evidently  having  an  increase 
of  suff'ering  if  placed  in  any  other  position.  One  old  enough  to  speak  and  in 
proper  mental  condition  makes  known  the  earache  as  soon  as  it  occurs.  In 
most  instances  the  scarlet  fever  has  continued  some  days  when  the  otitis 
begins.  The  otitis  may  begin  insidiously,  but  in  other  instances  it  begins 
with  a  chill  and  a  rise  of  temperature  to  104°  or  105°.  The  pain  referred  to 
the  ear  may  be  paroxysmal,  and  it  is  usually  worse  at  night.  It  may  radiate 
from  the  ear,  following  the  branches  of  the  fifth  nerve.  The  patient  expe- 
riences pain  on  pressure  upon  and  around  the  tragus,  and  when  the  inflamma- 
tion extends  to  the  mastoid  cells,  pressure  upon  the  mastoid  process  is  also 
painful.  The  otitis  may  be  unilateral,  but  in  a  large  proportion  of  cases  it 
is  bilateral. 

The  mucous  membrane  of  the  tympanum,  red  and  swollen  from  inflamma- 
tion, secretes  muco-pus  abundantly,  and  this,  pent  up  in  the  cavity,  must 
obtain  an  exit  before  relief  occurs.  It  is  well  if  the  secretion  escape,  though 
with  difiiculty,  down  the  Eustachian  tube.  The  destructive  action  of  the  pus 
upon  the  delicate  structure  of  the  ear  is  often  such  that  within  a  few  days 
irreparable  harm  is  done  and  more  or  less  deafness  results.  Relief  can  occur, 
if  the  Eustachian  tube  remain  closed,  only  by  perforation  of  the  membrane 
and  the  discharge  of  the  secretions  into  the  external  meatus.     When  this 


COMPLICATIONS  AND  SEQUELS.  297 

takes  place  the  inflammation  in  the  most  favorable  cases  gradually  abates,  the 
aperture  in  the  drum  closes,  and  the  integrity  of  the  auditory  apparatus  is 
preserved.  In  severe  cases  the  mastoid  cells  participating  in  the  inflammation 
become  tilled  with  muco-pus  and  tender  to  the  touch,  and  often  the  collateral 
u?dema  causes  tumefaction  and  narrowing  of  the  external  ear,  which  subside 
with  the  discharge  of  pus  from  the  tympanum. 

Unfortunately,  there  is  for  many  a  more  melancholy  history — a  more 
destructive  inflammation,  involving  permanent  impairment  or  total  loss  of 
hearing.  This  most  frequently  takes  place  in  strumous  or  feeble  children. 
All  grades  of  inflammation  and  destructive  action  occur  in  different  cases. 
The  perforation  in  the  drum-membrane  may  be  large  or  the  membrane  may  be 
completely  destroyed,  and  the  detached  ossicles  escape  one  by  one  into  the 
external  meatus,  and  in  a  few  instances,  fortunately  rare,  this  occurs  in  both 
ears,  porducing  complete  and  permanent  deafness.  In  my  own  practice  this 
has  never  occurred,  but  I  have  met  one  or  two  adults  who  were  totally  deaf 
from  this  cause. 

The  mucous  membrane  which  lines  the  bony  wall  of  the  middle  ear  has 
the  function  of  the  periosteum,  and  therefore  when  inflamed  and  subjected  to 
pressure  is  liable  to  ulcerate.  As  in  other  parts  of  the  skeleton  under  similar 
conditions,  superficial  caries  or  necrosis  of  the  underlying  bone  is  liable  to  occur. 
The  carious  or  necrotic  process  may  extend  to  the  mastoid  cells.  An  ofi"ensive 
otorrhoea,  continuing  for  months  or  years,  indicates  the  persistence  of  this 
pathological  state  of  the  tympanum,  which  is  rendered  so  obstinate  by  the 
presence  of  dead  bone.  A  moment's  survey  of  the  anatomical  relations  of 
the  middle  ear  shows  the  danger  to  which  these  patients  are  liable.  A  thin 
bony  septum,  perforated  with  blood-vessels,  and  sometimes  containing  con- 
genital apertures,  separates  the  tympanum  from  the  cranial  cavity  above. 
Posteriorly  lie  the  mastoid  cells,  connected  with  the  tympanum  by  one  large 
and  several  small  apertures.  Anteriorly  is  the  commencement  of  the  Eus- 
tachian tube,  and  in  close  proximity  to  the  tympanum  lies  the  carotid  canal, 
and  at  one  point  also  the  superior  petrosal  sinus.  Virchow  has  shown  how 
inflammation  extending  from  the  ear  in  otitis  media  sometimes  pi'oduces  such 
compression  of  the  veins  or  sinuses  by  the  swelling  from  the  infiltration  and 
exudation  that  the  circulation  is  arrested,  and  the  fibrin  contained  in  the 
blood  of  these  vessels  is  precipitated,  forming  thrombi,  with  the  most  disas- 
trous effect  upon  the  individual.  Pus  may  also  burrow  in  the  interstices  of 
the  bone,  causing  great  pain,  or  the  pent-up  secretions,  having  no  outlet  for 
escape,  may  in  time  undergo  caseous  degeneration,  producing  the  conditions 
in  which  tuberculosis  so  often  originates. 

Death  not  infrequently  occurs  in  chronic  otitis  media  in  another  way. 
The  otorrhoea,  after  months  or  years,  suddenly  ceases,  the  child  complains  of 
constant  severe  headache  and  is  feverish,  and  the  case  ends  in  coma,  preceded 
perhaps  by  convulsions.  Meningitis  has  occurred,  produced  by  extension  of 
the  inflammation  through  the  thin  bony  septum  which  divides  the  tympanum 
from  the  cranial  cavity,  and  at  the  autopsy  hyperaemia  of  the  meninges,  fibrin, 
pus,  perhaps  softening  of  the  brain  and  an  abscess,  are  found  in  the  portion 
of  the  encephalon  adjacent  to  the  tympanum.  Therefore,  otitis  media,  though 
it  often  ends  favorably,  is  in  many  patients  an  obstinate,  dangerous,  and  even 
fatal  sequel  of  scarlet  fever. 

The  complication  known  as  sc.arlatinona.  rheumatism  is  regarded  by  some 
as  a  synovitis,  but  its  symptoms,  especially  its  shifting  from  joint  to  joint, 
seem  to  ally  it  to  the  rheumatic  aff"ections.  In  some  epidemics  it  is  common. 
It  usually  begins  toward  the  close  of  the  first  week  or  in  the  second  week, 
and  its  common  seat  is  in  the  ankle,  phalangeal,  and  wrist  joints.  It  is 
attended  by  very  little  swelling  in  most  patients,  though  the  joints  are  tender 


298  SCARLET  FEVER. 

and  painful  on  pressure.  It  does  not  seem  to  retard  convalescence  materially, 
but  it  produces  suffering  and  involves  danger  as  regards  the  heart.  It  sub- 
sides in  a  few  days  with  the  ordinary  treatment  of  acute  rheumatism,  and 
even  without  special  treatment,  the  chief  danger  being  that,  as  in  idiopathic 
rheumatism,  endocarditis  may  arise,  with  permanent  crippling  of  the  valves. 
The  following  was  a  case  of  valvular  disease  having  this  origin.  It  occurred 
in  my  practice. 

Case  4. — Freddy  M ,  aged  four  years,  sickened  with  scarlet  fever  March 

6,  1879.  The  usual  vomiting  occurred  on  the  first  day,  and  the  temperature  was 
104°.  The  case  progressed  favorably  till  March  14th,  when  he  complained  of 
pain  in  both  wrists,  both  ankles,  and  both  knees.  On  March  17th  the  general 
condition  was  good,  the  urine  contained  no  albumen  and  apparently  few  urates, 
but  he  still  had  pain  in  the  joints  of  the  upper  and  lower  extremities  and  in  the 
back ;  pulse  140,  temperature  103° ;  breathes  with  a  slight  moan ;  urates  in  the 
urine,  but  no  albumen.  A  distinct  mitral  regurgitant  murmur  is  now  heard  for 
the  first  time.  Under  the  use  of  salicylate  of  sodium  the  pain  in  the  joints  soon 
leased,  but  the  mitral  murmur  is  permanent. 

The  following  prescription  is  for  a  child  of  five  years : 

R.  01.  gaultherise,  fgj  ; 

Sodii  salicylat.,  ^iij ; 

Syrupi,  f.^ij ; 

Aquse,  f^iv.     Misce. 

Sig. :  Give  one  teaspoonfull  every  four  hours  in  water. 

Of  the  serous  inflammations  complicating  scarlet  fever,  pericarditis  has 
been,  according  to  Rilliet  and  Barthez,  most  frequently  observed.  In  this 
country  it  is  probably  more  common  than  is  usually  supposed,  but  it  is  less 
frequently  detected  than  pleuritis,  the  symptoms  of  which  are  more  con- 
spicuous. 

The  following  case,  which  occurred  in  my  practice,  was  an  example  of  this 
■complication : 

Case  5. — C ,  girl,  aged  five  years  and  ten  months,  sickened  with  severe 

scarlet  fever  on  April  4th.  Was  delirious  ;  pulse  158  ;  had  vomiting  and  consti- 
pation. April  10th,  pulse  varies  from  124  to  153,  no  delirium;  a  considerable 
quantity  of  urates  in  the  urine.  April  11th,  has  to-day,  for  the  first  time,  severe 
pain  in  the  epigastrium,  with  tenderness  and  moderate  distension.  Otherwise 
symptoms  favorable,  but  severe ;  jjulse  140 ;  respiration  moderately  accelerated 
and  vesicular  in  every  part  of  the  chest.  From  this  date  the  symptoms  continued 
about  the  same  till  April  14th,  when  the  dyspnoea  became  more  marked  and  the 
action  of  the  heart  rapid  and  tumultuous.  The  epigastric  pain,  distension,  and 
tenderness  continued ;  the  percussion  sound  was  dull  over  the  lower  part  of  the 
chest ;  the  dyspnoea  became  rapidly  worse,  although  the  pulse  had  considerable 
Tolume ;  and  at  5  p.  M.  death  occurred.  At  the  autopsy  about  one  ounce  of  tur- 
bid serum,  with  a  soft  deposit  of  fibrin,  was  found  in  the  pericardium.  Each 
pleural  cavity  contained  from  six  to  eight  ounces  of  transparent  serum,  and  both 
lungs  were  readily  inflated,  except  a  little  of  the  posterior  portions  of  both  lower 
lobes ;  no  fibrinous  exudation  over  the  lungs.  The  liver  extended  four  inches 
below  the  margin  of  the  ribs,  and  upon  its  convex  surface  in  the  epigastrium, 
corresponding  with  the  seat  of  the  pain,  was  a  rough  patch  of  fibrin  about  one 
and  a  half  inches  in  diameter.  The  bronchial  mucous  membrane  was  moderately 
injected,  as  was  also  that  of  the  colon,  and  the  kidneys  appeared  hypersemic. 

Among  the  serous  inflammations  which  complicate  or  follow  scarlet  fever, 
pleuritis  is  one  of  the  most  important.  It  usually  begins  in  the  desquamative 
stage,  and  is  frequently  suppurative,  on  account  of  the  feeble  state  of  the 


COMPLICATloyS  AND  SEQUKLjE.  2!ji) 

patient  when  it  commences.  It  has,  in  my  practice,  been  tedious,  as  all 
empyemas  are,  and  it  does  not  differ  in  its  clinical  history  from  the  idiopathic 
disease.  I  have  met  cases  of  scarlatinous  empyema  in  which,  from  opposition 
of  the  family  or  for  other  reasons,  thoracentesis  was  not  performed  and  death 
occurred  ;  others  in  which  this  operation  effected  a  cure  ;  and  one,  at  least, 
in  which  the  patient  recovered  by  escape  of  pus  througii  a  bronchial  tube  and 
its  expectoration.  The  pleuritis  is  seldom  latent,  or  so  masked  by  the  symp- 
toms of  the  general  disease  that  it  is  liable  to  be  overlooked.  On  the  other 
hand,  the  cough,  embarrassment  of  respiration,  and  pain  referred  to  the  affected 
.side  render  diagnosis  easy. 

Dilatation  of  the  heart  is  common  in  grave  cases  of  scarlet  fever,  such 
cases  as  are  properly  termed  malignant.  It  is  indicated  by  a  feeble  and  quick 
pulse.  Acute  infectious  maladies,  especially  those  of  a  malignant  type  and 
accompanied  by  a  marked  rise  in  temperature,  are  very  liable  to  cause  paren- 
chymatous degenerations  in  organs,  prominent  among  which  is  granulo-fatty 
degeneration  of  the  muscular  fibres  of  the  heart.  This  weakens  very  much 
the  contractile  power  of  the  heart.  But  early  in  malignant  cases,  probably 
before  the  muscular  fibres  are  damaged,  the  contractile  power  of  the  heart  is 
feeble  from  impaired  innervation,  the  result  of  the  general  weakness.  Hence 
this  organ,  when  weakened  by  structural  change  and  insufficiently  stimulated 
through  diminished  innervation,  may  not  fully  empty  itself  during  the  systole, 
and  consequently  it  becomes  dilated.  Dilatation  of  the  heart  and  imperfect 
contraction  of  its  auricular  and  ventricular  walls  facilitate  the  formation  of 
clots  in  the  cavities  of  the  heart ;  and  this  appears  to  be  the  immediate  cause 
of  death  in  not  a  few  instances.  An  ante-mortem  clot  occurring  in  any  of 
the  cavities  of  the  heart  necessarily  seriously  obstructs  the  circulation,  unless 
it  be  of  small  size.  Hence  the  dyspnoea,  which  may  occur  suddenly,  and  the 
change  of  pulse  to  one  of  marked  feebleness  and  frequency.  Large,  firm 
white  clots  are  most  frequently  found  in  the  right  cavities.  They  interlace 
with  the  chordce  tendinea3,  lie  even  within  the  auriculo-ventricular  opening, 
and  send  prolongations  into  the  pulmonary  artery  and  the  cavae.  Associated 
with  the  white  clots  are  dark,  soft  clots  and  fluid  blood.  The  left  cavities 
may  be  contracted  and  empty,  or  they  may  contain  dark,  soft  clots  or  white 
ante-mortem  clots.  Clots  in  the  left  ventricle  are  sometimes  prolonged  into 
the  aorta  as  far  as  the  brachiocephalic  branches,  while  those  in  the  left  auricle 
may  extend  to  the  pulmonary  veins.  If  dilatation  of  the  heart  be  so  great 
that  clots  form  in  its  cavities,  .speedy  death  is  probable.  Sometimes  a  patient 
passes  through  scarlet  fever  and  appears  in  a  fair  way  to  recover,  when  he 
succumbs  to  some  exhausting  sequel  distinct  from  the  heart,  and  at  the 
autopsy  the  heart  is  found  dilated  and  containing  whitish  clots,  which  are 
probably  ante-mortem,  and  which  hastened  death  by  obstructing  the  circula- 
tion. Under  such  circumstances  this  state  of  the  heart  is  attributable  in 
great  measure  to  the  complication  which  has  weakened  its  contractile  power. 

The  following  was  a  case  in  point ;  it  occurred  in  the  New  York  Found- 
ling Asylum  : 

Cas£  6. — R.  A ,  aged  three  years,  had  scarlet  fever,  beginning  March 

23,  1882.  The  symptoms  were  favorable  at  first,  but  serious  complications  and 
sequelae  occurred,  which  were  fatal.  The  record  of  April  18th  reads :  "  Appears 
well  nourished,  but  is  anaemic ;  has  otorrhoea ;  no  cedema ;  skin  desquamating  ; 
dulness  on  percussion  over  upper  third  of  right  side  of  chest,  anteriorly  and  pos- 
teriorly ;  mucous  rales  and  rude  breathing  over  same  area  ;  fine  rales  posteriorly 
over  lower  part  of  left  side  of  chest;  pulse  160,  respiration  68,  temp.  101?"^." 
April  20th,  is  feeble  and  takes  nutriment  with  difficulty ;  tongue  thickly  coated ; 
pulse  160,  respiration  68,  temp.  101 -|°.  April  26th,  condition  about  the  same  as 
at  last  record,  but  he  is  evidently  weaker ;  the  lips  are  ulcerated  and  fauces  still 


300  SCARLET  FEVER. 

swollen.  May  2d,  cannot  speak  distinctly ;  a  brownish,  foul-smelling  secretion 
lodges  on  the  spoon  used  in  depressing  the  tongue ;  left  side  of  face  swollen.  On 
the  following  night  eight  convulsions  occurred,  attended  by  orthopncea  and 
mucous  rales  in  the  chest  from  pulmonary  oedema.  Diarrhoea  supervened  and 
the  patient  died  about  midnight. 

Autopsy. — Body  moderately  wasted  and  very  white ;  several  dark-blue  spots  on 
scalp  and  face  from  hemorrhages  underneath.  A  careful  examination  showed 
the  presence  of  broncho-pneumonia  in  each  lung,  with  considerable  infiltration 
of  the  walls  of  the  bronchi  and  cylindrical  dilatation  of  many  of  them  ;  cavities, 
of  the  heart  dilated,  so  that  this  organ  appears  much  enlarged,  and  its  shape 
approaches  the  globular;  its  apex  is  rounded  or  obtuse;  transverse  diameter  of 
the  right  ventricle,  when  its  walls  were  open  and  drawn  apart,  was  three  and  a 
fourth  inches ;  that  of  the  left  ventricle,  three  and  a  quarter  inches.  Similar  meas- 
urements of  the  heart  of  another  child  of  about  the  same  age,  believed  to  be  normal,, 
were  about  one  inch  less  in  each  direction.  All  the  cavities  contain  white  firm 
clots  along  with  soft  dark  clots.  Lesions  observed  in  other  organs  were  carefully 
noted,  some  of  which  were  serious ;  but  the  immediate  cause  of  death  appeared 
to  be  imperfect  contraction  of  the  heart  and  the  formation  of  clots  in  its  cavities. 

There  can  be  little  doubt  that  nephritis  in  its  milder  form  is  much  more 
common  than  was  formerly  supposed.  A  few  years  since  little  attention  was 
given  by  a  large  proportion  of  physicians  to  the  state  of  the  kidneys,  and  the 
urine  was  not  examined  till  dropsy  made  its  appearance,  which  only  occurs 
in  the  more  severe  forms  of  nephritis  and  is  a  late  symptom.  It  is  now 
known  that  catarrh  of  the  renal  tubes  frequently  occurs  in  a  mild  form  early 
in  scarlet  fever,  without  causing  albuminuria,  dropsy,  or  any  notable  symp- 
tom. It  may  produce  a  smoky  color  of  the  urine,  and  the  appearance  in  it 
of  granular  epithelial  cells,  with  an  increase  of  mucus,  but  no  albumen. 
With  careful  treatment  and  no  exposure  to  cold  the  renal  catarrh  abates 
with  the  decline  of  the  scarlet  fever.  It  is  scarcely  severe  enough  to  merit 
the  name  desquamative,  tubal,  or  parenchymatous  nephritis,  though  it  is  a 
mild  form  of  the  same  pathological  state.  Steiner  says,  as  the  result  of 
many  careful  examinations  of  cases,  that  hyperaemia  of  the  kidneys  was  always 
present  in  those  who  died  early  in  scarlet  fever,  and  that  in  a  certain  propor- 
tion of  these  cases  catarrh  of  the  renal  tubules  was  present  in  addition  to  the 
congestion.  Even  in  some  who  died  on  the  second  or  third  day  he  found 
cloudiness  of  the  epithelium  in  the  renal  tubes,  although  the  urine  had  not 
indicated  such  a  change.  The  opinion  has  even  been  expressed  that  catarrh 
of  the  renal  tubes  is  as  common  in  scarlet  fever  as  that  of  the  bronchial 
tubes  in  measles ;  that  is,  it  is  a  uniform  element  in  the  disease  ;  but  this 
appears  to  be  an  exaggerated  statement,  for  others  have  failed  to  find  any 
evidence  of  renal  catarrh  in  certain  cases. 

The  nephritis  which  gives  rise  to  .symptoms,  and  therefore  interests  the 
practitioner,  commonly  begins  in  the  declining  period  of  scarlet  fever  or  dur- 
ing the  desquamative  stage,  and  is  in  many  instances  plainly  attributable  to 
exposure  to  cold  or  to  currents  of  air.  It  originates  either  during  this  period, 
or,  if  it  have  previously  existed  as  a  mild  renal  catarrh,  it  now  becomes  aggra- 
vated. Dropsy,  which  always  attracts  attention,  does  not  occur  till  the  nephri- 
tis has  continued  for  some  time. 

Why  nephritis,  with  the  subsequent  dropsy,  so  frequently  occurs  after 
scarlet  fever  is  not  fully  understood.  Rilliet  and  Barthez  attribute  it  to  dis- 
turbance of  the  function  of  the  skin.  The  fact  has  long  been  observed  that 
the  kidneys  become  affected  nearly  if  not  quite  as  frequently  after  mild  as 
severe  cases.  Indeed,  the  chief  danger  in  mild  cases,  when  the  patients  are 
but  a  short  time  in  bed  and  are  soon  allowed  to  go  about,  is  from  the  nephri- 
tis. Chilling  the  surface  and  checking  cutaneous  transpiration  appear  to  be 
the  immediate  cause  of  this  inflammation  in  a  considerable  proportion  of 


COMPLICATIONS  AND  SEQUELJFJ.  301 

cases.  Therefore,  severe  attacks  of  scarlet  fever  witli  abundant  rasli  and  des- 
quamation, which  require  the  patient  to  be  kept  in  bed  the  proper  time  and 
in  a  warm  room  two  or  three  weeks,  appear  to  be  less  frequently  followed  by 
this  renal  disease  than  are  milder  cases  which  are  more  carelessly  treated. 

The  most  thorough  and  minute  microscopic  examinations  of  the  state  of 
the  kidneys  in  scarlet  fever  which  have  come  to  my  notice  were  those  of  K. 
Klein,  published  in  the  Loud.  Path.  Soc.  Trans,  and  illustrated  by  micro- 
scopic drawings.  It  appears  from  these  examinations  that  the  changes  in  the 
kidneys  are  complex,  among  which  we  recognize  both  those  of  parenchyma- 
tous or  desquamative  nephritis  and  interstitial  nephritis  ;  but  we  would  infer 
that  the  interstitial  nephritis  is  mild  in  degree  and  quite  subordinate,  or  else 
confined  to  portions  of  the  organ,  from  the  fact  that  so  'many  permanently 
and  fully  recover.  The  following  is  a  resume  of  Klein's  examinations  in 
twenty-three  cases.  We  conclude  from  the.se  microscopic  researches  that  the 
anatomical  changes  of  both  parenchymatous  and  interstitial  nephritis  are 
commonly  present  in  greater  or  less  degree  in  cases  of  scarlet  fever.  If 
they  are  mild  or  confined  to  portions  of  the  kidneys,  no  symptoms  occur ; 
but  if  they  are  sufficient  in  extent  or  degree  to  impair  the  function  of  these 
organs,  then  symptoms,  as  albuminuria,  diminution  of  urine,  etc.,  appear. 

1.  Parenchj/matous  Nt'phritis,  ProUftration  of  Nuclei.,  Hyaline  Degenera- 
tion of  Arterioles. —  The  Glomeriilo-nepliritis  of  Klehs. — Klein  found  increase 
of  nuclei  (probably  epithelial)  in  the  glomeruli,  and  hyaline  degeneration 
of  the  intinia  of  minute  arteries,  especially  marked  in  the  afferent  arte- 
rioles of  the  Malpighian  bodies.  The  intima  of  these  vessels  was  in  places 
so  swollen  as  to  resemble  cylindrical  or  spindle-shaped  hyaline  masses,  and 
cause  narrowing  of  the  luraina  of  the  vessels  in  which  this  degeneration 
occurred.  Klein  observed  in  some  specimens  so  great  hyaline  degeneration 
of  the  capillaries  of  the  Malpighian  bodies  that  circulation  through  them  was 
obstructed.  In  the  more  advanced  or  protracted  cases  this  hyaline  substance 
in  the  glomeruli  began  to  assume  a  fibrous  appearance.  Bowman's  capsule 
was  considerably  thickened.  This  hyaline  degeneration  of  the  3Ialpighian 
bodies  Klein  discovered  in  the  earliest  cases  which  fell  under  his  obser- 
vation. 

Also  in  the  earliest  cases  the  multiplication  or  germination  of  the  nuclei 
of  the  muscular  coat  of  the  arterioles  was  observed,  with  a  corresponding 
increase  in  the  thickness  of  the  walls  of  these  vessels.  This  change  in  the 
muscular  element  was  found  in  the  arterioles  in  different  parts  of  the  kidney, 
but  it  was  most  conspicuous  in  these  vessels  at  their  point  of  entrance  into 
the  Malpighian  bodies  ;  and  it  was  distinctly  noticed  in  other  arterioles,  both 
in  the  cortex  and  in  the  base  of  the  pyramids. 

In  the  glandular  portion  of  the  kidneys  other  anatomical  alterations  were 
observed,  indicating  parenchymatous  nephritis.  There  were  swelling  of  the 
epithelial  lining  of  the  convoluted  tubes  ;  multiplication  of  nuclei  of  epithe- 
lial cells,  especially  in  ascending  tubules,  which  lay  close  to  the  afferent  arte- 
rioles of  Malpighian  corpuscles  ;  granular  matter,  and  even  blood,  in  the 
cavity  of  Bowman's  capsule  and  in  the  convoluted  tubes ;  cloudy  swelling 
and  granular  disintegration  of  epithelium  in  some  parts  of  the  convoluted 
tubes  ;  detachment  of  epithelium  from  the  membrane  of  larger  ducts  of  the 
pyramids  in  some  cases.  These  parenchymatous  changes  are  already  known 
to  the  profession  through  the  observations  and  writings  of  Dickinson,  Fen- 
wick,  Johnson,   Simon,  and  others. 

Klein,  in  commenting  on  the  hyaline  degeneration  which  he  observed, 
states  that  Neelsen  found  the  walls  of  the  capillaries  of  the  pia  mater  thick- 
ened, highly  refractive,  and  of  a  lardaceous  appearance  in  certain  acute  infec- 
tious maladies,  as  variola,  typhoid  fever,  measles,  and  in  one  case  scarlet 


302  SCARLET  FEVER. 

fever.'  Usually,  only  a  small  portion  of  the  capillaries  were  thus  affected, 
most  frequently  at  the  point  of  division  into  branchlets.  In  a  few  instances 
Neelsen  noticed  degeneration  of  arterioles  extending  a  considerable  distance, 
with  fusion  of  the  intima,  media,  and  adventitia,  and  chemical  examination 
showed  that  the  substance  produced  by  this  degeneration  had  similar  proper- 
ties to  elastic  tissue.  Although  the  examinations  by  Neelsen  relate  to  the 
pia  mater,  two  of  his  observations  are  especially  interesting :  first,  that  the 
hyaline  change  affects  chiefly  vessels  near  their  point  of  branching ;  and^ 
secondly,  that  the  hyaline  substance  is  of  the  nature  of  elastic  tissue,  for  in 
the  kidney  in  scarlatinous  nephritis  the  arterioles  undergo  the  change  in 
question  chiefly  near  their  point  of  branching  into  the  capillaries  of  the 
glomerulus ;  and  the  intima  being  the  part  which  undergoes  the  hyaline 
change,  it  is  probable,  in  the  opinion  of  Klein,  that  the  same  substance  is 
produced  by  the  degeneration  in  walls  of  the  vessels  of  the  kidney  which 
Neelsen  observed  in  the  pia  mater,  and  therefore  that  it  is  of  the  nature  of 
elastic  tissue. 

This  hyaline  degeneration  of  the  arterioles  is  also  very  marked  in  the 
spleen  in  scarlet  fever ;  and  in  studying  the  minute  anatomy  of  the  intestines 
and  spleen  in  typhoid  fever  Klein  has  found  the  same  degeneration  of  the 
intima  of  the  minute  vessels.  He  believes  that  this  hyaline  change  and  the 
proliferation  of  muscle-nuclei  which  thus  occur  at  an  early  period  in  scarlet 
fever  in  the  renal  vessels  when  the  kidneys  become  affected  are  due  to  an 
irritating  cause  acting  similarly  to  that  in  typhoid  fever. 

Klein  calls  attention  to  the  interesting  examinations  of  the  scarlatinous 
kidney  made  by  Klebs,  who  attributed  the  diminished  urination  and  the 
ursemic  poisoning  in  certain  cases  in  which  the  kidneys  do  not  exhibit  any 
marked  change  to  the  naked  eye  to  what  he  designates  glomerulo-nephritis. 
Klebs  says  :  "  In  the  post-mortem  examination  the  kidneys  are  found  slightly 
or  not  at  all  enlarged,  firm,  ....  the  parenchyma  very  hyperaemic.  Only 
the  glomeruli  appear,  on  close  inspection,  pale  like  small  white  dots.  The 
urinary  tubes  are  often  not  changed  at  all.  Occasionally  the  convoluted 
tubes  are  slightly  cloudy.  The  microscopic  examination  shows  that  there 
are  neither  interstitial  changes  nor  proliferation  of  epithelium,  the  so-called 
renal  catarrh  generally  supposed  to  be  present  in  these  conditions  on  account 
of  the  absence  of  other  perceptible  derangements ;  and  there  seems,  there- 
fore, leaving  out  the  glomeruli,  the  congestion  of  the  kidneys  alone  to  remain 
to  account  for  the  symptoms  during  life."  But  that  mere  congestion  is 
insufiicient  to  produce  the  symptoms  appears  from  the  fact  that  it  does  not 
cause  them  under  other  circumstances.  Klebs  finds,  "  on  microscopic  exam- 
ination of  the  glomerulus,  the  whole  space  of  the  capsule  filled  with  small 
somewhat  angular  nuclei,  imbedded  in  a  finely  gi-anular  mass.  The  vessels 
of  the  glomerulus  are  almost  completely  covered  by  nuclear  masses." 

Klein,  commenting  on  these  examinations  by  Klebs,  states  that  in  all 
early  cases  which  he  examined  he  observed  great  abundance  of  nuclei  of  the 
glomeruli,  but  a  condition  like  that  described  and  figured  by  Klebs ^  he  has 
seen  in  only  a  few  glomeruli ;  for  a  general  state  of  these  bodies,  as  described 
by  this  observer,  and  such  an  excessive  proliferation  of  the  nuclei  that  the 
blood-vessels  are  completely  compi-essed,  was  not  seen  in  one  of  the  twenty- 
three  cases.  Klein  therefore  questions  whether  the  diminished  urination  and 
retention  of  urea  in  scarlet  fever,  when  the  kidneys  do  not  exhibit  any  con- 
spicuous catarrhal  or  other  change,  is  due,  unless  in  exceptional  instances,  to 
compression  of  the  vessels  of  the  glomeruli  by  nuclear  germination,  but 
believes,  rather,  that  the  obstructed  circulation,  and  consequent  diminished 
urinary  excretion,  are  largely  due  to  the  changed  state  of  the  arterioles.. 

^  Archiv  der  Heilkunde,  1876.  ^  Handbuch  der  Pathol.,  p.  646,  fig.  72. 


COMPLICATIONS  AND  SEQUEL JE.  303 

Kloiii  adds  that  perliaps  undue  contractiou  ol'  the  arterioles,  tlirougli  stimu- 
lation by  the  blood-irritant,  may  also  be  a  factor  in  causing  arrest  of  cir- 
culation in  the  Malpighian  corpuscles.  As  regards  cases  that  perished 
early,  he  found  the  parenchymatous  change  slight,  so  that  a  careful  ex- 
amination was  i-equired  iti  order  to  detect  cloudy  swelling  and  granular 
degeneration. 

2.  Iidentitlal  Nephritis. — A  second  set  of  changes  Klein  observed  in 
ca.ses  that  died  about  the  ninth  or  tenth  day.  In  such  cases  he  found 
changes  due  to  interstitial,  in  addition  to  those  produced  by  parenchymatous, 
nephritis.  Round  cells,  lym})hoid  cells,  or  whatever  else  they  should  be 
called,  were  seen  in  the  connective  tissue  of  the  kidneys.  In  the  kidneys 
of  tho.se  that  died  at  the  end  of  the  first  week  after  the  commencement  of 
nephritis  infiltration  with  round  cells  was  observed  in  the  connective  tissue 
around  the  large  vascular  trunks.  At  a  later  stage  this  infiltration  had 
extended  into  the  bases  of  the  pyramids  and  into  the  cortex.  The  gradual 
increase  in  extent  and  intensity  of  this  infiltration  was  so  decided  in  the 
cases  which  Klein  observed  that  he  has  no  hesitation  in  concluding  that 
when  interstitial  nephritis  occurs  it  begins  about  the  end  of  the  first  week, 
in  the  manner  already  stated — to  wit,  as  a  slight  infiltration  of  the  tissues 
around  the  large  vascular  trunks,  and  gradually  extends,  so  that  portions 
of  the  cortex,  and  rarely  portions  of  the  base  of  the  pyramids,  are  changed 
into  firm,  pale,  round-cell  tissue  in  which  the  original  tubes  of  the  cortex 
become  lost. 

The  infiltration  of  the  cortex  with  round  cells,  beginning  at  the  roots  of 
the  interlobular  vessels,  spreads  rapidly  toward  the  capsule  of  the  kidney, 
and  laterally  among  the  Convoluted  tubes  around  the  Malpighian  bodies.  .  . 
.  .  In  the  course  of  this  process  considerable  parts  of  the  peripheral  cortex, 
occasionally  of  a  cuneiform  shape,  with  the  base  nearest  the  capsule  of  the 
kidney,  become  changed  into  whitish,  firm,  bloodless,  cellular  masses,  in 
which  Malpighian  corpuscles  and  urinary  tubes  are  only  imperfectly  recog- 
nized, being  more  or  less  degenerated.  In  some  cases  attended  by  this  infil- 
tration of  the  cortex  Klein  observed  a  more  or  less  dense  reticulation  of 
fibres,  especially  around  the  interlobular  arteries,  containing  in  its  meshes 
lymph-cells,  chiefly  uninuclear. 

In  a  child  of  five  years  that  died  after  a  sickness  of  thirteen  days  Klein 
found  evidence  of  intense  interstitial  inflammation,  and  also  emboli,  consist- 
ing of  fibrin  with  a  few  cells,  in  the  arteries,  both  in  those  of  large  size 
and  in  the  arterioles,  chiefly  where  they  enter  the  Malpighian  corpuscles. 
He  states  that  in  the  specimens  which  he  examined  the  more  intense  the 
degree  of  interstitial  change,  the  greater  was  the  enlargement  of  the  kid- 
neys, and  the  more  distinct  also  were  the  evidences  of  parenchymatous 
nephritis  in  the  urinary  tubes,  which  either  contained  casts  or  were  in  pro- 
cess of  destruction.  By  being  crowded  with  inflammatory  products,  espe- 
cially cells,  the  Malpighian  corpuscles  were  obliterated,  undergoing  fibrous 
degeneration.  A  very  curious  fact  observed  was  the  deposit  of  lime  in  the 
urinary  tubes,  first  of  the  cortex,  and  then  also  of  the  pyramids,  at  an  early 
stage  of  scarlet  fever,  when  the  kidneys  otherwise  showed  only  slight  change. 
Several  observers,  as  Biermer,  Coats,  and  Wagner,  have  each  described  a  case 
of  scarlet  fever  with  interstitial  nephritis,  which  they  consider  unusual ;  but 
Klein  has  apparently  demonstrated,  as  we  have  seen,  by  a  large  number  of 
microscopic  examinations,  that  this  form  of  nephritis  is  common  after  the 
ninth  or  tenth  day. 

Nephritis,  in  proportion  to  its  extent  and  gravity,  is  accompanied  by 
languor,  febrile  movement,  thirst,  loss  of  appetite  and  strength.  At  first  the 
patient  experiences  but  slight  pain  in  the  head  or  elsewhere,  and  the  quan- 


304  SCARLET  FEVER. 

tity  of  urine  is  not  notably  diminished  ;  but  as  the  disease  continues  urination 
becomes  less  frequent  and  the  urine  more  scanty.  Albuminuria  occurs,  while 
the  urea  is  only  partially  excreted,  and  therefore  it  accumulates  in  the  blood. 
If  the  nephritis  be  so  severe  or  protracted  that  this  principle  accumulates  to 
a  certain  extent,  grave  symptoms  occur,  as  headache,  vomiting,  apathy  or 
restlessness,  and,  more  dangerous  than  all,  eclampsia,  which  is  not  unusual 
in  these  cases.  Microscopic  examination  of  the  urine  shows  the  presence  in 
this  liquid  of  blood-corpuscles,  granular  epithelial  cells,  and  hyaline  or  granular 
casts  or  both.  The  specific  gravity  of  the  urine  is  diminished.  But  a 
large  quantity  of  albumen  in  the  urine  may  render  the  specific  gravity  as 
high  or  higher  than  in  health. 

The  altered  state  of  the  blood  soon  gives  rise  to  transudation  of  serum, 
first  observed  in  most  cases  as  an  anasarca  occurring  in  the  feet  and  ankles. 
The  oedema,  if  not  checked  by  treatment  or  through  mildness  of  the  disease, 
extends  over  the  limbs,  scrotum,  and  sometimes  upon  the  trunk.  It  is  well 
if  the  dropsy  remain  limited  to  the  subcutaneous  connective  tissue,  but, 
unfortunately,  it  is  apt  to  occur,  if  the  nephritis  continue,  in  and  around  the 
internal  organs,  producing,  mentioned  in  the  order  of  frequency,  pulmonary 
oedema,  effusion  into  the  pleural  and  peritoneal  cavities,  the  pericardium,  the 
encephalon,  and  lastly  into  the  connective  tissue  of  the  larynx,  causing  that 
very  fatal  complication,  oedema  of  the  glottis.  Although  this  is  the  common 
order  in  which  dropsies  occur,  exceptions  are  not  infrequent.  Even  the  ana- 
sarca may  not  be  the  first  to  appear,  although  in  the  vast  majority  of  cases 
it  has  the  precedence.  Thus,  Rilliet  relates  the  case  of  a  boy  of  five  years 
who  twenty  days  after  the  occurrence  of  scarlet  fever,  and  six  hours  after 
the  appearance  of  bloody  and  albuminous  urine,  had  double  hydrothorax, 
rapidly  developed.  As  long  as  the  hydrothorax  continued  no  anasarca  was 
observed,  but  as  it  declined  anasarca  appeared.  Legendre  cites  a  case  in 
which  oedema  of  the  lungs  occurred  without  anasarca  or  other  dropsy. 
Occasionally,  the  anasarca  and  internal  dropsies  take  place  nearly  simulta- 
neously. The  nephritis  and  consequent  serous  effusions  usually  appear 
within  three  weeks  after  scarlet  fever  ends,  but  cases  occur  in  which  the 
effusions  are  first  observed  as  late  as  the  fourth  and  fifth  weeks.  The  patient 
may  be  considered  to  possess  immunity  from  this  sequel  if  he  have  reached 
the  close  of  the  fifth  week  after  the  abatement  of  scarlet  fever  without  its 
occurrence. 

The  dropsy  is  usually  acute,  but  it  may  assume  the  chronic  form,  since 
the  nephritis  which  causes  it,  happily  curable  in  most  instances,  may,  if 
neglected,  become  chronic.  Whether  the  dropsy  in  itself  involve  danger 
depends  in  great  part  on  its  location.  Anasarca  and  ascites  may  exist  a  long 
time  with  little  suffering  or  danger,  but  a  small  amount  of  serum  in  certain 
other  localities  causes  alarming  symptoms  and  speedy  death.  (Edema  of  the 
lungs,  hydro-pericardium,  oedema  of  the  glottis,  and  intracranial  effusions 
are  always  dangerous,  and  the  last  two  are  sometimes  fatal  within  twenty- 
four  to  forty-eight  hours.  (Edema  of  the  lungs  has  been  fatal  within 
twelve  hours  from  the  appearance  of  the  first  symptoms  of  obstructed  respi- 
ration. 

Cerebral  symptoms  occurring  during  scarlatinous  nephritis  are  probably 
sometimes  due  to  the  irritating  effect  of  the  retained  urea  on  the  nervous 
centre.  In  other  cases  the  cause  appears  to  be  cerebral  oedema  or  compres- 
sion of  the  brain  by  effusion  of  serum  within  the  ventricles  and  upon  the 
surface  of  the  brain.  Headache,  dull  or  severe,  dilatation  of  the  pupils  or 
their  oscillation  in  a  uniform  light,  vomiting  with  little  apparent  nausea,  are 
common  symptoms  of  scarlatinous  nephritis  when  it  has  continued  a  few  days, 
and  the  excretion  of  urea  is  so  diminished  that  this  substance  begins  to  exert 


ANATOMICAL  CHARACTERS.  305 

its  poisonous  effect  on  tlie  system.  Such  symptoms  are  frequently  followed 
by  somnolence  threatening  coma  or  by  eclampsia,  unless  the  patients  are 
promptly  and  properly  treated.  In  some  patients  that  die  of  scarlatinous 
nephritis,  death  occurring  in  convulsions  or  coma,  no  appreciable  lesions  are 
observed  within  the  cranium,  unless  more  or  less  congestion,  the  fatal  ending 
being  attributable  to  the  uraimia.  In  other  instances  we  find  an  effusion  of 
serum  within  the  ventricles  or  upon  the  surface  of  the  brain.  Although  the 
symptoms  in  scarlatinous  nephritis  and  uraemia  may  appear  very  unfavorable, 
the  prognosis  is  usually  good  under  prompt  and  appropriate  treatment.  Thus 
severe  convulsions  and  a  degree  of  somnolence  that  bordered  on  coma  may 
abate,  and  convalescence  be  fully  established  within  a  few  days.  Rilliet  and 
Barthez  announce  ten  recoveries  in  thirteen  patients  affected  with  convulsions 
due  to  this  renal  affection. 

Anatomical  Characters. — Scarlet  fever  being,  as  we  have  seen,  a  con- 
stitutional febrile  disease  of  an  ataxic  nature,  and  accompanied  by  certain 
inflammations,  necessarily  affects  the  composition  of  the  blood  ;  but  since  this 
disease  varies  so  greatly  in  type  or  severity,  the  state  and  appearance  of  this 
liquid  also  vary.  At  the  autopsies  of  the  more  malignant  cases  we  find  the 
blood  dark  and  fluid,  with  small,  soft,  and  dark  clots  in  the  heart  and  large 
vessels.  In  other  cases  the  clots  are  large,  firm,  and  solid,  as  described  in  a 
preceding  page.  In  malignant  cases  that  end  fatally  Rilliet  and  Barthez 
state  that  both  the  large  and  small  vessels  of  the  cerebral  meninges  and  the 
brain  are  found  hypera^mic,  but  in  a  variable  degree.  In  those  who  die  in 
coma,  preceded  by  delirium  or  convulsions,  during  the  eruptive  stage  the 
intracranial  congestion  is  usually  marked,  with  perhaps  some  transudation 
of  serum,  but  without  inflammatory  lesions.  The  fibrin  in  scarlet  fever 
remains  in  about  normal  proportion,  except  as  it  is  increased  by  inflamma- 
tory complications.  Andral  found  an  increase  in  the  proportion  of  blood- 
corpuscles  from  127  to  136  parts  in  1000. 

The  respiratory  apparatus,  except  the  Schneiderian  membrane,  is  usually 
normal  when  no  complications  exist.  Samuel  Eenwick  ^  made  post-mortem 
examinations  in  sixteen  cases  of  scarlet  fever,  and  concludes  from  them  that 
inflammation  of  the  mucous  membrane  of  the  stomach  and  intestines  occurs 
like  that  of  the  skin,  followed  by  desquamation  of  the  epithelial  cells,  like 
that  of  the  epidermis.  I  have  had  the  opportunity  of  examining  the  stom- 
ach and  intestines  of  those  who  died  of  scarlet  fever  in  the  eruptive  stage, 
and  have  not  found  any  unusual  hyperaemia  of  the  gastro-intestinal  surface, 
except  when  gastro-intestinal  inflammation,  usually  indicated  by  diarrhoea, 
had  occurred  as  a  complication. 

In  some  cases  the  abdominal  organs  exhibit  changes  which  suggest  a 
resemblance  to  typhoid  fever.  The  spleen  is  enlarged  and  somewhat  soft- 
ened, and  Peyer's  patches  and  the  solitary  glands  are  thickened  and  promi- 
nent, but  less  in  degree  than  in  typhoid  fever.  The  mesenteric  glands  also 
are  in  a  state  of  hyperplasia.  In  other  patients  these  parts  appear 
normal. 

Klein  made  microscopic  examination  of  the  liver  in  eight  cases,  and  states 
that  he  found  granular  opaque  swelling  of  liver-cells,  and  changes  in  the 
internal  and  middle  coats  of  certain  arteries  similar  to  those  observed  in  the 
kidneys  which  have  been  described  above.  He  also  found  evidences  of  inter- 
stitial inflammation,  as  an  increase  of  round  cells  and  connective  tissue  in  the 
liver.  He  remarks  also  that  he  observed  hyaline  degeneration  of  the  intima 
of  arteries  in  the  spleen.  Rilliet  and  Barthez  state  that  swelling  and  soften- 
ing of  the  spleen  are  exceptional  in  scarlet  fever,  but  are  sufficiently  common 
to  merit  attention.     In  post-mortem  examinations  which  I  have  witnessed 

^  London  Lancet,  Julv  23,  1864. 
20 


306  SCARLET  FEVER. 

nothing  noteworthy  has  appeared  to  the  naked  eye  in  the  state  of  the  liver, 
nor  ordinarily  in  that  of  the  spleen. 

The  efflorescence,  though  one  of  the  anatomical  characters,  has  perhaps 
been  sufficiently  described  in  the  foregoing  pages.  It  begins  over  the  neck, 
chest,  and  groins  as  numerous  reddish  points  not  larger  than  a  pin's  head, 
closely  crowded  together,  but  with  skin  of  normal  color  between.  It  is  esti- 
mated that  the  aggregate  efflorescence  and  aggregate  normal  skin  over  a  given 
area  are  about  equal.  If  the  cutaneous  circulation  be  active  and  the  rise 
of  temperature  considerable,  these  spots  extend  and  coalesce,  producing  an 
efflorescence  like  erythema  or  like  the  hue  of  a  boiled  lobster,  to  which  it 
has  been  likened.  The  efflorescence,  less  upon  the  face  than  upon  the  trunk, 
contrasts  in  this  respect  with  that  of  measles,  in  which  the  rash  is  full  in  the 
face,  often  causing  some  swelling  of  the  features.  It  is  also  less  upon  the 
palmar  and  plantar  surfaces  than  elsewhere.  It  scarcely  causes  any  percep- 
tible elevation  of  the  skin,  but  in  certain  localities,  as  upon  the  backs  of  the 
hands  and  upon  the  forearms,  it  communicates  the  sensation  of  slight  rough- 
ness. The  seat  of  the  efflorescence  is  mainly  in  the  superficial  layers  of  the 
skin,  but  it  is  said  that  it  sometimes  has  occurred  upon  a  cicatrix,  as  that 
from  a  burn.  In  the  robust  and  in  favorable  cases  in  which  the  circulation 
is  active  the  rash  has  a  scarlet  hue,  and  when  the  cutaneous  capillaries  are 
emptied  and  the  skin  rendered  pale  by  pressure  with  the  fingers,  the  circula- 
tion immediately  returns  when  the  pressure  is  removed.  In  malignant  cases 
the  color  is  not  scarlet,  but  dusky  red,  and  so  sluggish  is  the  capillary  circula- 
tion that  the  skin  when  pressed  upon  recovers  the  blood  very  slowly.  In 
grave  cases  also  extravasation  of  blood  in  minute  points  or  transudation  of  its 
coloring  matter  sometimes  occurs  in  portions  of  the  surface  when,  of  course, 
decolorization  is  not  fully  produced  by  pressure.  In  cases  ending  fatally, 
during  the  eruptive  stage  the  efflorescence  may  entirely  disappear  in  the 
cadaver,  or  it  remains  upon  parts  of  the  surface,  especially  depending  por- 
tions. Desquamation  is  attributable  to  the  exaggerated  proliferation  of  the 
epidermis  and  the  loosening  of  its  attachment  by  the  inflammation. 

Diagnosis. — In  the  commencement  of  scarlet  fever,  prior  to  the  eruption, 
no  symptoms  or  appearances  exist  which  enable  us  to  make  a  positive  diag- 
nosis. Positive  statement  in  reference  to  the  nature  of  the  attack  should  be 
deferred,  for  the  credit  of  the  physician.  Still,  if  a  child  with  no  appreciable 
local  disease  sufficient  to  cause  the  symptoms  a  few  days  after  exposure  to 
scarlet  fever,  or  during  an  epidemic  of  this  malady,  be  suddenly  seized  with 
fever,  the  pulse  rising  to  110,  120,  or  more,  and  the  temperature  to  102°, 
103°,  or  105°,  scarlatina  should  be  suspected.  The  diagnosis  is  rendered  more 
certain  at  this  early  stage  if  vomiting  occur,  and  especially  if  the  fauces  be 
red,  for  hyperaemia  of  the  fauces,  due  to  commencing  pharyngitis,  is  one  of 
the  earliest  and  most  constant  of  the  local  manifestations  of  scarlatina. 

When  the  eruption  has  appeared  the  nature  of  the  malady  is  in  most 
Instances  apparent.  The  punctate  character  of  the  eruption  before  it 
becomes  confluent,  its  occurrence  within  twenty-four  hours  after  the  fever 
begins  over  almost  the  entire  surface,  but  its  absence  or  scantiness  upon  the 
face,  and  especially  around  the  mouth,  serve  to  distinguish  it  from  other 
diseases. 

Scarlet  fever  and  measles  were  long  considered  identical  by  the  profes- 
sion, and,  though  the  ordinary  forms  of  these  maladies  can  be  readily  distin- 
guished from  each  other,  cases  occur  in  which  the  differential  diagnosis  is 
attended  by  some  difficulty.  But  there  are  diff'erences  in  the  symptoms  and 
course  of  the  two  diseases  which  aid  in  discriminating  one  from  the  other. 
Measles  begins  with  marked  catarrhal  symptoms,  as  if  from  a  severe  cold. 
Mild  conjunctivitis,  causing  weak  and  watery  eyes,  coryza,  and  mild  laryngo- 


DIAGNOSIS.  307 

bronchitis,  with  accompanying  cough,  precede  the  eruption  three  or  four 
days  and  continue  during  the  eruptive  stage.  The  fever  during  the  first 
or  initial  stage  of  measles  is  remittent,  the  evening  temperature  being  two 
or  three  degrees  higher  than  that  in  the  morning.  Contrast  this  with  the  inva- 
sion of  scarlet  fever,  in  which  the  only  catarrh  is  that  of  the  buccal  and  faucial 
surfaces,  and  there  is  consequently  little  or  no  cough,  and  the  rise  in  tem- 
perature, ordinarily  high  in  the  beginning,  is  nearly  uniform  in  the  difierent 
hours  of  the  day.  The  scarlatinous  eruption  appears,  as  we  have  seen,  within 
twelve  to  twenty-four  hours  about  the  neck  and  upper  part  of  the  chest,  and 
spreads  over  the  body  in  a  shorter  time  than  that  of  measles,  which  appears 
on  the  third  day.  The  rash  of  measles  begins  to  fade  at  the  close  of  the 
third  or  in  the  fourth  day  after  its  appearance,  that  of  scarlet  fever  not  till 
from  the  sixth  to  the  eighth  day.  In  nearly  all  cases  of  measles,  even  when 
the  rash  is  confluent  upon  the  face  and  a  considerable  part  of  the  trunk  in 
consequence  of  the  high  fever  and  active  cutaneous  circulation,  we  observe 
the  characteristic  rubeolar  eruption  upon  certain  parts  of  the  surface,  as  the 
extremities;  which,  in  connection  with  the  history,  renders  diagnosis  certain. 

Erythema  resembles  the  scarlatinous  eruption,  but  its  duration  is  com- 
monly shorter.  It  is  limited  to  a  part  of  the  surface,  and  it  is  accompanied 
by  much  less  fever.  The  temperature  in  erythema  does  not  usually  rise 
above  100°,  unless  for  a  few  hours,  whereas  in  scarlet  fever  it  continues 
several  days  considerably  above  100°.  The  scarlatinous  efflorescence  has 
also  a  brighter  red  or  more  scarlet  hue  than  that  of  erythema,  except  in  the 
more  malignant  cases,  in  which  the  severity  of  the  symptoms  renders  the 
diagnosis  clear.  But  an  important  aid  in  diflferentiating  the  one  from  the 
other  of  these  diseases  is  the  fact  that  in  erythema  there  is,  with  few  excep- 
tions, no  faucial  inflammation,  and  in  the  few  instances  in  which  it  is  present 
it  is  slight  and  transient,  fading  within  a  day  or  two. 

Scarlet  fever  is  readily  diagnosticated  from  diphtheria,  although  the 
affinity  is  close  between  these  two  maladies.  The  early  appearance  of  the 
pseudo-membrane  upon  the  fauces  in  diphtheria,  its  absence  in  scarlet  fever, 
and  the  absence  of  any  appeai'ance  resembling  it  until  the  fever  has  continued 
some  days,  and  the  characteristic  efflorescence  upon  the  skin  in  scarlet  fever, 
render  diagnosis  easy.  If  scarlet  fever  have  continued  some  days  when 
first  seen  by  the  physician,  the  diphtheritic  pseudo-membrane  may  be  present 
as  a  complication,  or  the  fauces  may  present  an  appearance  like  diphtheria 
from  ulceration  or  sloughing  and  the  presence  of  foul  and  oflfensive  secretions, 
which  produce  a  dark -grayish  and  fetid  mass  over  the  faucial  surface.  Under 
such  circumstances  the  character  of  the  disease  is  ascertained  by  the  history 
of  the  case,  and  especially  by  the  occurrence  of  the  scarlatinous  eruption. 
An  erythema  transient  and  limited  to  a  part  of  the  surface  sometimes  appears 
in  the  commencement  of  diphtheria,  and  at  a  later  pei'iod,  as  a  result  of  the 
toxaemia  upon  the  extremities.  Roseoloid  points  and  patches  often  occur 
upon  the  extremities.  Both  kinds  of  rash  can  be  readily  diagnosticated  from 
that  of  scarlet  fever,  for  the  erythema,  as  has  been  stated,  is  transient  and 
partial,  and  does  not  exhibit  minute  points  of  deeper  injection,  while  the 
toxcemic  ra.sh  difl'ers  in  form  and  aspect  from  that  of  scarlet  fever,  and  appears 
at  a  stage  when  the  scarlatinous  efflorescence  has  faded  or  begun  to  fade. 

The  efflorescence  of  rotheln  sometimes  closely  resembles  that  of  scarlet 
fever,  though  it  is  usually  more  like  that  of  measles ;  but  it  is  ordinarily 
accompanied  by  symptoms  which  are  much  milder  than  those  of  scarlet  fever, 
and  it  begins  to  abate  as  early  as  the  third,  and  disappears  on  the  fourth, 
day.  The  eyes  have  a  suffused  appearance,  the  temperature  may  reach  102° 
or  103°,  arid  the  efflorescence  may  be  as  general  over  the  body  as  that  of 
scarlet  fever,  but  there  is  not   the  aspect  of  serious  indisposition,  and  the 


308  SCARLET  FEVER. 

speedy  abatement  of  the  symptoms  shows  that  the  disease  is  not  scarlet 
fever. 

Prognosis. — The  prognosis  depends  on  the  form  of  scarlet  fever,  whether 
mild  or  severe,  the  strength  of  the  patient,  and  the  presence  or  absence  of 
complications  or  sequelae.  The  type  of  the  disease  is  sometimes  so  mild 
throughout  an  epidemic  or  during  a  series  of  years  that  death  seldom  occurs, 
whatever  the  mode  of  treatment ;  but  afterward  the  type  changes,  and  the 
percentage  of  deaths  increases  and  remains  high  till  another  amelioration  in 
the  type  occurs. 

Sydenham  in  the  middle  of  the  seventeenth  century  stated  that  scarlet 
fever,  as  he  saw  it  in  London,  was  so  mild  that  it  scarcely  deserved  the  name 
of  disease:  "  Vix  nomen  morbi  merebatur."  Morton  some  years  later,  and 
Huxham  in  the  following  century,  had  abundant  reason  to  regret  the  change 
of  type,  and  now  throughout  Great  Britain  scarlet  fever  is  one  of  the  most 
fatal  and  most  dreaded  of  the  diseases  of  childhood.  In  Dublin  during  the 
present  century,  prior  to  1834,  scarlet  fever  was  uniformly  mild,  so  that  on 
one  occasion  of  eighty  patients  in  an  institution  all  recovered.  In  1834  the 
type  of  the  disease  totally  changed  and  epidemics  of  unusual  virulence 
occurred.  The  type  frequently  changes  from  mild  to  severe  or  severe  to 
mild,  not  only  in  consecutive  years,  but  in  consecutive  months.  A  few  years 
since  a  distinguished  physician  of  New  Yoi'k  treated  about  fifty  cases  of 
scarlet  fever  in  one  of  the  institutions  without  a  single  death,  but  a  few 
months  later  the  type  of  the  malady  changed,  and  his  own  son  was  among 
those  who  perished  from  it.  The  prevailing  type  of  the  disease  should  there- 
fore be  considered  in  giving  the  prognosis  when  in  the  commencement  of  a 
case  we  are  asked  the  probability  as  regards  the  termination. 

Extensive  statistics,  including  those  collected  by  Murchison  from  various 
sources,  show  that  in  different  epidemics  the  mortality  may  vary  as  much  as 
from  3  per  cent.  (Eulenberg  of  Coblentz)  to  19.3  per  cent,  (cases  seen  by 
myself  in  New  York  City  in  1881-82,  many  of  which  were  complicated  by 
diphtheria),  or  even  to  34  per  cent,  (epidemic  in  the  Palatinate  in  1868-69). 
The  hospital  statistics  of  Rilliet  and  Barthez  gave  46  deaths  in  87  cases,  or 
about  53  per  cent. 

Observations  have  thus  far  failed  to  establish  any  connection  in  the 
atmospheric  conditions  of  temperature  or  moisture  and  the  type  of  scarlet 
fever.  G-rave  as  well  as  mild  epidemics  have  occurred  in  all  climates  and 
seasons. 

The  mortality  is  nearly  equal  in  the  two  sexes,  but  age  has  a  marked 
influence  on  the  percentage  of  deaths.  The  period  of  the  greatest  mortality, 
and  also  of  the  greatest  frequency,  of  scarlet  fever  is  between  the  ages  of 
one  and  six  years.  The  following  are  statistics  bearing  on  the  relation  of  the 
age  to  the  percentage  of  deaths  : 

From  the  close    From  the  5th  to 
Under  1  year,    of  1st  till  close  the  12th 

of  5th  year.  year. 

Fleishman:  Cases       .  8  204  260 

Deaths    .6  88  51 

1st  to  close  of  6th  to  12th        From  the  12th 

6th  year.  year.  to  20th  year. 

Kraus:  Cases  13  113  106  40 

Deaths  4  29  10  2 

7th  to  16t!i  year. 
Volt:  Cases       .5  166  109 

Deaths     .1  24  10 


PROONOSIS. 

Under  1  year.    ^T^f^  ?^^!°" 

Roset : 

Cases 
Deaths 

43                     156 
16                      31 

Under  5  years.    5th  to  10th  year.    ; 

Russinger : 

Cases 
Deaths 

.        101                       126 
21                         20 

309 

Over  5  years. 


10th  to  15th  year.  Over  1.5  years. 

47  27 

3  0 


These  statistics,  which  I  believe  correspond  with  the  observations  of  others, 
show  that  although  few  ca.se.s  occur  in  the  first  year,  the  percentage  of  death.s 
is  large,  and  that  a  majority  of  the  total  death.s  from  this  malady  occur  under 
the  age  of  sis  years.  After  the  sixth  year  the  greater  the  age  the  less  the 
proportionate  number  of  deaths. 

Scarlet  fever  is  liable  to  so  many  complications  and  sequelae  that  a  physi- 
cian should  not  predict  a  certain  favorable  termination  in  the  beginning,  how- 
ever mild  and  regular  the  symptoms  may  be.  But  a  favorable  result  may 
be  expected  if  the  attack  be  mild,  the  efflorescence  appear  at  the  proper  time 
and  extend  over  the  entire  surface,  the  angina  be  moderate  and  accompanied 
by  little  or  no  cellulitis  or  adenitis,  with  pulse  under  140,  temperature  not 
above  103°,  and  no  marked  nervous  symptoms. 

Whether  the  complications  or  sequelae  be  dangerous  depends  upon  their 
character.  Rheumatism  has  never  in  my  practice  been  dangerous,  nor  has  it 
materially  retarded  convalescence,  except  when  it  affected  the  heart,  causing 
pericarditis  or  endocarditis,  when  it  involves  great  danger.  Nephritis,  if  it 
be  moderate,  attended  by  little  albuminuria  and  serous  effusion  and  by  the 
occurrence  of  few  renal  casts  in  the  urine,  commonly  ends  favorably  under 
judicious  treatment,  as  we  have  already  stated ;  but  severe  nephritis,  with 
abundant  albuminuria  and  casts  and  serous  eflFusions,  soon  gives  rise  to  alarm- 
ing symptoms,  and  is  the  cause  of  death  in  a  considerable  number  of  instances. 
A  similar  remark  is  applicable  to  the  angina,  which  occurs  in  all  grades  of 
severity.  If  it  be  attended  by  much  cellulitis,  with  considerable  ulceration 
or  necrosis,  the  state  is  one  of  danger  in  consequence  of  the  difficulty  in 
administering  sufficient  nuti'iment,  as  well  as  from  the  diminished  assimilation 
and  the  loss  of  strength  due  to  the  prolonged  inflammatory  fever,  the  septic 
poisoning,  and  the  occasional  hemorrhages.  Complication  by  pharyngeal  or 
nasal  diphtheria,  now  so  common  where  diphtheria  is  endemic,  also  greatly 
increases  the  danger. 

Many  cases,  even  when  their  course  is  normal  and  without  complications, 
involve  danger,  and  some  are  necessarily  fatal,  from  the  direct  effect  of  scar- 
latinous blood-poisoning.  Such  are  grave  or  malignant  forms  of  the  disease 
which  the  experienced  eye  recognizes  at  a  glance.  Death  often  occurs  rap- 
idly from  the  toxaemia.  Such  cases  are  characterized  by  high  temperature 
(105°  or  106°),  rapid  pulse,  dusky-red  hue  of  the  surface  from  languid 
capillary  circulation,  pungent  heat,  frequent  vomiting,  diarrhoeal  stools,  a  dry- 
brown  tongue,  and  marked  nervous  symptoms,  such  as  delirium,  great  rest- 
lessness, or  stupor.  Not  a  few  in  this  form  of  scarlet  fever  take  eclampsia, 
which  is  likely  to  be  severe  and  repeated,  and  to  end   in  fatal  coma. 

Other  inflammatory  complications  and  sequelae,  which  have  been  described 
in  the  preceding  pages,  retard  convalescence  and  jeopardize  the  life  of  the 
patient,  such  as  empyema,  endocarditis,  pericarditis,  and  pneumonia.  Otitis 
media  is  seldom  immediately  dangerous,  although  it  may  be  painful  and 
involve  serious  consequences,  even  a  fatal  meningitis,  as  has  been  stated 
above,  after  months  or  years  of  otorrhoea.  Anomalous  cases  are  believed  to 
be,  as  a  rule,  more  dangerous  than  such  as  are  attended  by  an  early  and  full 
efflorescence  and  have  the  usual  symptoms. 


310  SCARLET  FEVER. 

Treatment.— P;'op%?aa;(^s. — Since  the  discovery  by  Jenner  of  the  pro- 
phylactic power  of  vaccination  as  regards  smallpox,  the  attention  of  the  pro- 
fession has  been  frequently  directed  to  the  prevention  of  scarlet  fever.  Bel- 
ladonna has  been  employed  for  this  purpose  by  a  class  of  practitioners  who 
believe  in  the  theory  that  an  agent  which  produces  symptoms  similar  to  those 
of  a  disease  is  antagonistic  to  that  disease,  and  therefore  tends  to  prevent  it, 
or,  if  it  be  present,  to  render  it  milder ;  and  since  this  herb  causes  an  efflo- 
rescence upon  the  skin  and  redness  of  the  fauces,  it  was  selected  as  the 
proper  preventive  and  remedial  agent  for  scarlet  fever.  Its,  use,  however, 
for  this  purpose  has  been  fruitless,  and  it  is  now  nearly  or  quite  discarded. 

It  is  now  known,  from  a  considerable  number  of  observations,  that  scarlet 
fever  occasionally  occurs  in  the  domestic  animals  during  epidemics  of  the 
disease  in  children.  It  is  stated  that  Spinola  observed  it  in  the  horse ;  that 
Heim  saw  a  dog  that  occupied  the  same  bed  with  a  scarlatinous  patient  sicken 
with  fever,  which  was  followed  by  desquamation  ;  that  Letheby  saw  scarla- 
tina in  swine,  and  Kraus  in  young  cattle.  Prominent  veterinary  surgeons,  as 
Williams  of  Great  Britain,  admit  the  occurrence  of  scarlatina  in  animals,  and 
the  hope  has  arisen  that  since  smallpox  is  modified  in  cattle  so  as  to  afford  us 
the  vaccine  virus,  perhaps  scarlet  fever  may  also  be  modified  by  passing 
through  one  of  the  lower  animals,  so  that  a  milder  and  less  fatal  form  of  the 
disease  might  be  produced  in  man  by  inoculation  from  the  animal.  This 
theory,  though  it  deserves  investigation,  is  far  from  being  established.  It 
has  not  yet,  so  far  as  I  am  aware,  been  shown  that  scarlet  fever  is  milder  in 
any  animal  than  in  man,  nor,  if  we  admit  that  it  is  modified  in  the  animal,  is 
it  certain  that  the  disease  could  be  returned  to  man  in  the  modified  form. 
In  the  Neio  York  Medical  Record  for  March  24,  1883,  some  experiments  are 
detailed  by  S.  W.  Strieker  of  Orange,  New  Jersey.  He  cites  experiments  of 
Caze  and  Feltz,  who  injected  scarlatinal  blood  under  the  skin  of  Q>&  rabbits, 
and  of  these  62  died  within  eighteen  hours  to  fourteen  days,  which  indicated 
a  highly  poisonous  state  of  the  blood  employed,  either  septic  or  scarlatinous, 
and  certainly  no  mitigation  of  the  virulence  of  the  scarlet  fever.  Strickler 
obtained  from  Williams  of  Edinburgh  nasal  mucus  from  a  horse  supposed  to 
have  scarlatina,  and  with  it  inoculated  twelve  children,  all  of  whom  had  sores 
at  the  point  of  inoculation,  with  redness  of  the  skin  around  the  sores,  and  in 
some  instances  swelling  of  the  adjacent  lymphatic  glands.  It  is  stated  that 
the  children  thus  inoculated  did  not  contract  scarlet  fever  subsequently  when 
they  were  exposed  to  it.  Obviously,  there  is  a  serious  objection  to  such 
experiments  upon  children,  so  that  they  may  not  be  repeated.  Children 
thus  experimented  on  might,  like  the  rabbits,  die.  The  experiments  involve 
too  great  a  risk  as  regards  the  health  and  safety  of  the  children  experimented 
on.  Under  the  circumstances  the  experimenter  who  propagates  so  dangerous 
a  disease  by  inoculation  renders  himself  liable,  it  seems  to  me,  to  criminal 
proceedings  in  the  courts. 

It  is  a  matter  of  great  interest  and  importance,  and  one  not  yet  elucidated, 
whether  or  to  what  extent  disinfectant  and  antiseptic  remedies,  administered 
internally,  prevent  the  occurrence  of  the  infectious  maladies  in  those  who 
have  been  exposed  and  aid  in  curing  those  who  are  sick  with  them.  Sodium 
sulphocarbolate,  from  which,  by  decomposition  in  the  system,  carbolic  acid  is 
supposed  to  be  set  free,  has  been  used  for  this  purpose.  It  is  administered 
to  adults  in  doses  of  ten  to  thirty  grains,  and  to  children  in  doses  proportion- 
ate to  their  age.  Declat  has  prepared  a  syrup  of  phenic  (carbolic)  acid  as  a 
preventive  and  curative  agent  in  the  infectious  diseases.  It  is  now  employed 
by  several  of  the  New  York  physicians,  but  thus  far  the  statistics  of  its  use 
are  not  sufficient  to  determine  its  efficacy.  It  is  a  question  whether  the 
so-called  antiseptics  can,  on  account  of  their  toxic  properties,  be  used  with 


TREATMENT.  311 

safety  in  doses  sufl6ciently  large  to  be  antidotal  to  the  specific  principle  of 
scarlet  fever. 

In  the  present  state  of  our  knowledge  the  most  reliable  and  certain 
prophylaxis  is  the  isolation  of  patient  and  nurses  and  the  thorough  and 
judicious  eniploynient  of  disinfectants  upon  their  persons  and  in  the  apart- 
ments. All  furniture  and  articles  not  absolutely  required  should  be  removed 
from  the  sick-room,  and  no,  one  should  be  allowed  to  enter  it  except  the  med- 
ical attendant  and  nurses.  Constant  ventilation  should  be  insisted  on  by 
lowering  the  upper  and  raising  the  lower  sash  of  the  window  two  or  three 
inches  in  mild  weather.  Even  in  stormy  weather  sufficient  ventilation  can 
be  obtained  in  this  way  without  exposing  the  patient  to  currents  of  air,  which 
should  be  avoided. 

The  New  York  Board  of  Health  enforces  the  following  regulations  to 
prevent  the  spread  of  scarlet  fever  as  well  as  other  acute  infectious  maladies : 

"  Care  of  Fatientf. — The  patient  should  be  placed  in  a  separate  room,  and 
no  person  except  the  physician,  nurse,  or  mother  allowed  to  enter  the  room 
or  to  touch  the  bedding  or  clothing  used  in  the  sick-room  until  they  have 
been  thoroughly  disinfected. 

"  Infected  Articles. — iVll  clothing,  bedding,  or  other  articles  not  absolutely 
necessary  for  the  use  of  the  patient  should  be  removed  from  the  sick-room. 
Articles  used  about  the  patients,  such  as  sheets,  pillow-cases,  blankets,  or 
clothes,  must  not  be  removed  from  the  sick-room  until  they  have  been  disin- 
fected by  placing  them  in  a  tub  with  the  following  disinfecting  fluid :  eight 
ounces  of  sulphate  of  zinc,  one  ounce  of  cai'bolic  acid,  three  gallons  of  water. 
They  should  be  soaked  in  this  fluid  for  at  least  an  hour,  and  then  placed  in 
boiling  water  for  washing. 

''  A  piece  of  muslin  one  foot  square  should  be  dipped  in  the  same  solution 
and  suspended  in  the  sick-room  constantly,  and  the  same  should  be  done  in 
the  hallway  adjoining  the  sick-room. 

"  All  vessels  used  for  receiving  the  discharges  of  patients  should  have 
some  of  the  same  disinfecting  fluid  constantly  therein,  and  immediately  after 
being  used  by  the  patient  should  be  einptied  and  cleansed  with  boiling  water. 
Water-closets  and  privies  should  also  be  disinfected  daily  with  the  same  fluid 
or  a  solution  of  chloride  of  iron,  one  pound  to  a  gallon  of  water,  adding  one 
or  two  ounces  of  carbolic  acid. 

"  All  straw  beds  should  be  burned. 

"  It  is  advised  not  to  use  handkerchiefs  about  the  patient,  but  rather  soft 
rags,  for  cleansing  the  nostrils  and  mouth,  which  should  be  immediately  there- 
after burned. 

"  The  ceilings  and  side-walls  of  a  sick-room  after  removal  of  the  patient 
should  be  thoroughly  cleaned  and  lime-washed,  and  the  woodwork  and  floor 
thoroughly  scrubbed  with  soap  and  water." 

By  such  measures  of  prevention  there  can  be  no  doubt  that  the  number 
of  cases  of  scarlet  fever  has  been  reduced. 

But  do  the  health  boards  accomplish  all  that  they  are  able  to  do  in  sup- 
pressing scarlet  fever  as  well  as  diphtheria  ?  The  New  York  Health  Board 
excludes  children  from  the  schools  who  live  in  the  houses  where  these  diseases 
are  occurring,  gives  directions  in  reference  to  the  care  of  the  patient  and  the 
disposition  of  infected  articles,  and  promises  to  disinfect  the  sick-room  when 
word  is  sent  to  the  boai'd.  But  these  measures  are  inadequate  or  are  only 
partially  successful  in  preventing  these  diseases.  To  my  knowledge,  many 
families  in  New  York  never  send  word  that  they  are  ready  for  the  disinfection 
of  the  apartments,  and  many  families  in  the  tenement-houses  move  away  as 
soon  as  possible.  The  vacated  rooms  are  re-rented  to  families  who  have  no 
knowledge  of  the  previous  sickness,  and  are  surprised  when  their  children 


312  SCARLET  FEVER. 

immediately  after  are  taken  sick.  It  would  be  better  if  the  health  board  in 
every  instance  disinfected  the  infected  apartments  after  the  termination  of 
the  sickness,  whether  the  family  are  willing  or  not.  Moreover,  the  reader  is 
referred  to  our  remarks  on  the  prevention  of  diphtheria  for  evidence  of  the 
inadequacy  of  the  sulphur  fumigation.  In  my  opinion,  fumigation  both  by 
burning  sulphur  and  by  chlorine,  as  employed  by  Prof.  Doremus  in  Bellevue 
Hospital,  .should  be  used  before  the  apartments  are  reopened  for  occupancy, 
and  the  ceiling,  walls,  and  floor  should  be  washed  with  a  corrosive-sublimate 
solution  or  other  efficient  antiseptic  lotion. 

But  the  suppression  of  scarlet  fever  cannot  be  eflfected  without  the 
co-operation  of  the  attending  physician.  He  can  accomplish  more  than  the 
health  board  in  the  way  of  prophylaxis.  Twenty-one  years  ago  the  late 
Dr.  William  Budd  of  England  recommended  prophylactic  measures,  and 
the  following  is  his  testimony  in  regard  to  the  result :  "  The  success  of 
this  method  in  my  own  hands  has  been  vei'y  remarkable.  For  a  jjeriod 
of  nearly  twenty  years,  during  which  I  have  employed  it  in  a  very  wide 
field,  I  have  never  known  the  disease  to  spread  beyond  the  sick-room  in  a 
single  instance,  and  in  very  few  instances  within  it.  Time  after  time  I  have 
treated  this  fever  in  houses  crowded  from  attic  to  basement  with  children 
and  others,  who  have  nevertheless  escaped  infection.  The  two  elements  in 
the  method  are  separation  on  the  one  hand  and  disinfection  on  the  other."  ^ 

In  my  opinion  it  is  quite  possible  to  realize  the  experience  of  Dr.  Budd 
if  proper  prophylactic  measures  be  employed  from  the  beginning  of  the  sick- 
ness. The  attending  physician  at  his  first  visit  and  at  each  subsequent  visit 
should  consider  it  an  imperative  duty  to  direct  the  employment  of  adequate 
preventive  measures.  Health  boards  give  directions  that  objects  not  required 
to  promote  the  comfort  of  the  patient  should  be  removed  from  the  sick-room, 
and  no  one  be  allowed  to  enter  it  except  the  physician,  nurse,  and  mother. 
The  floor  and  walls  of  the  apartment  should  be  bare,  but  I  would  go  farther 
than  the  health  board,  and  insist  that  no  reading  matter,  especially  books  and 
primers,  be  allowed  in  the  room,  or  if  allowed  they  should  subsequently  be 
burnt,  since,  as  we  have  seen,  the  specific  poison  obtaining  lodgment  between 
the  leaves  is  not  readily  reached  by  disinfectants,  and  may  communicate  the 
disease  months  afterward.  I  recommend  for  disinfection  of  the  room  at  my 
first  visit,  and  also  for  cases  of  diphtheria,  the  following  prescription  : 

R.  Acidi  carbolici, 

01.  eucalypti,  aa.  ,^j  ; 

Spts.  terebinth.,  ^vj.     Misce. 

Two  tablespoonfuls  are  added  to  one  quart  of  water  in  a  tin  wash-basin  or  sim- 
ilar vessel  with  broad  surface,  and  maintained  in  a  state  of  constant  simmering 
over  a  gas-  or  oil-stove  during  the  entire  sickness.  The  odor  of  this  vapor  is 
agreeable  rather  than  unpleasant,  and  it  appears  to  disinfect  to  a  considerable 
extent  the  breath  and  exhalations  from  the  body  of  the  patient.  At  the 
same  time,  I  order  inunction  of  the  entire  surface  every  third  hour  with  the 
following : 

R.  Acidi  carbolici, 

01.  eucalypti,  da.  .^j  ; 

01.  olivse,  ^vij. 

Dr.   Jamieson    recommends   disinfection   of  the   fauces   by  the  frequent 

application  of   a   saturated   solution   of   boracic   acid   in   glycerin.     This   or 

some  other  non-irritating  solution  should  be  often  applied,  not  only  to  the 

fauces,  but  also  in  the  anginose  cases  to  the  nostrils.     I  have  recommended 

^  British  MedicalJournal,  January  9,  1869. 


TREATMENT.  313 

the  application  of  corrosive-sublimate  solution,  two  grains  to  the  pint,  applied 
to  the  fauces  by  a  camel-hair  pencil  or  by  cotton  wadding  wound  around  a 
slender  stick,  in  the  same  manner  in  which  Dr.  Oatman  and  others  employ  it 
in  diphtheria. 

The  cautious  physician  in  attending  a  case  of  scarlet  fever  will  always 
bear  in  mind  the  possibility  that  his  person  or  clothing  may  become  infected^ 
and  be  the  vehicle  through  which  the  poison  may  be  communicated  to  others. 
In  examining  the  fauces  of  a  patient  he  should  stand  a  little  to  one  side,  so 
that  no  muco-pus,  if  the  patient  cough,  be  received  on  his  clothing;  nor  will 
he  go  directly  from  a  scarlatinous  patient  to  a  child  with  another  sickness,  or 
to  a  midwifery  case,  without  first  washing  his  hands,  hair,  and  face  in  a 
corrosive-sublimate  solution,  and  changing  his  outer  apparel ;  or  if  he  visit 
a  child  without  such  precautionary  measures,  he  will  not  approach  any  nearer 
than  is  sufficient  to  enable  him  to  determine  its  ailment  and  condition. 

Uyijicnic  Treatment. — The  room  occupied  by  a  scarlatinous  patient  should 
be  commodious  and  sufficiently  ventilated.  Its  temperature  should  be  uni- 
form at  about  70°  during  the  course  of  the  fever.  When  the  fever  begins  to 
abate  and  desquamation  commences,  a  temperature  of  72°  to  75°  is  prefer- 
able, so  that  there  is  less  danger  that  the  surface  may  be  chilled  during 
unguarded  moments,  as  at  night,  when  the  body  may  be  accidentally  uncov- 
ered, since  sudden  cooling  of  the  surface  at  this  time  may  cause  nephritis  or 
some  other  dangerous  inflammation.  Henoch  does  not  believe  in  the  theory 
that  the  nephritis  is  commonly  produced  by  catching  cold,  but  many  observa- 
tions show  that  those  who  are  carefully  protected  from  vicissitudes  of  tem- 
perature, who  remain  during  convalescence  in  a  warm  room,  and  are  pro- 
tected by  abundant  clothing,  more  frequently  escape  this  complication  than 
such  as  are  under  no  restraint  of  this  kind  and  are  carelessly  exposed  in  times 
of  changeable  weather.  Nevertheless,  it  is  true  that  a  certain  proportion 
suffer  from  nephritis  however  judicious  the  after-treatment  may  be.  The 
best  hygienic  management  does  not  always  prevent  its  occurrence.  The 
patient  should  not,  therefore,  leave  the  house  until  four  weeks  after  the 
beginning  of  the  fever,  and  in  inclement  weather  not  till  a  longer  time  has. 
elapsed.  So  long  as  desquamation  is  going  on  and  the  skin  has  not  regained 
its  normal  function,  the  patient  should  remain  indoor,  and  when  finally  he  is- 
allowed  to  leave  the  house  he  should  be  warmly  clothed. 

Therapeutic  Treatment. — In  order  to  treat  scarlet  fever  successfully,  it  is 
necessary  to  bear  in  mind  that  it  is  a  self-limited  disease,  running  a  certain 
time  and  through  certain  stages,  and  that  it  is  not  abbreviated  by  any  known 
treatment.  Therapeutic  measures  can  only  moderate  its  symptoms  and  ren- 
der it  milder.  The  severity  of  the  disease  is  indicated  by  its  symptoms,  and 
the  symptoms  are  to  a  certain  extent  under  our  control. 

Mild  Cases. — A  patient  with  a  temperature  under  103°  and  with  only  a 
moderate  angina  does  not  require  active  treatment,  but,  however  light  the 
disease,  he  should  always  be  in  bed  and  in  a  room  of  uniform  temperature, 
as  stated  above.  Instances  have  come  to  my  notice  in  the  poor  families  of 
New  York  in  which  scarlet  fever  was  not  diagnosticated,  and  the  patients 
were  allowed  to  go  about  the  house,  and  even  in  the  open  air,  in  the  eruptive 
stage,  till  some  severe  complication  or  an  aggravation  of  the  type  created 
alarm  and  medical  advice  was  sought,  when  it  appeared  that  a  grave  and  dan- 
gerous condition  had,  through  carelessness  and  ignorance,  resulted  from  a 
mild  and  favorable  form  of  the  malady.  The  physician,  when  summoned  to 
a  case  however  mild,  should  never  fail  to  take  the  temperature,  note  the 
pulse,  inspect  the  fauces,  and  inquire  in  reference  to  the  fecal  and  urinary 
evacuations,  that  he  may  detect  early  any  unfavorable  changes  which  may 
occur. 


314  SCARLET  FEVER. 

Since  in  all  cases  angina  and  more  or  less  blood-deterioration  are  present, 
the  following  prescription  will  be  found  useful  in  mild  as  well  as  severe  scar- 
let fever : 

R.  Potass,  chlorat.,  ^ss; 

Tr.  ferri  chloridi,        f^ij  ; 
Syrupi,  f^iv.     Misce. 

Sig. :  Dose,  one  teaspoonful  every  hour  to  two  hours  to  a  child  of  three  years. 

Small  doses  of  this  medicine  frequently  administered  act  beneficially  on  the 
surface  of  the  throat  and  tend  to  prevent  the  anaemia  which  is  so  common 
after  scarlet  fever.  If  the  medicine  be  given  gradually,  diluted  with  only  a 
moderate  amount  of  water,  the  effect  is  better  on  the  inflamed  fauces.  Potas- 
sium chlorate  is  known  to  be  an  irritant  to  the  kidneys  in  large  doses,  caus- 
ing intense  hypersemia  of  these  organs,  with  bloody  urine  or  suppression  of 
urine.  The  melancholy  fate  of  Fountaine,  who  died  from  the  eff"ects  of  one 
ounce  of  this  medicine,  is  known  to  the  profession.  I  have  seen  a  similar 
instance  in  a  child.  But  doses  of  half  a  grain  to  two  grains,  according  to 
the  age,  can  be  administered  with  safety  to  children,  so  that  twenty  to  thirty 
grains  are  taken  in  twenty-four  hours.  A  quantity  much  exceeding  this 
amount  involves  risk. 

R.  Qniniae  snlphat.,  gr.  xvj  ; 

Syr.  pruni  virginiani, 

Syr.  yerbse  santse  comp.,  da.  §j.     Misce. 

Sig. :  One  teaspoonful  every  fourth  hour  to  a  child  of  three  to  five  years,  the  potassium 
chlorate  and  iron  mixture  being  administered  twice  between. 

The  treatment  of  scarlatina  by  antiseptic  remedies  will  be  considered 
hereafter. 

The  itching  and  dryness  of  the  surface,  which  increase  the  discomfort  of 
the  patient  in  mild  as  well  as  severe  scarlatina,  are  relieved  by  the  ointment 
mentioned  in  treating  of  prophylaxis.  The  linen  should  be  changed  every 
day  and  the  bed  thoroughly  aired. 

Ordinary  Cases  and  Cases  of  Severe  Type. — A  safe  temperature  in  scarlet 
fever  may  be  considered  at  or  below  103°.  If  it  rise  above  this,  measures 
designed  to  abstract  heat  are  very  important — more  important  even  in  many 
cases  than  the  medicinal  agents  which  are  commonly  used  to  combat  this 
disease.  Since  a  high  temperature  retards  assimilation,  promotes  deleterious 
tissue-change,  and  causes  rapid  emaciation  and  loss  of  strength,  measures 
designed  to  reduce  it  are  urgently  needed.  "  The  production  of  heat  depends 
chiefly  on  oxidation  of  the  constituents  of  the  body  "  (Billroth).  Therefore, 
fever  indicates  an  increase  of  the  oxidation  and  a  molecular  disintegration 
above  the  healthy  standard.  Hence  the  augmentation  of  urea  in  the  urine 
and  the  progressive  emaciation  and  loss  of  weight  which  characterize  the 
febrile  state.  Fever  also  diminishes  the  secretions  by  which  food  is  digested 
and  destroys  the  appetite,  so  that  repair  of  the  waste  is  insufficient.-  More- 
ever,  a  high  temperature  continuing  for  a  time  tends  to  produce  degenerative 
changes,  albuminous  and  fatty,  in  the  tissues,  the  more  rapidly  the  higher 
the  temperature,  so  that  the  functions  of  organs  are  seriously  impaired. 
Among  the  most  dangerous  of  the  tissue-changes  is  granulo-fatty  degenera- 
tion of  the  muscular  fibres  of  the  heart.  In  dogs  and  rabbits  that  have  per- 
ished from  a  high  temperature  artificially  produced  by  experimenters  gran- 
ular clouding  of  the  elementary  tissues  has  been  found  after  death.^  A  high 
temperature,  therefore,  in  itself  involves  danger,  and  if  it  occur  in  an  ataxic 

^  See  experiments  by  Mr.  J.  W.  Legg,  Lond..  Path.  Soc.  Trans,,  vol.  xxiv.,  and 
others. 


TREATMENT.  315 

disease  like  scarlet  fever,  and  be  protracted,  it  greatly  diminishes  the  chances 
of  a  favorable  issue. 

The  temperature  can  be  reduced  without  shock  or  injury  to  the  child  by 
the  judicious  use  of  cold  water  externally.  The  cold-water  treatment  is  not 
necessary  if  the  temperature  be  under  103°,  though  useful  if  judiciou.sly 
employed  by  sponging  when  the  temperature  is  at  102°  or  103°;  but  if  it 
rise  above  103°  it  is  required,  and  the  more  urgently  the  higher  the  tempera- 
ture. The  external  use  of  cold  water  as  an  antipyretic  in  the  febrile  diseases 
is  now  almost  universally  recommended  by  physicians,  but  it  still  meets  with 
opposition  on  the  part  of  families,  especially  in  the  treatment  of  the  exanthe- 
matic  fevers,  and  the  directions  for  its  employment  are  therefore  not  likely  to 
be  fully  carried  out  during  the  absence  of  the  medical  attendant.  The  old 
theory  that  the  fevers  require  warmth  and  sweating  has  such  a  firm  hold  on 
the  popular  mind  that  some  years  longer  will  be  required  for  its  removal. 

The  modes  of  applying  cold  water  recommended  by  cautious  and  expe- 
rienced physicians  are  various.  Von  Ziemssen  recommended  that  the  patient 
be  immersed  in  water  at  a  temperature  of  90°,  and  cool  water  be  gradually 
added  till  the  temperature  fall  to  77°.  In  a  few  minutes  the  patient  is 
returned  to  his  bed,  his  surface  dried,  and  he  is  covered  by  the  proper  bed- 
clothes, when  his  temperature  will  probably  be  found  reduced  two  or  two  and 
a  half  degrees.  If  the  patient  complain  of  chilliness  or  his  pulse  be  feeble, 
he  should  be  immediately  removed  from  the  bath  and  stimulants  administered, 
either  whiskey  or  brandy,  for  if  the  extremities  remain  cool  and  the  capillary 
circulation  sluggish,  the  effect  may  be  injurious,  since  some  internal  inflam- 
mation may  arise  to  complicate  the  fever.  Under  such  circumstances  increased 
alcoholic  stimulation  is  required. 

The  cold  pack  is  also  eff"ectual  for  reducing  the  temperature.  The  patient 
is  placed  upon  a  mattress  protected  by  oil  cloth,  and  is  covered  by  a  sheet 
wrung  out  of  water  at  a  temperature  of  70°.  This  is  covered  by  one  or  two 
blankets.  In  half  an  hour  he  is  returned  to  bed,  and  will  be  found  to  have  a 
temperature  two  or  three  degrees  less  than  that  before  the  bath.  Another 
method  is  to  apply  the  sheet  wrung  out  of  water  at  90°,  and  then  reduce  the 
temperature  by  adding  water  at  a  lower  degree  from  a  sprinkler.  In  most 
cases,  however,  I  prefer  to  reduce  the  temperature  by  the  constant  application 
to  the  head  of  an  India-rubber  bag  containing  ice.  The  bag  should  be  about 
one-third  filled,  so  that  it  should  fit  over  the  head  like  a  cap.  At  the  same 
time,  as  a  potent  means  of  abstracting  heat,  at  least  when  the  temperature  is 
at  or  above  104°,  a  similar  application  should  be  made  by  an  elongated  rub- 
ber bag  lying  over  the  neck  and  extending  from  ear  to  ear.  Cold  applied 
over  the  great  vessels  of  the  neck  promptly  abstracts  heat  from  the  blood, 
while  it  diminishes  the  pharyngitis,  adenitis,  and  cellulitis ;  which  is  an 
important  gain.  At  the  same  time,  it  is  proper  to  sponge  frequently  the 
hands  and  arms  with  cool  water.  If  the  temperature  with  this  treatment  be 
not  sufficiently  reduced,  one  or  two  thicknesses  of  muslin  frequently  wrung 
out  of  ice-water  should  be  placed  along  the  arms  and  upon  either  side  of  the 
face.  By  such  local  measures,  which  are  agreeable  to  the  patient  and  with- 
out shock  or  perturbing  eifect  on  the  system,  we  can  reduce  the  temperature 
two  or  three  degrees.  By  adding  alcohol  or  one  of  the  alcoholic  compounds 
to  the  water  the  popular  objection  to  the  use  of  cold  is  overcome. 

Trousseau,  in  the  treatment  of  sthenic  cases  attended  by  a  high  tempera- 
ture, was  in  the  habit  of  placing  the  patient  naked  in  a  bath-tub,  and  directing 
three  or  four  pailfuls  of  water  to  be  thrown  over  him  in  a  space  of  time  vary- 
ing from  one-quarter  of  a  minute  to  one  minute  after  which  he  was  returned 
to  bed  and  covered  by  the  bedclothes  without  being  dried.  Reaction  imme- 
diately occurred,  often  with  more  or  less  perspiration.     This  treatment  was 


316  SCARLET  FEVER. 

repeated  once  or  twice  daily,  according  to  the  gravity  of  tlie  symptoms. 
Trousseau,  alluding  to  this  treatment,  says :  "  I  have  never  administered  it 
without  deriving  some  benefit."  But  the  application  of  cold  water  in  a  man- 
ner that  does  not  excite  or  frighten  the  patient  seems  preferable.  Henoch, 
having  a  large  experience,  gives  the  following  advice  in  reference  to  the  water 
treatment :  "  If  the  fever  continue  high  and  the  apparently  malignant  symp- 
toms described  above  develop,  the  head  should  be  covered  with  an  ice-bag, 
....  and  the  child  placed  in  a  lukewarm  bath,  not  under  25°  K,.  (88.25°  F.). 
I  decidedly  oppose  cooler  baths,  because  in  scarlatina,  which  presents  a  tend- 
ency to  heart-failure,  cold  may  produce  an  unexpected  rapid  collapse  more 
than  in  any  other  affection.  But  I  strongly  recommend  washing  the  entire 
body  every  three  hours  with  a  sponge  dipped  in  cool  water  and  vinegar."^ 
In  grave  cases  with  a  high  temperature  the  application  of  cold  should  be  suf- 
ficient to  produce  a  decided  reduction  of  heat,  otherwise  the  full  benefit  from 
its  use  is  not  obtained.  With  proper  stimulation  and  proper  precautions 
prostration  does  not  occur  from  the  ice-bags  to  the  head  and  neck  and  cool 
sponging  of  other  parts  so  long  as  the  temperature  does  not  fall  below  102° 
or  103°.  The  danger  alluded  to  by  Henoch  can  only  occur  from  the  use  of 
the  pack  or  general  bath,  and  the  water  treatment  can  be  efficiently  carried 
out  and  the  temperature  sufficiently  reduced  without  resorting  to  these. 
Even  Currie  of  Edinburgh,  who  first  drew  attention  to  the  benefit  from  the 
cold-water  treatment  of  scarlet  fever  in  an  age  when  the  sweating  treatment^ 
and  even  the  exclusion  of  cool  and  fresh  air  from  the  apartment,  were  deemed 
necessary,  recommended  cold  effusion  only  in  sthenic  cases  with  full  and  strong 
pulse ;  and  he  mentions  as  a  warning  two  cases  with  quick  and  feeble  pulse 
and  cool  extremities  in  which  death  occurred  immediately  after  the  use  of  the 
water. 

Sodium  salicylate  is  in  some  instances  a  useful  remedy  for  the  reduction 
of  heat  in  the  infectious  diseases.  It  seems  to  be  more  decidedly  antipyretic 
than  quinine  in  the  febrile  and  inflammatory  diseases,  though  somewhat 
depressing  to  the  heart's  action.  James  Couldrey  writes  to  the  London 
Lancet  (Dec,  1882,  p.  1064)  that  he  has  derived  great  benefit  from  its  use  in 
seven  cases  of  scarlet  fever.  He  administered  it  every  two  hours  till  ringing 
in  the  ears  was  produced,  and  afterward  every  four  hours,  prescribing  one 
grain  for  each  year  in  the  age  of  the  patient.  It  is,  in  my  opinion,  a  proper 
remedy  when  the  pulse  is  full  and  strong  and  the  temperature  is  not  suf- 
ficiently reduced  by  the  cold-water  treatment. 

Aconite  and  veratrum  viride  reduce  fever,  but  they  are  too  depressing  to 
be  safely  employed  in  grave  scarlet  fever,  and  their  antipyretic  effect  is  less 
than  that  of  water.  The  use  of  digitalis  might  be  suggested  by  the  quick 
and  feeble  pulse  in  certain  cases  that  are  attended  by  high  temperature,  but 
the  judgment  of  the  profession  is  for  the  most  part  against  its  use  in  such 
cases.  What  Stille  and  Maisch  state  of  its  employment  in  typhoid  fever 
appears  equally  applicable  to  scarlet  fever :  "  Even  its  advocates  have  not 
shown  that  it  abridges  the  disease  or  lessens  its  mortality,  while  it  is  abun- 
dantly demonstrated  to  impair  the  digestion,  reduce  the  strength,  and  even 
to  occasion  sudden  death.  The  use  of  digitalis  in  other  forms  of  fever  is 
equally  unsatisfactory,  and  justifies  the  judgment  of  Traube,  that  the  true 
field  of  action  for  digitalis  is  not  fever." 

Quinine  is  the  medicine  which  above  all  others  has  been  heretofore  most 
used,  by  almost  common  consent  of  the  profession,  to  reduce  the  temperature 
in  malignant  scarlet  fever,  but  its  use  for  this  purpose  is,  according  to  my 
observations,  far  from  satisfactory.  To  obtain  its  antipyretic  action  it  must 
be  administered  in  large  doses,  and  if  any  of  the  quinine  salts  in  ordinary 

^  Diseases  of  Children. 


TREATMENT.  317 

use  be  administered  by  the  moutli  in  sufficient  quantit}',  tliey  are  liable  to  be 
vomited.  To  a  child  of  five  years  five  grains  should  be  administered  twice 
daily  by  the  mouth,  or  ten  grains  of  a  soluble  salt,  as  the  bisulphate,  may  be 
given  per  rectum,  dissolved  in  a  little  warm  water.  Administered  per  rectum, 
it  is  frequently  not  retained  unless  held  for  a  time  by  a  napkin.  When  the 
antipyretic  doses  of  quinine  are  discontinued,  this  agent  may  be  prescribed  as 
a  tonic  in  doses  recommended  for  the  treatment  of  mild  scarlet  fever. 

Antiityrine  and  antifebrin  are  efficient  and  certain  antipyretics,  but  in  dis- 
eases attended  by  depression  they  are  not  safe  remedies.  When  employed  in 
such  diseases  the  physician  should  visit  the  ])atient  at  short  intervals,  so  that 
the  medicine  wwiy  be  omitted  if  the  action  of  the  heart  becomes  feeble.  When 
these  agents  are  employed  an  alcoholic  stimulant  should  be  given  at  the  same 
time.  In  my  practice  antipyrine  has  been  more  employed  tlian  antifebrin.  If 
the  patient  have  a  temperature  at  or  above  105°,  not  reduced  by  the  cold 
bathing  or  by  the  sodium  salicylate  or  quinine,  and  especially  if  the  patient 
Lave  jactitation  and  delirium,  so  that  convulsions  are  imminent,  the  threat- 
ening danger  may  perhaps  be  averted  by  prescribing  three  to  five  grains  of  anti- 
pyrine, with  double  or  treble  its  amount  of  bi'omide  of  sodium  or  potassium, 
to  be  given  at  intervals  of  three  hours.  The  preferable  antipyretic  is,  how- 
ever, in  my  opinion,  phenacetin,  which  can  be  given  in  powder  every  third 
hour  in  doses  of  two  or  three  grains,  with  or  without  the  bromide,  to  a  child 
of  five  years. 

In  severe  cases  with  frequent  and  rapid  pulse,  in  which  ante-mortem 
heart-clots  are  liable  to  occur,  the  ammonium  carbonate  is  often  useful.  It 
should  be  dissolved  in  water  and  given  in  milk  in  as  large  doses  as  three  grains 
every  hour  or  second  hour  to  a  child  of  five  years.  It  aids  in  producing 
stronger  contraction  of  the  cardiac  muscular  fibres,  and  thus  diminishes  the 
danger  of  the  formation  of  thrombi.  Ten-drop  doses  of  the  aromatic  spirits 
of  ammonia  may  be  employed  instead  of  the  carbonate,  given  in  sweetened 
water.  It  is  especially  useful  if  the  stomach  be  irritable.  A  wineglassful 
of  milk  should  be  employed  for  this  purpose,  so  that  the  medicine  do  not 
eause  gastritis. 

In  severe  cases  attended  by  considerable  angina  and  foul  and  offensive 
secretions  upon  the  faucial  surface  an  antiseptic,  as  boracic  acid,  in  small 
■quantity  should  be  added  to  the  potash  and  iron  mixture  recommended 
above.  If  no  drink  be  allowed  for  a  few  minutes  after  the  dose,  so  as  not 
to  wash  it  too  soon  from  the  fauces,  the  antiseptic  effect  is  more  certainly 
produced.  Those  old  enough  should  be  directed  to  hold  the  medicine  for  a 
moment  like  a  gargle  in  the  throat  before  swallowing  it.  I  employ  boracic 
•acid  by  preference,  as  in  the  following  formula : 

R.  Acid,  boracic,  ,^ss  ; 

Potass,  chlorat.,  J^ss ; 

Tr.  ferri  chloridi,  f^ij  ! 

Glvcerini,  -.  j.^. 

o  •       •      '  aa.  iX} : 

Aqufe,  f3ij.     Misce. 

Sig. :   Give  one  teaspoonful  every  two  hours  to  a  child  of  five  years. 


More  minute  directions  will  presently  be  given  for  the  treatment  of  the 
pharyngitis  when  we  speak  of  the  complications. 

Alcohol,  whether  administered  in  one  of  the  stronger  wines,  as  sherry,  or 
in  whiskey  or  brandy,  is  a  most  useful  remedy  in  scarlet  fever,  and  is  indeed 
indispensable  in  all  grave  cases  which  are  attended  by  feeble  capillary  circu- 
lation and  evidences  of  prostration.  Milk  is  also  the  best  vehicle  for  this 
agent.     The  wine-whey  or  milk-punch  should  be  given  every  hour  or  sec- 


318  SCARLET  FEVER. 

ond  hour.  In  scarlet  fever,  as  well  as  diphtheria,  comparatively  large  doses 
are  required,  as  a  teaspoonful  of  the  stimulant  every  hour  or  second  hour 
for  a  child  of  five  years. 

During  convalescence  the  hygienic  treatment  already  described  is  import- 
ant. Nutritious  diet  and  a  moderate  amount  of  alcoholic  stimulants  are 
required,  while  the  patient  is  kept  indoor  and  protected  from  currents  of 
air  as  long  as  desquamation  is  occurring.  More  or  less  anaemia  is  pi'esent 
in  most  convalescent  patients,  so  that  a  mild  tonic  containing  iron  will  aid 
in  restoring  the  health.  Elixir  of  calisaya-bark  and  iron,  preparations  of 
beef,  iron,  and  wine,  or  the  liquor  ferripeptonati  in  teaspoonful  doses  will  be 
found  useful  under  such  circumstances. 

Antisejitic  Treatment. — As  stated  above,  it  is  still  undetermined  whether  or 
to  what  extent  antiseptics,  administered  internally,  antagonize  and  control  the 
scarlatinous  poison,  and  are  therefore  curative  of  scarlet  fever.  An  important 
agent  of  this  class,  carbolic  acid,  can  only  be  employed  in  small  doses,  for  a 
dose  much  exceeding  a  drop  for  a  child,  or  even  exceeding  a  fractional  part 
of  a  drop  for  a  young  child,  might  produce  poisonous  symptoms.  Carbolic 
acid  is  a  cardiac  and  arterial  sedative,  and  it  appears  to  reduce  temperature. 
Intra-uterine  injections  of  carbolized  water  in  the  treatment  of  puerperal 
fever  are  known  to  reduce  temperature,  even  when  there  is  no  septic  matter 
in  the  uterus  to  be  disinfected  and  washed  away,  as  in  the  case  related  to  me 
in  which  the  fever  proved  to  be  due  to  measles.  It  is  not  improbable  that 
the  antipyretic  action  in  patients  of  this  class  who  have  no  septic  substance 
within  the  uterus  is  due  largely,  if  not  mainly,  to  the  absorption  of  carbolic 
acid  from  the  uterine  surface  and  its  sedative  action  on  the  vascular  system. 
Whether  this  agent,  so  highly  extolled  by  Declat,  and  to  which  I  have  alluded 
in  a  preceding  page,  can  be  safely  employed  in  doses  large  enough  to  be 
efficient  and  curative,  will  be  determined  by  future  observations.  Since 
scarlet  fever  resembles  diphtheria  in  many  particulars,  it  is  a  proper  ques- 
tion whether  the  antiseptic  remedies  now  largely  used  in  the  treatment  of 
diphtheria,  and  with  apparent  benefit,  may  not  be  useful  in  scarlet  fever. 
The  sulphocarbolate  of  sodium  has  indeed  been  employed  internally  in  scar- 
latina, with  alleged  benefit.  Its  antiseptic  action  is  attributed  to  the  carbolic 
acid  in  its  composition,  which  is  set  free.  It  is  certainly  a  useful  remedy 
in  severe  anginose  scarle*;  fever  with  fetid  breath,  whether  used  internally  or 
as  a  gargle.  It  may  be  given  in  doses  of  five  grains,  dissolved  in  water,  every 
three  hours  to  a  child  of  five  years.  In  the  gangrenous  pharyngitis  of  scar- 
let fever  probably  the  gargles  or  sprays  of  the  corrosive-sublimate  solution 
may  be  useful,  as  they  are  in  diphtheritic  pharyngitis.  The  apparent  benefit 
derived  from  the  internal  use  of  corrosive  sublimate  in  diphtheria  suggests 
its  internal  use  also  in  scarlet  fever,  but  it  has  seldom  been  employed  in  this 
manner. 

Treatment  of  Complications  and  Sequelse. — Local  measures  designed  to 
diminish  or  cure  the  pharyngitis  are  important  in  all  but  the  mildest  cases. 
They  are  more  especially  required  in  the  anginose  variety  and  in  those  not 
infrequent  cases  in  which  diphtheria  complicates  scarlatina.  Formerly  it 
was  necessary,  in  making  applications  to  the  fauces,  to  employ  the  brush  or 
probang  for  those  too  young  to  use  the  gargle,  but  hand-atomizers,  as  Rich- 
ardson's or  Delano's,  which  are  now  in  common  use,  afford  a  quick  and  easy 
method  for  making  such  applications.  Six  or  eight  compressions  of  the  bulb 
of  a  good  atomizer  are  sufficient  to  cover  the  fauces  with  the  spray.  Those 
hand-atomizers  in  the  shops  which  have  slender  metallic  points  are  likely  to 
prick  the  buccal  surface  and  cause  bleeding  if  the  child  resist  and  toss  the 
head.  To  prevent  this,  I  am  in  the  habit  of  directing  India-rubber  tubing 
to  be  drawn  over  the  point  in  such  a  way  as  not  to  obstruct  its  action.     The 


TREATMENT.  319 

following  will  be  found  useful  mixtures  for  the  atomizer :  For  ordinary 
cases, 

R.  Acidi  carbolici,  .^ss,  vel.  Acid,  boracic,  3ij  ; 

Potass,  chlorat.,  .jj ; 

Glycerini,  f^ij ; 

Aquae,  ^S^j.     Misce. 

If  the  surface  of  the  throat  be  covered  by  foul  secretions, 

R.  Acidi  carbolici,  .^ss; 

Potass,  ciilorat.,  ,^j ; 

Glycerini,  f,^j  ; 

Aquae  calcis,  f^vij.     Misce. 

If  diphtheritic  exudation  complicate  the  scarlatinous  angina,  or  the  surface 
of  the  throat  in  consequence  of  ulceration  or  necrosis  present  an  appearance 
like  that  in  diphtheria  when  the  exudation  begins  to  soften,  being  foul, 
jagged,  of  a  dirty-brown  appearance  from  dead  matter  and  fetid  secre- 
tions, those  mixtures  for  spraying  the  throat  will  be  found  useful  which 
are  recommended  in  our  remarks  relating  to  the  local  treatment  of  diph- 
theria. 

The  following  mixture  is  also  beneficial  for  local  treatment  when  the 
faucial  "surface  is  foul  and  ofi"ensive  from  the  exudations  and  secretions. 
It  should  be  applied  by  a  large  camel's-hair  pencil  every  three  to  six 
hours : 

R.  Acidi  carbolici,  gtt.  x  ; 

Liq.  ferri  subsulphatis,  fgij  ; 

Glycerinae,  f^j.     Misce. 

In  all  cases  of  scarlatinous  pharyngitis  sufficiently  severe  to  require 
special  treatment,  cool  applications  should  be  made  over  the  neck  from  ear 
to  ear,  as  by  two  thicknesses  of  muslin  frequently  squeezed  out  of  cold  water, 
or  by  the  elongated  India-rubber  bag  already  recommended  in  our  remarks 
relating  to  the  methods  to  reduce  temperature. 

In  the  first  days  of  scarlet  fever  the  coryza  is  slight  and  no  discharge 
from  the  nostrils  occurs,  so  that  no  local  treatment  is  required ;  but  before 
the  termination  of  the  malady,  in  cases  of  ordinary  gravity,  a  nasal  dis- 
charge usually  supervenes,  producing  more  or  less  redness  and  excoriating 
the  upper  lip.  Moreover,  in  localities  where  diphtheria  occurs,  if  this  mal- 
ady complicate  scarlet  fever,  it  usually  affects  the  nostrils  at  the  same  time 
that  the  fauces  are  invaded.  These  conditions  require  local  treatment  of  the 
nares.  It  should  be  remembered  that  the  Schneiderian  membrane  is  midway 
in  sensitiveness,  as  it  is  in  location,  between  the  conjunctival  and  buccal  sur- 
faces, and  is  readily  irritated  by  strong  applications.  Medicinal  applications 
made  to  it  must  be  much  milder  than  those  which  the  fauces  tolerate.  They 
should  always  be  applied  warm,  and  a  teaspoonful  of  any  mixture  properly  em- 
ployed is  sufficient  for  each  nostril  at  one  sitting.  The  applications  should 
usually  be  made  every  two  to  four  hours,  according  to  the  gravity  of  the  case 
and  the  amount  of  the  discharge.  The  best  instrument  for  this  purpose  is 
a  small  syringe  of  glass  with  curved  neck  and  bulbous  tip.  The  child's 
head  should  be  thrown  back  and  the  piston  depressed  rapidly,  so  as 
thoroughly  to  wash  out  the  nasal  cavity.  The  application  can  also  be  made 
through  an  atomizer  with  a  rounded  tip  or  a  tip  covered  by  rubber  tubing. 
The  following  is  a  useful  prescription  : 


320  SCARLET  FEVER. 

R.  Acidi  borici,  3J  ; 

Sodii  biborat.,  ^ij  ; 

Aquse  purse,  Oj.     Misce. 

It  is  evident,  from  what  has  been  stated  above,  that  the  condition  of  the 
ear  should  be  closely  observed  in  and  after  scarlet  fever.  If  the  patient  have 
earache,  considerable  relief  may  be  obtained  in  the  commencement  by  drop- 
ping a  few  drops  of  laudanum  and  sweet  oil  into  the  ear  and  covering  it  by 
some  hot  application,  either  dry  or  moist,  which  will  retain  the  heat.  A  light 
bag  containing  common  table-salt,  heated,  or  dry  and  hot  chamomile-flowers, 
will  also  answer  the  purpose.  Water  as  hot  as  can  be  well  tolerated  dropped 
into  the  ear  or  allowed  to  trickle  from  a  fountain  syringe,  so  as  to  fill  the  ear, 
is  also  very  beneficial  in  allaying  the  pain.  A  4  per  cent,  solution  of  nitrate 
of  cocaine,  with  an  equal  quantity  of  laudanum,  dropped  into  the  ear,  will 
often  give  considerable  relief.  If  the  hot  applications  over  the  ear  are  not 
well  borne.  Dr.  C.  H.  May,  aurist,  recommends  applying  a  long  and  narrow 
ice-bag  immediately  behind  the  auricle  and  extending  under  and  in  front  of 
the  ear,  so  as  to  cover  the  temporo-maxillary  region,  and  at  the  same  time 
instilling  into  the  ear  hot  salt  water  (gj  to  Oj),  to  which  laudanum  or  cocaine 
is  added.  He  also  states  that  antipyrine  in  large  doses  is  also  useful  in 
relieving  the  pain.^  If  the  pain  be  not  quickly  relieved,  a  leech  should  be 
applied  at  the  base  of  the  tragus.  0.  D.  Pomeroy,  an  experienced  aurist  of 
New  York,  says :  "  Leeching  employed  at  the  right  time  rarely  fails  to  sub- 
due the  pain  and  inflammation.  The  posterior  face  of  the  tragus  is  ordinarily 
the  best  place  for  applying  the  leech,  but  it  may  be  applied  in  front  of  the 
ear  or  behind,  wherever  the  tenderness  on  pressure  is  greatest.  In  my 
opinion,  paracentesis  may  frequently  be  rendered  unnecessary  by  the  timely 
use  of  one  or  two  leeches  applied  to  the  meatus." 

If  the  otitis  continue,  as  shown  by  pain  in  the  ear,  of  which  children  old 
enough  to  speak  bitterly  complain,  and  which  causes  those  too  young  to  speak 
to  press  their  fingers  into  or  against  their  ears,  this  inflammation  should  not 
be  neglected,  as  it  may  involve  serious  consequences.  Multitudes  of  children 
have  had  permanent  impairment  or  even  loss  of  hearing,  with  caries  or  necro- 
sis of  the  walls  of  the  middle  ear  and  of  the  mastoid  cells,  which  might  have 
been  prevented  by  prompt  and  skilful  management  of  the  ear  in  the  early 
stage  of  the  inflammation.  If,  therefore,  the  otitis  continue  without  mitiga- 
tion of  pain  after  the  above  measures  have  been  employed,  paracentesis  of 
the  drumhead  is  probably  required.  The  following  directions  for  performing 
this  operation,  which  will  be  useful  to  country  practitioners  who  may  not  be 
able  to  obtain  the  assistance  of  a  specialist,  are  furnished  by  Dr.  Pomeroy : 
'•  The  forehead  mirror  should  be  worn,  in  order  to  leave  the  hand  free  to 
operate  by  either  artificial  or  day  light.  A  good-sized  speculum  is  introduced 
into  the  meatus.  Then  an  ordinary  broad  needle,  about  one  line  in  diameter, 
with  a  shank  of  about  two  inches,  such  as  oculists  use  for  puncturing  the 
cornea,  should  be  held  between  the  thumb  and  fingers,  lightly  pressed,  so  as 
not  to  dull  delicate  tactile  sensibility.  The  part  being  well  under  light,  the 
most  bulging  portion  of  the  membrane  should  be  lightly  and  quickly  punc- 
tured with  a  very  slight  amount  of  force.  The  posterior  and  superior  por- 
tion of  the  membrane  is  the  most  likely  to  bulge.  The  chordas  tympani 
nerve  ordinarily  lies  too  high  up  to  be  wounded.  The  ossicles  are  avoided 
by  selecting  a  posterior  portion  of  the  membrane.  After  puncture  the  ear 
should  be  inflated  by  an  ear-bag  whose  nozzle  is  inserted  into  a  nostril,  both 
nostrils  being  closed,  so  as  to  force  the  fluid  from  the  tympanum.  The  punc- 
ture may  need  to  be  repeated  at  intervals  of  a  day  or  two,  provided  that  the 
pain  and  bulging  return." 

1  Pediatric  Sec.  of  N.  Y.  Acad,  of  Med.,  March  14,  1889. 


TREATMENT.  321 

Albert  H.  Buck  of  New  York,  in  a  highly  instructive  paper  read  before 
the  International  Medical  Congress  in  1876,  writes  as  follows  of  paracentesis 
of  the  membrana  tympani  in  scarlatinous  otitis :  "  In  this  one  slight  opera- 
tion, which  in  itself  is  neither  dangerous  nor  very  painful,  lies  the  power  to 
prevent  the  whole  train  of  disagreeable  and  dangerous  symptoms."  Buck 
relates  an  instructive  example :  The  age  of  the  patient  was  three  years,  and 
the  earache  had  been  complained  of  only  about  twenty-four  hours.     "  Toward 

morning,"  says  he,  "  I  was  sent  for,  as  the  pain  had  become  constant 

An  examination  with  the  speculum  and  reflected  light  showed  an  cedematous 
and  bulging  membrana  tympani  (posterior  half),  the  neighboring  parts  being 
very  red,  though  as  yet  but  little  swollen.  In  the  most  prominent  portion 
of  the  membrane  I  made  an  incision  scarcely  three  millimetres  (one-tenth 
inch)  in  length,  and  involving  simply  the  different  layers  of  the  membrana 
tympani.  This  was  almost  immediately  followed  by  a  watery  discharge  (with- 
out the  aid  of  inflation),  which  ran  down  over  the  child's  cheek.  At  the  end 
of  three  or  four  minutes  the  child  had  ceased  crying,  and  in  less  than  a  quar- 
ter of  an  hour  she  was  fast  asleep.  At  first  the  discharge  was  very  abun- 
dant and  mainly  watery  in  character,  but  it  steadily  diminished  in  quantity 
and  became  thicker,  till  finally,  on  the  fourth  day,  it  ceased  altogether.  On 
the  tenth  day  the  most  careful  examination  of  the  ear  could  not  detect  any 
trace  of  either  the  inflammation  or  the  artificial  opening."  The  ear  had  prob- 
ably been  saved  from  ulceration  of  the  drum  membrane,  long-continued  sup- 
purative otitis,  and  perhaps  permanent  impairment  of  hearing. 

When  an  opening  has  been  made  in  the  membrana  tympani,  either  by 
incision  or  ulceration,  it  is  advisable  in  some  instances  to  inflate  the  tym- 
panum by  Politzer's  method,  which  has  been  alluded  to  above.  The  nozzle 
of  an  India-rubber  bag  with  a  flexible  tube  attached  is  introduced  into  the 
nostril  on  the  aff"ected  side,  and  both  nostrils  are  compressed  against  it.  The 
patient  fills  his  mouth  with  water,  which  he  swallows  at  a  given  signal,  as 
after  the  words  one,  two,  three,  spoken  by  the  operator.  During  the  act  of 
swallowing,  which  opens  the  Eustachian  tube,  the  rubber  bag  is  forcibly  com- 
pressed, which  forces  the  air  along  the  tube  into  the  middle  ear  and  facilitates 
the  escape  of  the  pent-up  secretions  in  the  tympanic  cavity.  Dr.  May  recom- 
mends cleansing  the  nostrils  and  pharynx  with  a  warm  solution  of  salt,  one 
drachm  to  the  pint,  before  the  use  of  Politzer's  bag. 

If  the  otitis  have  continued  unchecked  by  treatment  until  the  secretions 
within  it,  after  days  and  nights  of  sufiiering,  have  escaped  by  ulceration 
through  the  drumhead,  the  opportunity  for  prompt  and  certain  cure  is  passed. 
Still,  the  patient  under  these  circumstances  may  quickly  recover,  or  there 
may  be  the  other  alternative  described  above,  in  which  the  ear  is  badly  dam- 
aged and  chronic  inflammation  established  in  the  walls  of  the  tympanum, 
giving  rise  to  an  off"ensive  otorrhoea.  In  this  state  of  the  ear  internal  rem- 
edies are  indicated,  such  as  surgeons  employ  in  suppurative  inflammations  of 
bone  occurring  in  other  parts  of  the  system.  Cod-liver  oil  and  iodide  of  iron 
are  required,  especially  by  patients  of  strumous  diathesis,  the  object  being  to 
promote  a  more  healthy  state  of  system,  so  as  to  prevent  extension  of  the 
inflammation  and  facilitate  the  healing  process.  Carbolized  solutions,  as  the 
following,  syringed  warm  into  the  ear  in  which  otorrhoea  is  occurring,  are 
useful  in  promoting  cleanliness  and  increasing  the  comfort  of  the  patient : 

R.  Acidi  carbolici,  .^ss; 

Glycerini,  f^ij ; 

Aquae,  f!§iv.     Misce. 

But  recently  an  effectual  curative  agent  for  local  treatment  has  been  disco v- 
21 


322  SCARLET  FEVER. 

ered  in  boracic  acid,  by  the  use  of  which  the  discharge  quickly  diminishes 
and  the  condition  of  the  ear  more  certainly  and  rapidly  improves  than  by  the 
use  of  the  carbolized  lotions. 

R.  Acidi  borici,  Sijss; 

Glycerini, 

Aquse,  da.  f^j. 

Sig. :  Instil  sufficient  to  fill  the  external  ear  three  or  four  times  daily. 

The  beneficial  effects  observed  from  the  use  of  boracic  acid  in  aural  sur- 
gery have  given  it  nearly  the  same  position  as  a  curative  agent  to  diseases 
of  the  ear  which  atropine  holds  to  diseases  of  the  eye.  Recently  aurists 
are  employing  finely  triturated  powder  of  boracic  acid  dusted  into  the  ear. 
The  patient  lies  upon  the  side  with  the  affected  ear  uppermost.  The  ear  is 
thoroughly  cleaned  by  syringing  with  tepid  water,  and  by  means  of  a  little 
scoop  made  of  stiff  paper  or  pasteboard  or  the  segment  of  quill  as  much  of 
the  powder  is  introduced  into  the  ear  as  will  cover  a  five-cent  silver  piece. 
By  working  the  ear  it  descends  to  the  drumhead.  I  can  bear  witness  to  its 
efficacy  in  the  otorrhoea  of  children  when  it  is  used  in  this  manner  three  times 
daily. 

The  following  astringent  has  also  been  employed  with  good  results  for 
the  otorrhoea  resulting  from  scarlet  fever  as  well  as  from  other  causes  : 

R.  Zinci  sulphatis, 

Aluminis,  da.  gr.  v  ; 

Aquse,  f^.     Misce. 

A  few  drops  of  this  should  be  dropped  into  the  ear,  or,  if  the  ear  be  sensitive 
and  painful,  five  drops  should  be  added  to  a  teaspoonful  of  warm  water  and 
dropped  or  syringed  into  the  ear. 

But  in  recent  times  aurists  have  discovered  a  remedy  superior  to  the 
above  in  iodoform,  the  action  of  which  is  safe  and  efficient  for  protracted 
otorrhoea  with  granulations,  and  it  is  superseding  to  a  great  extent  the  agents 
heretofore  used  in  the  treatment  of  this  disease.  The  ear  should  first  be 
thoroughly  cleaned  by  syringing  with  warm  water  and  dried,  and  iodoform, 
to  which  a  little  balsam  of  Peru  is  added  to  mask  the  disagreeable  odor, 
should  be  pressed  down  to  the  bottom  of  the  auditory  canal  by  any  conveni- 
ent instrument.  It  is  anodyne,  astringent,  and  disinfectant,  and  should  be 
employed  in  a  dry  state  in  considerable  quantity. 

The  sequelae  of  otitis  media,  such  as  granulations  sprouting  out  from  the 
drumhead,  some  of  which  may  be  of  large  size  and  are  known  as  polypi,  may 
require  treatment  by  the  aurist.  A  polypus  may  sometimes  be  removed  by 
the  forceps,  or,  better,  by  the  snare.  Polypi  not  large  and  favorably  located 
can  sometimes  be  cured  by  an  astringent  powder,  as  iodoform,  sulphate  of 
zinc,  or  alum,  or  by  applying  the  liquid  subsulphate  of  iron.  The  otitis 
externa  produced  by  the  irritating  discharge  which  flows  from  the  middle  ear 
soon  disappears  when  the  flow  ceases. 

The  renal  affection — which,  as  we  have  seen,  so  often  commences  in  the 
declining  period  of  scarlet  fever  or  during  convalescence  in  mild  as  well  as 
severe  cases — is  frequently  more  dangerous  than  the  primary  disease.  It 
largely  increases  the  percentage  of  deaths.  A  clear  appreciation  of  its  thera- 
peutic requirements  is  important,  since  by  judicious  treatment  many  recover 
who  would  inevitably  be  sacrificed  by  improper  measures.  The  family  should 
be  informed  that  the  danger  from  scarlet  fever  does  not  cease  with  the  decline 
of  the  eruption,  and  that  the  kidneys  may  become  seriously  affected  by  too 
early  exposure  of  the  patient  to  currents  of  air  or  sudden   changes  of  tem- 


TREATMENT.  323 

perature,  by  which  cutaneous  transpiration  is  checked.  He  should  therefore 
be  kept  indoor  in  a  comfortable  and  uniform  temperature  three  or  four  weeks 
after  the  termination  of  the  fever,  until  desquamation  has  entirely  ceased  and 
the  new  epiderm  is  sufhciently  thick  and  firm  to  protect  the  surface.  During 
the  changeable  temperature  of  the  autumnal,  winter,  and  spring  months  even 
longer  confinement  at  home  may  be  advisable. 

The  nephritis  and  consef|uent  albuminuria  antedate  by  some  days  the 
occurrence  of  dropsy,  and  a  physician  should  never  discharge  a  scarlatinous 
patient  without  one  or  more  examinations  of  his  urine.  When  his  visits 
cease  the  nurse  should  be  instructed  to  make  the  examinations  by  heat  and 
nitric  acid  during  the  ensuing  month,  and  if  any  evidence,  however  slight, 
appear  that  the  kidneys  are  involved,  he  should  be  notified,  in  order  that 
appropriate  treatment  may  be  immediately  commenced.  Pearly  and  correct 
treatment  of  the  nephritis  is  attended  by  much  better  results  than  delayed 
treatment,  and  many  more  patients  are  doubtless  now  saved  than  in  former 
times,  when  little  attention  was  given  to  the  state  of  the  kidneys  until  dropsy 
or  other  prominent  symptoms  appeared.  I  have  found  no  mother  or  nurse 
so  ignorant  that  she  could  not  properly  employ  the  test  of  nitric  acid  and 
heat,  and  if  she  be  solicitous  for  the  welfare  of  the  child,  she  will  not  hesi- 
tate to  carry  out  the  directions  and  immediately  notify  the  physician  if  the 
tests  employed  produce  the  least  cloudiness  or  turbidity  of  the  urine. 

The  patient  as  soon  as  nephritis  commences,  as  shown  by  the  state  of  the 
urine,  should  be  put  to  bed  in  a  room  of  warm  and  equable  temperature  {1'2° 
to  75°  F.).  His  diet  should  be  liquid,  consisting  of  milk,  farinaceous  food, 
and  a  moderate  quantity  of  animal  broths.  He  may  drink  liquids  freely, 
especially  water  not  too  cool,  to  which  spiritus  setheris  nitrosi  is  added.  If 
he  be  prostrated  by  the  primary  disease,  alcoholic  stimulants  should  be  allowed. 

The  indications  are  to  relieve  the  hypera^mic  kidneys  by  diaphoresis  and 
purgation.  To  produce  the  former  the  patient  should  be  immersed  in  a  warm 
bath  at  about  the  temperature  of  the  body  (98°  to  100°),  in  which,  if  he  be 
quiet  and  comfortable,  he  should  remain  from  fifteen  to  twenty  minutes,  but 
a  shorter  time  if  restless  and  frightened  by  the  water,  after  which  he  should 
be  placed  in  a  warm  bed  and  well  covered  by  blankets.  If  perspiration  result, 
the  bath  has  been  useful,  and  it  may  be  employed  in  grave  cases  two  or  three 
times  daily.  If  perspiration  do  not  result,  it  may  be  produced  by  surround- 
ing the  body  either  by  hot  dry  or  moist  air.  Hot  air  may  be  produced  by 
burning  alcohol  in  a  thin  layer  upon  a  plate  under  a  chair,  upon  which  the 
patient  sits  while  he  is  surrounded  by  a  blanket,  or  he  may  be  covered  in  bed 
and  the  hot  air  introduced  under  the  bedclothes.  In  New  York  a  convenient 
apparatus  is  used  for  this  purpose,  consisting  of  a  small  sheet-iron  pipe 
enclosed  in  a  small  box  of  the  same  material.  The  box  is  in  the  form  of  a 
trunk,  with  a  handle  for  convenience  in  carrying,  and  the  lower  end  of  the 
pipe,  which  extends  nearly  to  the  floor,  contains  an  alcohol  lamp.  Hot  moist 
air  may  be  produced  by  placing  against  the  patient  bottles  of  hot  water  sur- 
rounded by  towels  wrung  out  of  water.  The  steam  arising  from  them  and 
enveloping  the  body  and  limbs  produces  a  prompt  sudorific  effect.  There  is 
in  use  in  this  city,  in  the  treatment  of  these  and  similar  cases  requiring 
diaphoresis,  a  convenient  apparatus  for  generating  steam.  It  consists  of  a 
cylinder  pierced  with  holes  for  the  admission  of  air  and  containing  a  spirit 
lamp,  over  which  is  a  pan  or  pail  holding  a  little  water.  The  patient,  nearly 
naked,  is  placed  in  a  chair  with  the  apparatus  underneath,  and  is  covered  by 
a  blanket,  so  that  the  steam  surrounds  the  body.  This  gives  rise  to  free 
perspiration,  which  continues  after  the  patient  is  placed  in  bed.  This  treat- 
ment should  be  repeated  one  or  more  times  daily,  according  to  the  gravity  of 
the  case. 


324  SCARLET  FEVER. 

The  sudorific  effect  of  the  treatment  by  external  warmth  described  above 
should  be  aided  by  employing  diaphoretics.  Those  which  have  been  most 
used  are  the  acetates  of  ammonium  and  potassium,  the  bitartrate  and  citrate 
of  potassium,  and  spiritus  aetheris  nitrosi.  If  employed  when  the  surface  is 
cool  they  act  rather  as  diuretics  than  diaphoretics.  These  agents,  being 
simple  in  their  action  and  without  deleterious  effect,  may  be  given  frequently 
and  in  large  proportionate  doses  for  the  age. 

But  lately  a  diaphoretic  which  far  surpasses  these  in  efficiency  has  been 
discovered  in  pilocarpine,  the  active  principle  of  jaborandi.  Being  soluble  in 
water  and  tasteless,  it  is  easily  administered,  and  is  retained  when,  on  account 
of  the  uraemic  poisoning  present  in  scarlatinous  nephritis,  the  stomach  is 
irritable  and  other  medicines,  as  digitalis,  are  rejected.  Ether  may  be 
employed  with  it,  or  the  amount  of  alcoholic  stimulant  may  be  increased 
at  the  time  of  its  exhibition  in  order  to  guard  against  any  depressing  effect. 
To  a  child  of  two  years  one-fortieth  to  one-twentieth  of  a  grain  may  be  given 
every  six  hours  by  the  mouth.  It  may  also  be  employed  hypodermically,  as 
one-twentieth  of  a  grain  to  a  child  of  five  years.  It  has  both  a  diaphoretic 
and  a  diuretic  action,  while  it  stimulates  both  the  salivary  and  mucous  secre- 
tions. According  to  one  observer,  an  adult  when  fully  under  the  influence 
of  pilocarpine  secretes  from  one  pint  to  one  quart  of  saliva  within  two  hours, 
and  Leyden  reports  a  case  of  diphtheritic  nephritis  in  which  the  quantity  of 
urine  rose  from  half  a  pint  to  five  pints  daily.  But  its  most  prompt  and 
certain  action  is  upon  the  sweat-glands.  Hirschfelder  speaks  of  its  beneficial 
action  in  relieving  various  forms  of  dropsy,  and  adds :  "  In  one  morbid  con- 
dition of  the  kidney,  however,  jaborandi  is  the  remedy  par  excellence,  and 
that  is  the  acute  parenchymatous  nephritis  which  frequently  follows  scar- 
latina  This  disease  heals  spontaneously  if  the  danger  that  threatens 

life  from  reduction  of  the  urine  and  from  the  effusions  of  fluid  into  the  cav- 
ities of  the  body  be  averted.  In  this  disease  jaborandi  works  wonders."  I 
have  also  found  it  an  invaluable  agent  when  the  older  remedies  failed  and 
death  seemed  imminent.  The  following  cases,  in  which  the  beneficial  action 
of  this  agent  was  apparent,  occurred  in  my  practice : 

Case  1. — G ,  male,  aged  five  years  and  six  months,  sickened  with  scarlet 

fever  on  June  2,  1882.  It  began  with  vomiting,  and  was  attended  by  a  degree  of 
fever  which  indicated  an  attack  of  rather  more  than  the  average  gravity.  The 
fauces  at  one  time  exhibited  a  slight  exudation  like  that  of  diphtheria.  In 
the  declining  stage  of  the  malady  rheumatic  pain  and  tenderness  occurred 
in  the  wrist-  and  finger-joints,  but  not  in  those  of  the  lower  extremities.  The 
case,  however,  progressed  favorably,  and  during  the  convalescence  my  attend- 
'  ance  ceased.  On  June  24th  my  attention  was  again  called  to  the  child,  when 
the  urine  was  found  to  be  scanty  and  very  albuminous.  External  measures,  such 
as  are  described  in  the  foregoing  pages,  were  employed,  and  the  infusion  of  digi- 
talis with  potassium  acetate  ordered  to  be  given  every  three  hours;  but  this  med- 
icine was  for  the  most  part  vomited.  The  bowels  were  kept  open  by  jalap  and 
the  potassium  bitartrate.  The  urine,  however,  continued  scanty,  and  on  June 
28th  severe  convulsions  occurred.  At  this  time  the  quantity  of  urine  was  only 
fgij  in  twenty-four  hours.  The  pulse  in  the  convulsions  was  quick  and  feeble. 
the  skin  very  hot,  and  the  axillary  temp.  103°.  The  eclampsia  continued  one  hour, 
and  was  controlled  by  large  and  repeated  doses  of  bromide  of  potassium,  aided  by 
clysters  of  five  grains  of  hydrate  of  chloral  in  water.  Muriate  of  pilocarpine  was 
now  directed  to  be  given  in  doses  of  one-thirty-second  of  a  grain  every  three 
hours,  dissolved  in  cold  water.  This  agent  was  not  vomited,  and  it  must  have 
been  given  by  the  parents  in  the  fright  and  anxiety  in  larger  or  more  frequent 
doses  than  were  directed,  for  on  July  1st  the  bottle  containing  one  grain  was 
empty.  Free  diaphoresis  resulted  from  the  pilocarpine,  and  the  quantity  of 
urine  was  increased.  The  mother  stated  that  the  child  had  taken  only  two  doses, 
or  one-sixteenth  of  a  grain,  of  pilocarpine  when  the  diuretic  effect  was  apparent 


TREATMENT.  325 

and  free  diaphoresis  also  occurred.  She  also  stated  subsequently  that  the 
quantity  of  urine  was  larger  when  the  pilocarpine  was  administered  every 
tnird  hour  than  when  given  at  a  longer  interval.  A  flaxseed  poultice  on  which 
mustard  was  dusted  was  also  applied  over  the  kidneys.  On  June  20th  the  pulse 
was  96,  temperature  100.5°;  occasional  convulsive  attacks  occurred,  which  were 
readily  controlled  by  enemata  of  hydrate  of  chloral.  On  June  30th  the  symp- 
toms were  all  better;  no  more  attacks  of  eclampsia  had  occurred,  and  the  urine 
was  more  abundant  and  less  albuminous.  The  mother  remarked  that  the  new 
medicine  (pilocarpine)  had  settled  the  stomach  and  increased  the  urine.  The 
patient  continued  to  improve,  and  on  July  4th  the  record  states :  "  Now  takes 
the  pilocarpine,  gr.  ^^,  every  six  hours;  passes  urine  freely  since  yesterday;  has 
not  vomited  since  he  began  to  take  the  pilocarpine ;  pulse  100°,  axillary  temp. 
99°;  is  playful  and  takes  milk  freely,  nearly  three  quarts  in  twenty-four  hours, 
with  some  farinaceous  food.  Digitalis  with  potassium  acetate  is  also  given  in 
occasional  doses."  July  6th,  pulse  92,  temp.  99°;  perspires  much,  and  urine 
nearly  normal  in  quantity  and  character. 

Case  2.— Mary  S ,  aged  five  years,  on  Dec.  22,  1882,  presented  the  symp- 
toms of  severe  nephritis.  Her  brother  had  scarlet  fever  two  weeks  previously, 
and  she  had  sore  throat  at  about  the  same  time,  but  without  efflorescence ;  pulse 
98,  temperature  98.5°;  her  urine  highly  albuminous,  and  reduced  to  fgiv  in 
twenty-four  hours;  bowels  constipated.     Ordered  a  single  dose  of 

R.  Hydrarg.  chlor.  mitis,         gr.  iij  ; 

Resin,  podophylli,  gr.  ^.     Misce. 

The  muriate  of  pilocarpine  was  also  ordered,  gr.  ^^jj,  but  the  patient  vomited  soon 
after  taking  it.  Another  dose  was  retained,  and  was  followed  by  considerable 
perspiration.  Dec.  23d,  had  one  stool  from  the  powder  of  yesterday.  Has  taken 
five  doses  of  pilocarpine,  but  vomited  after  three  of  them.  The  last  dose  was 
administered  at  10  P.  M.,  and  the  mother  says  she  "  sweat  fearfully  "  during  the 
night.  The  patient  was  kept  warm  in  bed ;  stimulating  poultices  of  mustard  and 
flaxseed,  one  to  sixteen,  were  constantly  in  use  over  the  kidneys,  and  the  pilocar- 
pine was  administered  three  or  four  times  a  day.  The  record  for  Dec.  26th  states : 
"  Took  the  pilocarpine  four  times  since  yesterday  morning,  and  each  dose  is  fol- 
lowed by  perspiration  lasting  from  one  to  one  and  a  half  hours ;  quantity  of  urine, 
from  f3\'j  to  fgviij  daily  ;  vomited  twice  yesterday,  not  to-day ;  pulse  104;  temp. 
97.75°  ;  complains  of  frontal  headache ;  bowels  regular ;  has  considerable  saliva- 
tion. The  patient  is  warm  in  bed,  and  the  flaxseed  and  mustard  poultice  over  the 
kidneys  is  continued."  Dec.  28th,  specific  gravity  of  urine  1019 :  urine  still  quite 
albuminous  and  containing  blood-corpuscles  and  granular  casts,  also  crystals  of 
oxalate  of  lime.  Dec.  30th,  takes  gr.  -^^  pilocarpine  twice  daily,  and  occasional 
doses  of  infusion  of  digitalis ;  urine  more  abundant ;  its  specific  gravity  1014, 
slightly  albuminous,  and  containing  very  few  granular  casts  and  blood-corpuscles; 
has  lost  its  smoky  appearance ;  reaction  alkaline ;  perspiration  slight ;  patient 
convalescent. 

In  another  instance  a  child  of  five  years,  from  three  to  four  weeks  after 
scarlet  fever,  was  noticed  to  have  anasarca  of  the  face  and  extremities,  with 
scanty  and  albuminous  urine.  One-thirty-second  of  a  grain  of  muriate  of 
pilocarpine  was  administered  every  six  hours  without  the  desired  sudorific 
eff'ect.  It  was  then  administered  every  four  hours,  with  an  increase  of  per- 
spiration and  urination,  so  that  the  nephritic  symptoms  were  relieved  and 
the  patient  apparently  out  of  danger  within  three  or  four  days. 

In  a  fourth  patient,  a  girl  of  three  years  having  scarlatinous  nephritis, 
with  symptoms  very  similar  to  those  in  the  last  case,  the  administration  of 
one-twentieth  grain  doses  of  pilocarpine  in  conjunction  with  the  hot-air 
bath  was  followed  by  increased  perspiration  and  urination,  and  progressive 
and  rather  rapid  convalescence.  This  child  had  been  taking  bichloride  of 
mercury  in  one-fiftieth  grain  doses,  prescribed  by  a  homoeopathic  physician, 
without  appreciable  benefit,  it  having  been  for  the  most  part  vomited. 

Given,  as  in  the  above  cases,  in  moderate  doses  and  with  sufiicient  inter- 
val, pilocarpine  has  never  in  my  practice  had  any  deleterious  efi"ect,  and  I 


326  SCARLET  FEVER. 

regard  it  as  a  very  important  addition  to  the  remedies  for  the  relief  of  scar- 
latinous nephritis.  It  is  apparently  the  most  useful  and  important  diapho- 
retic for  this  disease  which  we  possess. 

Cathartics,  especially  those  of  a  hydragogue  nature,  are  also  very  bene- 
ficial. Their  action  is  more  certain  than  that  of  most  diaphoretics  and  diu- 
retics, and  their  employment  is  imperatively  required  in  severe  or  dangerous 
cases  in  which  it  is  necessary  to  remove  as  soon  as  possible  the  serum  or  urea 
which  endangers  life.  Young  children  or  those  with  delicate  stomachs  and 
those  much  enfeebled  by  the  primary  disease  may  take  magnesia,  either  the 
citrate  or  the  calcined.  A  good  cathartic  for  ordinary  cases  is  a  mixture 
of  jalap  and  potassium  bitartrate,  the  pulvis  jalapse  compositus,  consisting 
of  one  part  of  jalap  and  two  of  cream  of  tartar.  Ten  grains  of  the  mixture 
may  be  given  to  a  child  of  five  years,  and  repeated  according  to  circumstances. 
Its  eff"ect  is  increased  by  dissolving  a  teaspoonful  of  potassium  bitartate  in  a 
gobletful  of  water  and  allowing  the  patient  to  drink  from  it.  The  following 
cathartic  also  acts  promptly  and  beneficially  in  the  treatment  of  scarlatinous 
nephritis : 

R.  01.  cinnamomi,  gtt.  v; 

Magnes.  sulphat.,         ^  ; 

Potass,  bitartrat.,         gij.     Misce. 
Dose :  One  teaspoonful  repeated  from  two  to  four  hours  until  catharsis  occurs. 

After  the  use  of  laxative  agents  the  kidneys,  being  less  congested  on 
account  of  the  diversion  that  has  occurred,  often  begin  to  excrete  urine  more 
freely.  But  if  the  patient  be  anaemic  or  enfeebled  and  the  symptoms  are 
not  urgent,  it  is  frequently  better  to  avoid  active  catharsis,  which  more  or 
less  reduces  the  strength,  and  employ  remedies  of  a  sustaining  character,  as 
in  the  following  case,  which  occurred  in  my  practice :  A  little  boy,  pallid  and 
scrofulous,  began  to  have  anasarca  after  scarlet  fever,  chiefly  in  the  scrotum, 
accompanied  by  a  moderate  degree  of  ascites.  The  urine,  which  was  passed 
in  nearly  the  normal  quantity,  contained  albumen,  but  not  in  large  amount. 
This  patient  gradually  and  fully  recovered,  with  no  treatment  except  the  use 
of  an  oil-silk  jacket  over  the  kidneys  and  abdomen  to  promote  diaphoresis, 
and  the  use  of  iron.  Such  a  patient,  treated  by  the  powerful  eliminatives 
which  we  employ  for  the  more  urgent  and  robust  cases,  would  probably  have 
been  injured  rather  than  benefited.  No  treatment  can  therefore  be  recom- 
mended in  a  treatise  on  scarlatinous  nephritis  which  will  be  strictly  applica- 
ble for  all  cases.  Variations  are  demanded  according  to  the  state  of  the 
patient  and  the  form  and  gravity  of  the  disease. 

Diuretics  which  do  not  stimulate  the  kidneys  are  proper  at  an  early  as 
well  as  late  period  of  the  renal  malady,  and  digitalis  is  the  one  usually  pre- 
scribed. I  do  not  hesitate  to  order  it  from  the  first  day  in  combination  with 
the  acetate  of  potassium.  One  teaspoonful  of  the  infusion  may  be  given 
every  third  hour  to  a  child  of  five  years.  The  following  formula  is  for  one 
of  this  age  in  good  general  condition  : 

R.  Potass,  acetatis,  ,^ss ; 

Infus.  digitalis,  f^vj.     Misce. 

The  following  formulae  are  recommended  by  Meigs  and  Pepper : 

R.  Potass,  bitart.,  3j  ; 

Spt.  junip.  comp.,  fjij  ; 

Spt.  fether.  nitros.,  fjj  ; 

Tr.  digitalis,  Ti^xv ; 

Syrupi,  f;^v ; 

Aquse,  f^ij.     Misce. 

Dose :  One  teaspoonful  every  two  hours  to  a  child  of  two  to  four  years. 


TREATMENT.  327 

R.  Potass,  acetat.,  3J  ; 

Tr.  digitalis,  fj^ss ; 

Syr.  scilhv,  f;5i-j  ; 

Syr.  ziiigib.,  f^v ; 

Aquae,  q.  s.  ad  f^iij.     Misce. 

Dose  :  A  teaspoonful  every  two  or  three  hours  to  children  two  or  three  years  old. 

Local  treatment  is  important.  L.  Thomas,  Romberg,  and  others  recom- 
mend the  application  of  leeches,  three  or  more,  over  the  kidneys.  Thomas 
says  :  "  In  many  cases  the  abstraction  of  blood  causes  immediate  and  per- 
manent relief ;  the  fever  and  the  pain  in  the  region  of  the  kidneys  cease,  the 
secretion  of  urine  becomes  augmented,  the  albuminui'ia  lessens  from  day  to 
day,  and  the  moderate  degree  of  dropsy  that  has  been  developed  disappears." 
It  is  only  in  the  more  robust  children,  who  have  been  but  little  reduced  by  the 
primary  disease,  that  leeching  is,  in  my  opinion,  admissible.  In  the  majority 
of  cases  instead  of  depletion  a  poultice  slightly  irritating,  so  as  to  cause  red- 
ness of  the  skin,  should  be  applied  over  the  kidneys,  or  for  older  children, 
not  likely  to  be  frightened  by  the  process,  the  dry  cups  may  be  applied  daily. 
In  subacute  cases,  not  attended  by  any  alarming;  symptoms,  sufficient  redness 
may  be  produced  by  one  of  the  irritating  plasters  which  the  shops  contain, 
constantly  worn. 

Eclampsia,  described  in  the  preceding  pages,  is  produced,  as  we  have  seen, 
during  the  course  of  scarlet  fever  by  the  irritating  effect  of  the  scarlatinous 
poison  upon  the  nervous  centres ;  but,  occurring  after  the  decline  of  scarlet 
fever,  it  is  ordinarily  produced  by  the  retained  urea.  The  same  remedies  are 
required  to  control  the  convulsive  movements  as  when  they  occur  under 
other  circumstances.  The  bromide  of  potassium  should  be  immediately 
administered  in  large  doses  whenever  eclamptic  symptoms  arise.  During 
eclampsia  a  child  of  three  years  should  take  five  grains  of  this  agent  every 
five  to  ten  minutes  till  the  attack  ceases,  and  then  at  longer  intervals.  The 
hydrate  of  chloral  is  a  more  powerful  agent,  and  if  the  eclampsia  be  not 
quickly  controlled,  I  commonly  employ  it  per  rectum,  dissolved  in  one  or  two 
teaspoonfuls  of  water.  For  a  child  of  three  to  five  years  five  grains  should 
be  thrown  into  the  rectum  by  a  small  glass  or  gutta-percha  syringe,  and 
retained  by  pressure.  Properly  administered  and  retained,  it  rarely  fails  to 
control  the  eclampsia  within  ten  or  fifteen  minutes.  Subsequently,  occa- 
sional doses  of  the  bromide  should  be  given  to  prevent  the  occurrence  of 
eclampsia  while  the  measures  described  above  are  being  employed  to  elimi- 
nate the  urea. 

Rheumatism,  endocarditis,  and  pei'icarditis,  arising  as  complications  or 
sequelee,  require  the  treatment  which  is  appropriate  when  they  occur  under 
other  circumstances,  but  the  remedies  should  not  be  depressing,  as  the  sys- 
tem is  already  enfeebled  by  the  primary  disease.  The  rheumatism,  if  mild, 
usually  abates  in  a  few  days  without  -medication,  and  the  affected  joints 
require  only  some  soothing  lotion  and  support  by  a  bandage.  The  following 
liniment  may  be  applied  upon  muslin  and  covered  by  cotton  wadding : 

R.  Acid,  carbolioi,  f;^j  ; 

Tine,  belladonnse,         f5j  ; 
01.  camphorati,  f3ij. 

If  the  rheumatism  be  severe  and  affect  several  joints,  the  sodium  salicylate 
should  be  prescribed,  as  in  the  idiopathic  disease,  with  an  occasional  opiate  to 
procure  rest. 

Endocarditis  and  pericarditis  require  rest  in  the  horizontal  position,  avoid- 
ance of  all  excitement,  the  use  of  the  tincture  or  infusion  of  digritalis  or  the 


328  ROTHELN. 

tincture  of  strophanthus  to  procure  a  slow  and  steady  action  of  the  heart. 
Three  drops  of  the  tincture  of  digitalis  or  one  to  one  and  a  half  drops  of 
the  tincture  of  strophanthus  may  be  given  every  four  hours  to  a  child  of  five 
years.  The  same  external  measures  should  be  employed  as  in  acute  pleu- 
ritis.  I  prefer  the  application  of  a  thin  poultice  of  flaxseed  containing  one- 
sixteenth  part  of  mustard  and  covered  with  oiled  silk.  The  cardiac  inflam- 
mations, as  well  as  rheumatism,  require  opiates  in  sufiicient  doses  to  procure 
rest  and  sleep. 

Pleuritis,  which  we  have  stated  is  often  suppurative,  demands  the  same 
treatment  as  the  idiopathic  disease  when  it  occurs  in  cachectic  patients. 


CHAPTER    III. 

EOTHELN. 

This  disease  has  also  been  designated  rubella,  epidemic  roseola,  rosalia, 
rubeola  notha,  and  German  measles.  Some  recent  writers  incline  to  the 
belief  that  it  occurred  in  Europe  in  the  eighteenth  century,  having  the 
name  rubeola.  Thomas  states  that,  according  to  Formey,  457  died  from 
rubeola,  172  from  scarlet  fever,  and  53  from  measles  in  Berlin  in  the  decade 
beginning  with  1784 ;  but  he  also  states  that  many  who  observed  these  epi- 
demics believed  that  the  rubeola  was  a  species  of  measles.  We  infer  that 
this  was  the  correct  opinion,  and  that  the  rubeola  of  the  eighteenth  century 
was  not  the  rbtheln  of  the  present  time,  since  the  latter  is  almost  never  fatal, 
except  from  complications.  In  Great  Britain,  from  the  year  1840  onward, 
various  writers,  when  treating  of  measles  and  scarlet  fever,  make  statements 
which  lead  us  to  think  that  they  may  have  sometimes  mistaken  epidemics  of 
rotheln  for  modified  forms  of  measles  or  scarlet  fever.  Perhaps  it  is  not  too 
much  to  claim  that  the  first  clear  and  distinct  diff"erentiation  of  rotheln  was 
made  in  this  country.  Cases  of  rbtheln  occurring  in  and  about  Boston  were 
described  by  Dr.  Homans,  Sr.,  in  1845,  and  at  a  later  date — to  wit,  in  1853 
and  1871 — B.  E.  Cotting  and  Mr.  D.  Howard  saw  cases,  and  described  them 
in  papers  read  before  local  societies  (^Bost.  Med.  and  Surg.  Jour.^  March  15, 
1873).  In  1874,  Dr.  Caleb  Green  of  Homer,  Cortland  co.,  New  York,  an 
accurate  and  intelligent  observer,  also  witnessed  an  epidemic. 

Rbtheln  was  not,  however,  noticed  in  American  treatises,  and  it  scarcely 
received  recognition  in  America,  until  an  epidemic  of  it  occurred  in  the  New 
York  Foundling  Asylum  and  in  New  York  City  in  1873-74,  which  furnished 
the  material  for  a  paper  published  in  the  Archives  of  Dermatology  in  1874. 
This  epidemic  began  in  the  latter  part  of  1873,  and  attained  its  maximum  in 
March  and  April,  1874,  after  which  it  gradually  declined.  This,  so  far  as  I 
can  learn,  was  the  first  occurrence  of  rbtheln  in  this  locality.  In  a  general 
practice  of  more  than  twenty  years,  extending  over  a  considerable  portion 
of  this  city,  I  had  previously  seen  nothing  like  it,  and  other  older  physicians, 
having  a  large  general  practice,  informed  me  that  they  considered  it  an  en- 
tirely new  disease  with  us.  Those  who  believed  that  they  had  occasionally 
observed  isolated  cases  of  it  previously  to  this  epidemic  probably  referred  to 
roseola. 

The  first  case  which  I  observed  occurred  in  the  middle  of  December, 
1873,  in  West  Seventy-first  street,  in  the  northern  suburbs  of  New  York. 
A  few  weeks  later  cases  were  so  numerous  in  the  more  thickly-populated 


ROTHELN.  329 

section  of  the  city  as  to  attract  the  attention  of  many  physicians.  It  was 
evident  that  a  disease  had  appeared  with  which  we  were  not  familiar,  and  as 
the  eruption  occurred  in  points  and  small  circumscribed  patches,  it  was 
usually  designated  by  the  physicians,  in  want  of  a  more  accurate  name,  epi- 
demic roseola,  or  was  spoken  of  as  a  spurious  measles.  Physicians  who 
were  familiar  with  foreign  medical  literature  saw  the  resemblance  between 
these  cases  and  those  of  rotheln  as  described  by  British  and  continental  wri- 
ters, but  in  certain  at  least  of  the  foreign  cases  the  duration  of  the  rash  was 
said  to  be  seven  days  (Liveing,  London  Lancet^  March  14,  1874,  and  3IeiL 
News  and  Libran/,  May,  1874),  whereas  in  the  cases  in  New  York  it  com- 
monly disappeared  by  the  fourth  day.  This  discrepancy,  however,  was  not 
sufficient  to  invalidate  the  belief  in  the  identity  of  the  New  York  disease 
with  the  foreign  rotheln.  It  was  readily  explained  by  the  difference  in  the 
seasons  in  which  the  cases  occurred,  for  Liveing  observed  his  cases  in  June 
and  July,  and.  as  we  will  see,  the  greater  the  external  heat  the  longer  is  the 
duration  of  the  eruption. 

Between  the  middle  of  December,  1873,  and  May  1,  1874,  I  had 
observed  and  treated  this  malady  in  eighteen  families.  Cases  occurred  in 
three  other  families  living  in  the  same  houses  with  some  of  those  which  I 
attended,  and,  as  they  were  fully  and  clearly  described  to  me,  so  that  there 
could  be  no  doubt  as  to  their  nature,  I  have  included  them  in  my  statistics. 
The  total  number  of  cases  in  these  twenty-one  families  was  48.  During 
May,  when  the  epidemic  was  declining,  I  saw  6  additional  cases,  occurring 
singly,  making    a    total    of    54.       Their  ages    are    given    in    the   following 

table : 

Age.  Cases. 

From  eight  months  to  one  year 2 

"      one  year  to  two  years ,    .    .  4 

"      two  years  to  five  years 16 

"      five  years  to  ten  years 23 

"      ten  years  to  fifteen  years 3 

"      fifteen  years  to  thirty  years 6 

Total  number  of  cases 54 

The  age  of  the  youngest  patient  was  eight  months  and  that  of  the  oldest 
thirty  years :  72  per  cent,  of  the  total  number  were  between  the  ages  of  two 
and  ten  years,  so  that  rotheln  is  pre-eminently  a  disease  of  childhood.  Indi- 
viduals in  and  beyond  the  middle  period  of  life  seem  to  have  nearly  an 
immunity  from  it.  The  age  of  the  oldest  patient  of  whom  I  was  informed 
in  the  epidemic  of  1873  and  1874  was  about  forty  years.  On  March  25, 
1873,  during  my  attendance  in  the  New  York  Foundling  Asylum,  rotheln 
appeared  in  a  boy  of  four  years ;  in  the  following  month  about  thirty  more 
cases  occurred  in  this  institution,  all  children,  while  among  the  large  num- 
ber of  female  nurses  and  employes,  who  were  chiefly  between  the  ages  of 
twenty  and  thirty  years,  all  but  three  escaped. 

From  1874  to  1880  rotheln  did  not  prevail  in  New  York,  unless  now  and 
then  an  isolated  or  sporadic  case,  the  nature  of  which  was  not  recognized 
and  which  was  supposed  to  be  roseola.  On  August  9,  1880,  two  cases 
appeared  in  different  wards  of  the  New  York  Foundling  Asylum,  when  it 
was  remembered  that  two  weeks  previously  these  children  had  been  exposed 
to  a  patient  in  the  hospital  attached  to  the  institution  who  had  what  the  phy- 
sician in  attendance  supposed  at  the  time  to  be  roseola. 

Commencing  with  these  two  cases,  an  epidemic  occurred  in  the  asylum, 
mild  in  type,  affecting  only  a  few  at  a  time,  but  extending  over  several 
months,  until  about  sixty  inmates,  chiefly  children,  were  attacked.  Toward 
the  close  of  1880  rotheln  began  to  appear  in  the  northern  part  of  the  city, 


330  ROTHELN. 

in  which  the  asylum  is  located  and  over  which  my  practice  extends.  Its 
maximum  prevalence  was  attained  in  the  latter  part  of  March  and  April, 
1881,  when  it  particularly  attracted  the  attention  of  physicians.  A  large 
proportion  of  the  children  attending  certain  public  and  private  schools  were 
attacked.  It  occurred  in  seventeen  families  in  my  practice.  The  ages  of 
the  patients  in  these  families  are  given  in  the  following  table : 

Age.  Cases. 

From  one  to  two  years 3 

"      two  to  five  years 8 

"      five  to  ten  years 18 

"     ten  to  fifteen  years 11 

There   were  2  cases  over  fifteen  years,   aged  respectively  twenty- 
two  and  forty-two  years 2 

Total  number  of  cases 42 

Premonitory  Stage. — Premonitory  symptoms  are  in  most  instances 
absent  or  so  mild  as  to  attract  but  little  attention.  It  not  infrequently  hap- 
pened in  the  New  York  epidemics  that  the  parents  or  the  teachers  in  the 
schools  were  first  made  aware  of  the  illness  of  the  children  by  observing  the 
eruption.  In  some  instances  children  were  sent  from  school,  not  because 
they  felt  too  ill  to  remain,  but  on  account  of  the  unusual  appearance  of  the 
skin.  Sometimes,  however,  in  those  old  enough  to  express  their  sensations  a 
premonitory  stage  of  some  hours  or  a  day,  or  even  of  longer  duration,  was 
present,  consisting  of  such  symptoms  as  usually  occur  when  one  has  taken  a 
severe  cold,  as  languor,  pain  in  the  head,  trunk,  or  limbs.  The  resident 
physician  of  the  New  York  Foundling  Asylum  was  so  ill  with  rotheln  that 
he  was  confined  to  his  bed  during  the  first  day  of  the  disease.  Now  and  then 
patients  experience  nausea  previously  to  the  eruption  and  in  the  first  and 
second  days  of  the  eruptive  stage.  In  only  one  instance  did  I  observe  grave 
prodromic  symptoms.  A  boy  aged  eight  years  was  suddenly  seized  with 
clonic  convulsions,  and  while  in  a  warm  bath  for  the  relief  of  these  the  rash 
appeared  upon  those  parts  of  the  body  which  were  immersed  in  water. 

Symptoms.  —  Tegumentary  System. — (o)  The  Skin. — The  eruption  com- 
monly commences  upon  the  forehead,  around  the  ears,  and  along  the  neck, 
as  in  measles.  Occasionally  it  may  appear  upon  the  back  or  chest,  as  in  the 
above-mentioned  case,  in  which  the  hot  water  accelerated  its  appearance. 
Commencing  above,  the  efflorescence  travels  downward,  appearing  after  some 
hours  upon  the  lower  part  of  the  trunk  and  on  the  legs,  resembling  in  this 
respect  the  eruption  of  measles  and  scarlatina.  It  occurs  upon  all  parts  of 
the  integument  except  the  scalp  and  palmar  and  plantar  surfaces.  In  the 
majority  of  the  cases  which  I  have  seen  it  gradually  faded  away,  disappear- 
ing by  the  fourth  day,  but  in  children  who  were  kept  warm  in  bed  or  in 
warm  apartments  it  remained  longer  than  on  others.  In  many  instances 
traces  of  the  rash  were  still  visible  several  days  after  recovery  when  the 
patients  were  heated  by  exercise  or  excitement.  It  reappeared  at  times, 
though  indistinctly,  on  a  girl  of  thirteen  years  for  three  weeks.  In  most  of 
the  cases  in  the  New  York  epidemics  the  eruption  commonly  occurred  in 
points  and  circular  spots  somewhat  smaller  than  those  of  measles.  These 
points  and  spots  were  numerous  and  thickly  set,  so  that,  in  the  aggregate, 
they  covered  at  least  half  of  the  surface,  while  between  them  the  skin  pre- 
sented nearly  or  quite  its  normal  appearance.  The  general  aspect  in  most 
cases  was  more  like  that  of  measles  than  that  of  scarlatina,  but  in  exceptional 
instances  the  skin  between  the  points  and  spots  had  a  redness  similar  to  that 
of  erythema,  and  the  resemblance  was  very  like  the  scarlatinous  efflorescence. 
Thus,  in  a  boy  of  three  years  the  eruption  so  closely  resembled  the  scar- 


SYMPTOMS.  331 

latinous  over  the  trunk  that  were  it  not  that  the  temperature  was  constantly 
below  100°,  and  the  fever  entirely  ceased  within  three  or  four  days,  I 
would  probably  have  considered  the  malady  a  mild  scarlatina.  In  certain 
patients  the  eruption,  beginning  in  circumscribed  spots,  lik«  that  of  measles, 
becomes  in  two  or  three  days  confluent,  so  as  to  resemble  that  of  scarlatina, 
while  over  other  parts  the  spots  remain  discrete.  This  was  the  character  of 
the  eruption  upon  the  third  and  fourth  days  on  the  extremities  of  a  little  boy 
in  the  Foundling  Asylum.  The  rash  is  attended  by  considerable  itching, 
from  which,  indeed,  many  patients  suffer  more  than  from  all  other  symptoms. 

The  eruption  disap])ears  on  pressure,  produces  a  slight  roughness  of  the 
surface,  as  ascertained  by  passing  the  fingers  gently  over  it,  and  usually  fades 
away  without  desquamation.  Exceptionally,  there  is  a  slight  branny  exfolia- 
tion, and  in  one  of  ray  patients  the  exfoliation  was  as  great  over  the  abdomen 
as  in  cases  of  scarlatina. 

(6)  The  Mucous  Membrane. — In  connection  with  the  cutaneous  eruption 
a  mild  inflammation  also  occurs  upon  the  mucous  membrane  covering  the 
fauces,  buccal  cavity,  and  nostrils,  and  upon  reflections  of  this  membrane 
over  the  eyes  and  eyelids — i.  e.  upon  the  conjunctiva.  In  certain  patients 
this  inflammation  is  scarcely  appreciable,  but  in  the  majority  it  arrests  atten- 
tion at  once.  It  produces  a  suff"used,  reddish,  or  weak  appearance  of  the 
eyes,  with  a  moderately  increased  lachrymation.  On  everting  the  eyelids  the 
palpebral  conjunctiva  is  seen  to  be  injected.  In  certain  patients  a  moderate 
puriform  secretion  collects  at  the  inner  angle  of  the  eyelids.  In  occasional 
cases  the  conjunctivitis  causes  oedema  of  the  lids,  usually  slight,  and  likely 
to  be  overlooked  by  the  physician ;  but  in  three  instances  which  I  now  recall 
to  mind  the  mothers  of  the  children  directed  my  attention  to  the  swollen 
state  of  the  lids.  In  one  of  these,  an  infant  of  twenty-three  months,  the 
tumefaction  was  so  great,  commencing  about  the  time  the  eruption  began  to 
fade,  that  light  was  totally  excluded  from  the  eyes  and  it  was  impossible  to 
ascertain  their  condition.  The  skin  over  the  eyelids  retained  nearly  its  nor- 
mal appearance,  and  a  puriform  secretion  appeared  between  the  lids.  In  three 
or  four  days  the  oedema  of  the  lids  and  the  hyperaemia  of  the  conjunctiva 
rapidly  declined.  The  coryza  is  in  most  cases  sufficient  to  cause  an  unpleas- 
ant sensation  in  the  nostrils  and  provoke  sneezing ;  but  the  flow  from  the 
nostrils,  though  present,  was  in  no  instance  under  my  observation  as  abundant 
as  in  ordinary  cases  of  scarlatina  or  even  of  measles.  The  fauces  present  an 
injected  appearance,  and  in  severe  cases  there  is  moderate  swelling  of  the 
tonsils.  The  same  catarrhal  hyperaemia  is  also  seen  in  spots  or  patches,  more 
or  less  difi"used,  upon  the  buccal  surfaces.  Both  the  faucial  and  buccal 
catarrh  are  less  in  degree,  however,  than  in  cases  of  rubeola  and  scarlatina, 
which  have  an  equal  intensity  of  cutaneous  eruption  ;  and  this  fact  aids  in 
diff"erential  diagnosis. 

The  Renpiratori/  Si/stem. — In  both  the  epidemics  which  I  have  witnessed 
the  mucous  membrane  of  the  larynx,  trachea,  and  bronchial  tubes  participated 
only  slightly  in  the  inflammation  which  involved  the  nasal,  buccal,  and  faucial 
surfaces.  Many  of  my  patients  had  no  cough,  but  others  had  a  mild  cough, 
lasting  a  few  days,  but  with  normal  respiration.  It  was  due  apparently  to 
a  very  mild  catarrh  of  the  respiratory  tract  at  the  time  when  the  nasal 
and  conjunctival  surfaces  were  the  most  aff"ected.  It  subsided  in  a  few  days 
without  treatment.     In  no  case  do  I  recollect  that  there  was  any  hoarseness. 

The  Digpstive  System. — The  tongue  in  rbtheln  is  moist  and  of  normal 
appearance  or  covered  by  a  slight  fur.  The  appetite  may  be  impaired,  but 
is  not  wanting  in  uncomplicated  cases.  The  patients  sometimes  say  that  it  is 
nearly  the  same  as  in  health ;  the  thirst  is  slight,  and  the  bowels  are  regular. 

Nausea  is  not  infrequent,  and  vomiting  was,  in  several  cases  in  my  prac- 


332  ROTHELN. 

tice,  one  of  the  initial  symptoms.  In  certain  patients  it  also  occurred  on  the 
first  or  second  day  of  the  eruption.  In  others  there  was  no  nausea,  so  far  as 
I  could  learn,  either  immediately  before  or  during  the  prevalence  of  the 
disease.  This  symptom  is  less  frequent  in  rotheln  than  in  scarlet  fever,  but 
is  as  common  apparently  as  in  measles.  I  have  never  found  albumen  in  the 
urine,  though  I  have  examined  that  passed  by  several  patients.  This  secre- 
tion did  not  appear  to  be  abnormal  except  as  it  contained  urates,  so  common 
in  febrile  states. 

The  Pulse  and  Temperature. — The  largest  number  of  accurate  daily 
observations  relating  to  the  temperature  was,  I  think,  that  of  Dr.  Reid  in 
the  New  York  Foundling  Asylum  during  the  month  of  March,  1874.  He 
has  kindly  furnished  me  with  his  statistics  relating  to  this  symptom,  as  fol- 
lows :  "  The  number  of  closely-observed  cases  in  which  the  temperature  was 
taken  was  24.  In  17  of  the  cases  the  temperature  ranged  from  97°  to  99°  ; 
in  6  it  reached  100°,  100i°,  and  lOOf  ° ;  in  1  it  reached  103i°  on  the  second 
day  of  the  eruption,  but  remained  so  elevated  only  one  day."  In  certain 
patients  Dr.  Reid  observed  what  he  designates  "■  a  tendency  to  the  develop- 
ment of  an  ephemeral  fever."  These  observations  correspond  closely  with 
those  made  by  myself  during  the  same  epidemic.  Thus,  in  16  cases  I  found 
the  axillary  temperature  taken  each  day  to  be  constantly  between  98°  and 
100°,  with  a  pulse  under  110,  except  in  1  case,  in  which  it  numbered  124. 
In  certain  other  patients  a  more  decided  rise  of  temperature  from  one  to 
two  or  three  days  occurred,  usually  in  the  commencement  of  the  malady. 
Thus,  a  girl  aged  three  and  a  half  years  had  a  temperature  of  101  f°  and  a 
pulse  of  128.  In  another  instance  the  pulse  was  124  and  the  temperature 
102°.  In  another,  a  girl  of  three  and  a  half  years,  considerable  fever 
occurred  without  apparent  cause  on  Saturday  night,  but  it  abated  on 
the  subsequent  day.  She  seemed  well  until  the  following  Tuesday,  when 
the  fever  returned  and  the  eruption  appeared.  On  Thursday  the  tem- 
perature from  102°  to  103°  fell  to  99^°,  and  within  a  day  or  two  she  was 
convalescent.  In  two  other  patients  from  two  to  four  days  after  the  disap- 
pearance of  the  eruption  an  accession  of  fever  occurred,  lasting  about  one 
day,  and  attended  by  pain  and  distress  in  the  epigastric  region,  but  without 
vomiting  or  diarrhoea.  In  one  of  these  the  temperature  was  103|°,  the  pulse 
130  per  minute.  In  the  other  case  the  temperature  and  pulse  did  not  seem 
to  be  under  these  figures,  but  were  not  accurately  ascertained.  Occasionally 
the  fever  is  due  more  to  complications  than  to  the  primary  disease.  Thus,  in 
two  of  my  patients  the  rise  of  temperature  was  mainly  attributable  to  diph- 
theritic inflammation  which  had  attacked  the  fauces.  But  while  the  fever 
in  rotheln  is  ordinarily  of  short  duration,  in  certain  patients  temporary 
exacerbations  may  occur  in  which  the  temperature  is  as  high  as  in  scarlet 
fever  or  measles. 

Complications  ;  Prognosis. — The  only  complication  which  occurred  in 
cases  in  my  practice  has  already  been  alluded  to — to  wit,  diphtheria,  which, 
when  prevalent,  usually  attacks  surfaces  already  inflamed.  In  the  Foundling 
Asylum  varicella  complicated  one  case  and  pneumonia  another.  In  a  third 
pneumonia  occurred  about  three  days  after  the  disappearance  of  the  eruption. 
The  prognosis  in  uncomplicated  cases  is  always  very  favorable,  and  there  is 
no  liability  to  sequelae  more  than  in  mild  catarrhal  inflammations  of  a  non- 
specific character.  The  duration  of  rotheln  is  short,  not  ordinarily  extending 
beyond  three  to  five  days. 

Nature  ;  Incubative  Period  ;  Contagiousness. — Is  rotheln  a  distinct 
malady,  or  one  with  which  we  are  familiar,  but  the  form  and  character  of 
which  are  modified  by  unusual  meteorological  conditions  ?  Is  it  roseola 
assuming  at  certain  periods  an  epidemic  character  and  appearing  to  be  con- 


NATURE,  ETC.  333 

tagious  ?  Or  is  it  at  all  times  infectious,  possessing  a  specific  principle,  and, 
like  other  infectious  diseases,  self-propagating?  Should  it  in  nosological 
classification  be  placed  among  the  non-contagious  and  local  or  among  the 
constitutional  and  infectious  maladies  ?  Let  us  consider  the  facts  observed 
in  the  New  York  epidemics. 

The  first  cases  of  rothetln  in  this  city  were  often  designated  roseola  by  the 
physicians  called  to  treat  them,  since  they  seemed  to  resemble  more  closely 
this  disease  than  any  other  with  which  they  were  familiar.  But  rbtheln 
■diff'ers  widely  from  the  peculiar  form  of  dermatitis  known  as  roseola.  The 
successive  occurrence  of  the  eruption  over  the  upper  and  then  the  lower 
parts  of  the  body,  but  covering  the  whole  surface,  and  the  definite  duration 
of  three  to  five  days,  are  points  of  diff'erence.  Moreover,  roseola  would  not, 
without  so  great  a  change  in  its  character  as  to  become  virtually  a  distinct 
disease,  occur  in  the  cool  months,  without  any  appreciable  dietetic  cause,  as 
an  epidemic  over  a  certain  area  and  for  a  limited  time,  affecting  whole  house- 
holds and  sparing  other  households  as  well  as  individuals  of  a  certain  age. 
We  therefore  consider  it  distinct  from  roseola. 

Most  of  the  cases  of  the  New  York  epidemics  bore  considerable  resem- 
Tjlance  to  measles,  both  as  regards  the  appearance  and  duration  of  the  erup- 
tion and  the  catarrh  of  the  mucous  surfaces.  Parents  often  diagnosticated 
measles  before  the  arrival  of  the  physician,  and  the  physician  himself,  at  first 
glance,  sometimes  made  the  same  diagnosis.  But  in  rbtheln  the  shortness 
and  mildness  of  the  stage  of  invasion,  the  absence  of  cough  or  the  presence 
of  one  trivial  and  scarcely  noticed,  appetite  good  or  but  slightly  impaired — 
in  fine,  symptoms  that  are  transient  or  slight — afford  a  striking  contrast  to 
the  graver  symptoms  of  measles.  But  the  decisive  proof  that  rotheln  is  not 
a  modified  measles  is  found  in  the  fact  that  one  does  not  prevent  the  other. 
Of  the  48  cases  observed  by  myself  prior  to  May  1st  in  the  epidemic  of 
1874,  19  at  least  had  had  measles,  and  1  who  had  rotheln  took  measles  sub- 
sequently. I  have  already  stated  that  in  the  New  York  Foundling  Asylum 
rotheln  in  1873  and  1874  closely  followed  an  epidemic  of  measles.  A  con- 
■siderable  number  of  the  children  attacked  by  the  former  disease  had  recently 
recovered  from  the  latter.  During  the  epidemic  of  1880  and  1881  the  same 
fact  was  observed — namely,  that  a  previous  attack  of  measles  as  well  as 
scarlet  fever  afforded  no  protection  from  rbtheln.  Dr.  Chadbourne,  the  resi- 
dent physician,  writes  of  the  cases  in  the  Foundling  Asylum  in  1880  and 
1881 :  "  Eight  children  had  rbtheln  who  had  had  both  scarlet  fever  and 
measles  within  six  months  under  my  observation,  while  certain  others  had 
Tiad  these  diseases  at  some  previous  time."  Of  the  cases  observed  by  myself 
in  family  practice  in  the  same  epidemic,  it  is  stated  in  my  notes  that  ten  had 
had  measles.  These  statistics  are  sufficient  to  show  that  rbtheln  is  a  distinct 
disease  from  measles,  however  close  the  kinship. 

That  rbtheln  is  not  a  form  of  scarlet  fever  is  evident  from  the  fact  that 
as  regards  at  least  the  New  York  epidemics  the  rash  was  in  most  instances 
quite  distinct  from  the  scarlatinous  efflorescence,  occurring,  as  we  have  said, 
in  small  more  or  less  circular  points  and  patches.  Moreover,  as  we  have 
remarked  above,  there  is  in  rbtheln  a  slight  febrile  movement  and  general 
mildness  of  symptoms  which  contrast  with  the  high  fever  and  other  pro- 
nounced symptoms  of  scarlatina,  or  if  there  be  considerable  febrile  move- 
ment its  duration  is  brief.  But  the  conclusive  proof  of  an  essential  differ- 
ence between  these  two  diseases  is  found  in  the  fact  already  stated  in  refer- 
ence to  measles,  that  the  attack  of  the  one  malady  does  not  prevent  the 
occurrence  of  the  other.  There  are,  it  is  true,  cases  in  which  it  is  difficult  at 
first  to  make  the  diff"erential  diagnosis  between  rbtheln  and  mild  measles  or 
mild  scarlet  fever,    but   when   the  course   of   the  malady  has  been  closely 


334  BOTHELN. 

observed  for  three  or  four  days,  it  will  rarely  happen,  I  think,  that  we  will 
be  unable  to  make  out  its  character. 

Those  cases  of  an  epidemic  which  arise  when  the  causes  or  conditions 
from  which  it  is  developed  are  most  strongly  operative,  and  which  at  this 
time  are  likely  to  be  typical,  obviously  afford  the  best  data  for  studying  its 
nature.  Such  were  the  48  cases  which  I  saw  in  the  epidemic  of  1873  and 
1874,  and  the  42  in  that  of  1880  and  1881.  As  regards  the  former  epi- 
demic, in  thirteen  of  the  twenty-one  families  embraced  in  my  statistics  the 
first  cases  were  children  who  up  to  the  time  of  the  seizure  were  attending 
public  and  private  schools,  and  in  certain  instances  those  who  were  nearly 
simultaneously  attacked,  living  perhaps  in  streets  widely  separated,  were 
attending  the  same  school.  During  the  epidemic  of  1880  and  1881  the 
first  patients  in  thirteen  of  the  eighteen  families  in  which  rbtheln  occurred  in 
my  practice  were  school-children  between  the  ages  of  six  and  twelve  years, 
and  in  most,  if  not  all,  the  different  schools  which  they  attended  rbtheln  was 
at  the  time  prevailing  as  an  epidemic,  as  I  ascertained  on  inquiry.  It  there- 
fore seemed  probable  that  these  children  whom  I  attended  had  contracted  it 
from  others  in  the  schools. 

In  both  the  New  York  epidemics  during  the  time  that  rbtheln  was  at  its 
maximum  prevalence,  in  most  of  the  families  containing  two  or  more  chil- 
dren the  cases  were  multiple,  not  occurring  simultaneously,  but  in  succes- 
sion, as  if  the  malady  were  contracted  from  those  first  affected.     This  is  what 

we  daily  witness  in  the  spread  of  exanthematic  fevers.     Thus  in  Mr.  E 's 

family  a  girl  attending  one  of  the  public  schools  took  rbtheln  in  the  middle 
of  December,  1873 ;  the  two  remaining  children  sickened  with  it  one  week 
and  two  weeks  later.  A  niece  visiting  in  the  family  at  the  time  when  the 
first  child  was  sick,  but  returning  home  to  another  street,  also  had  the  erup- 
tion on  December  27th.     Alice  R ,  aged  ten  years,  a  frequent  visitor  at 

Mr.   E 's,  living  in   the  same  street,  and  several  times  exposed  to  his 

children  during  their  illness,  also  took  rbtheln  about  January  4th.  West 
Seventy-first  street,  where  these  cases  occurred,  was  thinly  settled  and  subur- 
ban, and  I  could  learn   of  no  other  cases  in  the  vicinity.     A  child  of  Mr. 

P ,  aged  five  and  a  half  years,  had  been  in  the  habit  of  playing  with  two 

children  two  doors  away,  who  became  affected  with  rbtheln  in  the  beginning 
of  April,  1881,  On  April  14th  he  was  supposed  to  have  a  mild  coryza  from 
taking  cold,  as  he  sneezed  often,  but  in  a  few  hours  the  efflorescence  appeared. 
Four  days  subsequently,  on  the  18th,  an  infant  was  affected  in  the  same  way,, 
and  thirteen  days  later  another  child  in  the  family,  aged  twelve  years.  In  a 
similar  manner  rbtheln  occurred  in  the  families  of  two  brothers  living  in. 
adjoining  houses  in  West  Fifty-first  street.  The  first  patient  was  a  boy  of 
twelve  years.  It  appeared  successivel}''  in  the  children  of  these  two  families 
until  ten  had  been  affected.  In  a  family  in  West  Forty-sixth  street  the  first 
case  was  a  boy  attending  a  school  in  which  rbtheln  was  prevalent.  Within 
twenty  days — namely,  between  March  31st  and  April  20th — four  other  chil- 
dren were  attacked  in  succession. 

These  facts  and  cases  seem  to  demonstrate  the  contagiousness  of  rbtheln,. 
at  least  during  the  time  in  which  the  conditions  are  most  favorable  for  its 
development  or  during  the  time  in  which  the  epidemic  infiuence  is  most  pro- 
nounced. In  the  declining  period  of  both  the  New  York  epidemics  the  cases 
which  I  observed  occurred  for  the  most  part  singly,  although  there  was  no 
attempt  to  isolate  the  patients,  so  that  the  contagiousness  of  the  disease 
must  be  slight. 

Rbtheln  is,  in  my  opinion,  an  exanthematic  fever  feebly  contagious. 
It  resembles  varicella  in  general  mildness  of  symptoms,  in  the  absence 
of   dangerous    complications    or    sequelae,  and   in    the    uniformly   favorable 


DIAGNOSIS.  335 

prognosis,  while  its  symptoms  show  a  resemblance  to  measles  and  scar- 
let fever. 

If  the  above  view  be  correct,  rijtheln  must  possess  an  incubative  period 
which,  in  the  cases  observed  in  both  epidemics,  apparently  varied  between 
seven,  or  perhaps  less  than  seven,  and  twenty-one  days.  Its  incubation, 
therefore,  like  that  of  scarlet  fever  and  diphtheria,  apparently  varies  in  dif- 
ferent patients.  In  the  cases  which  came  under  my  notice  the  incubative 
period,  when  it  could  be  accurately  ascertained,  was  more  frequently  about 
two  weeks  than  a  longer  or  shorter  period.  The  resident  physician  of  the 
New  York  Foundling  Asylum,  when  the  epidemic  was  prevailing  in  that 
institution,  returned  to  his  home  in  the  State  of  Maine  to  a  locality  where 
rotheln  was  unknown.  Fourteen  days  from  the  date  of  his  departure  he  was 
himself  affected  with  the  disease  in  its  typical  form.  No  other  case  occurred 
at  his  home,  where  probably  the  atmospheric  conditions  were  unfavorable. 

Minnie  B ,  attending  a  school  in  which  there  were  many  eases,  had  the 

rash  on  April  5th.  On  the  23d  of  the  same  month,  eighteen  days  afterward, 
it  appeared  upon  the  servant  who  was  frequently  in  Minnie's  room.  Eliza- 
beth C ,  attending  a  school  in  which  rotheln  was  prevailing,  had  the 

eruption  on  x\pril  17th.  It  commenced  upon  her  sister  thirteen  days,  and 
upon   her  mother  fourteen  days,   subsequently. 

Other  cases  might  be  cited  of  an  apparently  shorter  as  well  as  longer 
incubative  period.  The  following  note  from  Dr.  Chadbourne  of  the  New 
York  Foundling  Asylum,  bearing  upon  this  subject,  is  interesting:  "I  am 
led  to  believe  from  my  observations  that  the  period  of  incubation  was,  in  the 
majority  of  cases,  from  twelve  to  fifteen  days.  The  disease  has  been  very 
feebly  contagious.  In  some  cases  one  child  would  have  rotheln,  while  the 
other,  nursed  by  the  same  woman,  escaped.  In  two  instances  women  had 
the  disease,  and  though  each  suckled  two  infants,  the  latter  escaped." 
Osborn  states  that  enlargement  of  the  small  glands  at  the  edge  of  the  hair 
on  the  postero-lateral  sides  of  the  neck  has  been  present  in  all  the  cases 
which  he  has  observed,  and  he  therefore  con.siders  it  an  important  diagnostic 
sign  (  Weekly  Med.  Rev.,  Dec.  24,  1887).  Several  other  writers  have  also 
observed  this  glandular  enlargement,  and  some  have  stated  that  it  occasion- 
ally precedes  the  efflorescence.  Swelling  of  the  lymphatic  glands  in  other 
parts  of  the  system  has  also  been  recorded  by  different  observers,  and  it 
rarely  goes  on  to  suppuration.  It  usually  subsides  with  the  disappearance 
of  the  rash,  but  Golson  has  observed  the  occurrence  of  abscesses  in  the  site 
of  the  submaxillary  lymphatic  glands.  Curtman  has  also  observed  the  for- 
mation of  abscesses  in  various  parts  of  the  body. 

Complications. — Recent  writers  have  recorded  a  considerable  number 
of  complications  and  sequelae,  the  more  important  of  which  we  will  briefly 
enumerate  as  follows,  but  the  occurrence  of  some  of  them  was  a  coincidence : 
severe  bronchitis,  pneumonia,  pleurisy,  enteritis,  entero-colitis,  colitis,  icterus, 
stomatitis,  rheumatism,  meningitis,  abscesses,  miliaria,  pemphigus,  erysipelas, 
oedema,  enlargement  of  the  thyroid,  otorrhoea,  earache,  and  keratitis.  Some 
of  these  complications  are  such  as  frequently  occur  in  measles,  to  which,  as 
we  have  seen,  rotheln  bears  considerable  resemblance. 

Diagnosis. — Hotheln  might  readily  be  mistaken  for  roseola  if  only  a  few 
and  isolated  cases  occur,  but  the  longer  continuance  of  the  eruption,  the 
catarrhal  symptoms,  though  slight,  and ,  in  most  instances  the  evidence  of 
contagion,  enable  us  to  make  the  diagnosis.  From  measles  this  disease  is 
distinguished  by  the  absence  of,  or  slight  and  transient  character  of,  the  pro- 
dromal stage.  The  fever  with  evening  exacerbations,  the  cough,  and  pro- 
nounced catarrhal  symptoms,  which  precede  the  rash  in  measles  three  or  four 
days,  do  not  occur  in  rotheln.     The  diagnosis  from  mild  scarlet  fever  in  the 


-336  VARIOLA— VARIOLOID. 

commencement  of  an  epidemic,  when  only  a  few  cases  are  observed,  may  be 
difficult,  but  no  epidemics  of  scarlet  fever  occur  in  which  the  type  remains 
so  mild  as  in  rotheln.  The  shorter  duration  of  the  rash,  the  absence  of  the 
initial  vomiting  and  of  the  strawberry  tongue,  the  usual  roseolar  rather  than 
erythematous  character  of  the  rash,  the  mildness,  sometimes  scarcely  appre- 
ciable, of  the  stomatitis  and  pharyngitis,  the  slight  indisposition,  so  that  the 
child,  if  it  followed  its  inclination,  would  not  be  under  restraint,  and  the 
absence,  with  few  exceptions,  of  complications  and  sequelae,  usually  render 
the  diagnosis  from   scarlet  fever  clear  and  unmistakable. 

Prognosis. — Death  does  not  occur  except  from  some  complication  or 
intercurrent  disease.  When  Forney  stated  that  in  Berlin  during  the  decade 
ending  with  1794,  457  died  from  rubeola,  172  from  scarlet  fever,  and  53 
from  measles,  he  could  not  by  the  term  "  rubeola  "  have  referred  to  rotheln, 
as  some  have  supposed,  or  the  nature  of  the  disease  has  totally  changed. 
Moreover,  in  the  literature  of  rotheln  the  assigned  causes  of  death  have  been, 
in  my  opinion,  in  some  instances,  concurrent  or  accidental  maladies  which  did 
not  result  from  this  disease. 

Treatment. — In  the  majority  of  cases  the  medicinal  ti'eatment  should 
be  of  the  mildest  kind  or  none  at  all.  As  death  has  occurred  from  bronchitis 
and  pneumonia  supervening  upon  rotheln,  the  patient  should  remain  in  a 
room  of  equable  temperature,  and  not  be  exposed  to  currents  of  air.  Any 
local  ailment  which  may  arise  or  any  intercurrent  disease  should  of  course 
be  promptly  treated,  since  death  may  occur  from  them,  while  the  primary 
disease  is  not  fatal  and  is  even  trivial. 


CHAPTER    IV. 

VAEIOLA— VAEIOLOID. 

Variola,  or  smallpox,  is  a  specific  febrile  affection,  accompanied  by  a 
vesiculo-pustular  eruption  upon  the  skin.  Since  the  discovery  of  the  protec- 
tive power  of  vaccination  it  has  been  shorn  of  much  of  its  terror,  but  it  is  still 
the  most  loathsome  and  most  dreaded  of  all  the  fevers.  Two  forms  of  this 
disease  are  recognized,  depending  on  the  fact  whether  there  have  been  pre- 
vious vaccination.  If  the  patient  have  been  vaccinated  at  some  period  in 
his  life,  the  disease,  which  is  rendered  milder  in  consequence,  is  designated 
varioloid.  If  there  have  been  no  vaccination,  it  is  called  variola  or  small- 
pox. Both  forms  are  identical  in  nature,  the  one  communicating  the  other ; 
they  differ  only  in  gravity. 

From  accounts  still  extant — which,  however,  are  vague — this  disease 
appears  to  have  prevailed  at  a  remote  period  in  China  and  Hindostan.  It 
was  carried  across  the  Asiatic  continent  by  caravans  engaged  in  the  silk- 
trade,  reaching  Europe  in  the  sixth  century.  Its  extension  to  countries 
previously  free  from  it  has  been  mainly  through  commerce  and  invading 
armies.  It  is  stated  that  it  reached  England  in  the  thirteenth  century  and 
Germany  and  Sweden  in  the  fifteenth  century.  It  was  introduced  into  Mex- 
ico by  the  invading  army  of  Cortez,  where  for  years  afterward  heaps  of  skele- 
tons of  those  who  had  perished  by  it  were  found  in  shaded  localities. 

Etiology. — Different  microscopists  have  observed  a  microbe  in  the  vario- 
lous eruption,  designated  the  micrococcus  tetragonus.  It  bears  some  resem- 
blance to  the  sarcina  ventriculi,  having  the  appearance  of  a  group  of  four. 


STAGE  OF  INVASION.  337 

It  is  readily  cultivated  in  diflFerent  media,  and  has  an  orange-yellow  color. 
Dr.  A.  Marotta  lias  performed  experiments  with  this  microbe  which  seem  to 
have  the  conditions  of"  scientific  exactness,  and  render  it  highly  probable  that 
it  is  the  specific  principle  of  smallpox.  He  states  that  he  inoculated  calves 
with  this  microbe  of  the  seventh  generation  of  cultivation,  and  produced  in 
them  an  eruption  appareiitly  identical  with  that  of  vaccinia,  but  inoculations 
of  dogs  and  guinea-pigs  were  without  result.^  These  experiments  of  Marotta 
require  verification,  (xuthmann  has  found  the  staphylococcus  pyogenes  and 
micrococcus  albus  in  the  variolous  lymph,  but  they  are  often  present  in  mal- 
adies entirely  distinct  from  variola,  and  are  therefore  not  believed  to  sustain 
a  causal  relation  to  the  latter.  Although  pathologists  do  not  doubt  the 
microbic  origin  of  variola,  the  microbe  which  causes  it  has  not  yet  been 
clearly  ascertained. 

Smallpox  presents  four  stages :  the  initial,  or  that  of  invasion  ;  the  erup- 
tive ;  that  of  desiccation ;  and,  lastly,  that  of  desquamation.  It  is  termed 
discrete  when  the  pustules  remain  separated  from  each  other ;  confluent 
when  they  unite.  This  division  is  made  according  to  the  character  of  the 
eruption  upon  the  face  and  hands.  There  are  parts  of  the  surface,  as  the 
abdomen,  where  the  pustules  are  always  discrete,  even  in  the  confluent  form. 

Incubative  Period. — During  the  last  half  of  the  last  century  inocula- 
tion with  variolous  matter  was  extensively  practised  in  Great  Britain  and  on 
the  Continent,  as  it  was  found  that  smallpox  thus  communicated  was  milder 
than  when  received  by  infection.  This  operation  enabled  physicians  to  deter- 
mine the  period  of  incubation,  which  was  found  to  be  from  eight  to  eleven 
days.  When  variola  is  communicated  through  the  air  the  incubative  period 
is  somewhat  longer — to  wit,  from  twelve  to  fourteen  days. 

Stage  of  Invasion. — Smallpox  begins  abruptly  with  chilliness.  In 
children  of  an  advanced  age  there  is  often,  as  in  the  adult,  a  distinct  chill. 
This  is  followed  by  fever  and  such  symptoms  as  usually  accompany  a  high 
temperature — to  wit,  lassitude,  anorexia,  and  thirst.  In  addition,  certain 
symptoms  arise  which,  though  not  peculiar  to  smallpox,  are  so  marked  in 
the  commencement  of  this  disease  that  they  possess  considerable  diagnostic 
value.  These  symptoms,  which  pertain  to  the  nervous  system  and  occur  in 
the  initial  stage  of  varioloid  as  well  as  variola,  are  severe  frontal  headache, 
pain  in  the  small  of  the  back,  and  great  drowsiness,  sometimes  with  delirium. 
In  many  children  convulsions  occur,  preceded  and  followed  by  a  degree  of 
stupor  which  is  almost  as  profound  as  coma.  Trousseau  suggests  the  name 
rachialgia  for  the  pain  in  the  back,  since  he  believes  that  it  is  located  in  or 
around  the  spinal  cord.  This  belief  is  based  on  the  fact  which  he,  as  well  as 
other  observers  has  noticed  that  there  is  sometimes  in  connection  with  this 
symptom  an  incomplete  paraplegia,  indicated  by  numbness  of  the  legs  or  even 
inability  to  use  them,  and  sometimes  more  or  less  paralysis  of  the  bladder. 
These  paraplegic  symptoms  pass  off  in  a  few  days.  Vomiting  is  also  a  com- 
mon symptom  in  this  stage,  and  one  also  of  diagnostic  value.  It  occurs  at 
short  intervals  for  twenty-four  to  thirty-six  hours.  The  same  symptom  is 
common  in  scarlet  fever,  and  not  infrequent  in  measles,  but  in  both  these 
maladies  irritability  of  stomach  is  much  less  persistent  than  in  smallpox  ; 
vomiting  does  not  occur  in  normal  rubeolous  and  scarlatinous  cases  more  than 
once  or  twice. 

The  tongue  is  covered  with  a  moist  fur.  If  the  disease  is  to  be  discrete, 
constipation  is  commonly  present  in  the  stage  of  invasion  ;  if  confluent, 
diarrhcea  is  a  common  symptom,  continuing  till  the  fourth  or  fifth  day.  or 
even  longer.  Roseola  or  erythema  sometimes  occurs  in  this  stage,  and  this 
may  lead  to  error  of  diagnosis,  the  disease  being  mistaken  for  one  of  these 

^  Dr.  A.  Marotta  :  Revista  Clinica  e  Therapeuiica,  Nov.  and  Dec,  1886. 
22 


338  VARIOLA— VARIOLOID. 

cutaneous  affections  or  even  for  scarlet  fever.  The  symptoms  in  the  stage 
of  invasion  are  usually  more  violent  in  confluent  than  in  discrete  variola,  but 
there  are  exceptions. 

Stage  op  Eruption. — The  eruption  commences  about  the  third  day,  earl- 
ier in  some  cases,  later  in  others.  The  average  duration,  therefore,  of  the  first 
stage  is  somewhat  shorter  than  in  measles,  but  considerably  longer  than  in 
scarlet  fever.  Sydenham  has  stated — and  observations  show  the  truth  of  the 
remark — that  the  shorter  the  first  stage  the  more  severe  the  disease  will 
prove  to  be  ;  and,  conversely,  the  longer  the  period  the  milder  will  be  its 
form.  Therefore,  if  the  eruption  begin  on  the  second  day,  it  will,  as  a  rule, 
be  confluent;  if  not  till  the  fifth  or  sixth  day,  it  will  be  scanty  and  the  dis- 
ease light. 

The  eruption  commences  in  minute  red  spots,  somewhat  like  those  of 
lichen,  which  gradually  enlarge.  It  is  first  observed  around  the  lips  and 
upon  the  neck,  then  upon  the  face,  scalp,  upper  part  of  chest,  arms,  and 
finally  upon  the  lower  part  of  the  chest,  the  abdomen,  and  legs.  It  is  some- 
times, especially  in  young  children,  first  observed  in  the  folds  of  the  skin,  as 
about  the  genitals  or  in  the  groin.  If  the  cuticle  be  irritated,  as  by  a  sina- 
pism, the  eruption  often  appears  first  upon  this  part  of  the  surface  and  in 
greater  abundance  than  elsewhere.  Commencing  in  a  minute  reddish  point, 
as  stated  above,  it  rapidly  enlarges,  and  soon  its  central  part  begins  to  be 
indurated  and  raised.  It  feels  round  and  hard  to  the  finger,  is  tender,  and 
its  diameter  does  not  ordinarily  exceed  two  lines.  This  is  the  papular  stage. 
The  papulse  increase  and  become  more  elevated,  and  in  twenty-four  to  forty- 
eight  hours  from  the  commencement  of  the  eruptive  stage  they  become  vesic- 
ular. On  the  fifth  day  of  the  eruption,  or  eighth  of  the  disease,  the  vesicle 
has  attained  its  full  size.  Its  diameter  is  then  about  one-fourth  of  an  inch 
and  its  elevation  is  two  or  three  lines.  Its  base  is  circular  and  indurated, 
and  it  is  surrounded  by  a  narrow  zone  of  inflammation,  indicated  by  redness 
and  tenderness  of  the  skin.  The  pock  commonly,  as  it  passes  from  the  papu- 
lar to  the  vesicular  stage,  loses  its  acuminate  form,  and  becomes  depressed  in 
the  centre,  but  in  most  cases  mixed  with  the  umbilicated  vesicles  are  some 
which  remain  acuminate. 

In  proportion  as  the  eruption  becomes  developed  in  discrete  variola  and  in 
varioloid,  the  symptoms  which  accompanied  the  stage  of  invasion  abate ;  the 
fever,  headache,  pain  in  the  back,  and  thirst  cease,  and  the  appetite  returns. 
In  the  confluent  form  the  fever  continues  with  little  abatement. 

Simultaneously  with  the  eruption  upon  the  skin  an  eruption  also  occui's 
upon  the  buccal  and  faucial  surfaces,  and  often  upon  that  of  the  air-passages. 
It  occurs  sometimes,  also,  upon  the  conjunctiva,  producing  dangerous  oph- 
thalmia, and  even  ulceration  with  loss  of  sight,  and  upon  the  mucous  sur- 
face of  the  genital  organs.  The  form  which  it  presents  upon  mucous  sur- 
faces is  somewhat  different  from  that  upon  the  skin.  There  is  at  first  a 
deposit  of  fibrin,  producing  a  small,  round,  grayish  spot  at  the  point  of 
eruption — firm,  slightly  elevated,  and  covered,  if  not  by  the  entire  mucous 
membrane,  at  least  by  its  epithelial  layer.  Ulceration  soon  occurs,  as  in 
ulcerous  stomatitis,  and  if  the  patient  live  the  reparative  process  succeeds, 
as  in  simple  ulcers.  The  eruption  upon  mucous  surfaces  increases  consider- 
ably the  suffering  of  the  patient,  in  consequence  of  the  tenderness  of  the 
ulcers  ;  and  if  its  seat  be  the  surface  of  the  larynx  or  trachea,  it  may  be  the 
immediate  cause  of  death,  especially  in  young  children,  by  obstructing 
respiration. 

The  cutaneous  eruption  has  been  traced  to  the  vesicular  stage.  On  or 
about  the  fifth  day  of  the  eruptive  period,  or  eighth  of  smallpox,  the  ves- 
icles gradually  change  their  character,  their  contents  becoming  thicker  and 


STAGE  OF  DESQUAMATION.  339 

turbid.  At  the  same  time  they  increase  still  more  in  size  and  the  central 
depression  disappears.  'J'liis  is  designated  the  stage  of  maturation  or  of 
ijuppuration,  though  it  is  known  that  the  turbidity  is  due  chiefly  to  another 
substance  than  pus.  The  pock,  having  undergone  these  changes,  is  termed 
the  pustule. 

In  discrete  variola  and  in  varioloid  the  fever  returns  during  the  pustular 
stage,  or  if  the  form  of  the  disease  be  confluent  and  the  fever  have  con- 
tinued, it  now  becomes  more  intense.  The  return  of  fever  or  its  increase 
is  denoted  by  increased  frequency  of  pulse,  elevation  of  temperature,  dry- 
ness of  skin,  anorexia,  and  thirst.  A  tendency  to  constipation  remains 
throughout  in  varioloid  and  discrete  variola  ;  in  the  confluent  form  diarrhoea 
more  frequently  occurs,  which,  if  it  continue,  is  an  unfavorable  prognostic 
sign. 

Other  changes  occur.  The  pustules  increase  somewhat  in  size  and  become 
more  globular.  Some  of  them,  when  most  distended,  break  through  friction 
of  the  clothes  or  scratching  of  the  child,  and  their  contents,  escaping,  add  to 
the  loathsomeness  of  the  disease.  There  is  in  the  pustular  stage  more  or  less 
redness  of  the  surface  between  the  eruptions,  and,  except  in  the  mildest 
cases,  tumefaction  from  subcutaneous  infiltration  occurs.  In  the  confluent 
form  at  this  period  the  features  are  often  so  swollen  that  the  friends  would 
not  recognize  the  patient.  The  eyelids  may  be  so  oedematous  that  the  eyes 
are  for  a  time  concealed  from  view.  This  oedema  of  the  surface  is  not  alto- 
gether absent  in  the  vesicular  stage,  but  it  increases  during  the  time  of 
maturation,  after  which  it  subsides. 

Stage  op  Desiccation. — This  immediately  succeeds  the  full  develop- 
ment of  the  pustules.  The  liquid  portion  of  the  contents  of  the  pustules 
which  are  broken  evaporates,  leaving  a  crust.  If  there  be  no  rupture,  the 
liquid  is  absorbed  and  a  scab  results,  which,  though  smaller,  preserves  in  a 
measure  the  form  of  the  pustule.  While  the  pustule  desiccates  the  sur- 
rounding inflammation  rapidly  abates.  The  crusts  occur  first  upon  the  face, 
and  on  other  parts  in  the  order  in  which  the  eruption  appeared.  The  odor 
from  the  patient  at  this  time  is  peculiar.  In  the  confluent  form  especially  it 
is  very  oftensive,  and  can  be  noticed  at  a  distance  from  the  bedside.  Killiet 
and  Barthez  call  it  nauseous  and  fetid.  As  desiccation  progresses  the  symp- 
toms, local  and  general,  abate.  The  pulse  and  temperature,  if  the  case  be 
favorable,  return  to  the  normal ;  the  cough,  hoarseness,  and  thirst  disappear, 
while  the  appetite  returns  ;  the  sleep  is  more  tranquil,  and  the  functions  gen- 
erally are  more  regularly  performed. 

The  last  stage  is  that  of  desquamation  ;  it  commences  between  the 
eleventh  and  sixteenth  days.  The  scabs,  which  present  a  dark  or  brownish 
appearance,  are  successively  detached.  This  period  lasts  several  days ;  some- 
times two  or  three  weeks  even  elapse  before  all  the  crusts  separate.  In  the 
mean  time,  the  patient  gradually  recovers  his  health  and  former  strength. 
After  the  fall  of  the  crust  the  cicatrix  underneath  presents  a  reddish  appear- 
ance. The  color  gradually  fades,  and  there  remains  an  irregular  depression, 
or  pit,  of  a  lighter  color  than  the  surrounding  surface,  and,  if  there  have 
been  a  full  development  of  the  eruption,  disfiguring  the  patient  for  life. 

Such  is  the  clinical  history  of  variola  when  it  is  favorable  and  its  course 
is  regular.  The  disease  is  sometimes  irregular.  In  rare  instances  the  erup- 
tion occurs  almost  at  the  commencement  of  the  attack.  The  form  is  then 
likely  to  be  confluent.  There  are  irregularities  also  in  consequence  of 
diarrhoea,  hemorrhages,  or  other  complications.  I  have  known  the  eruption 
appear  first  on  the  limbs,  and  last  on  the  trunk  and  face,  and  the  appearance 
of  the  eruption  is  not  always  the  same.  In  the  anaemic  and  feeble  child  it 
often  presents  a  pale  color,  with  some  induration  at  its  base,  but  without  the 


340  VARIOLA— VARIOLOID. 

red  areola  around  it  or  with  tliis  quite  indistinct.  In  rare  instances  the  ves- 
icles have  a  reddish  color,  their  contents  being  tinged  with  blood.  This  form 
of  variola  is  designated  hemorrhagic.  It  indicates  a  profoundly  altered  state 
of  the  blood.  The  eruption  in  this  form  is  of  small  size,  and  if  the  pock  is 
broken,  blood  oozes  from  it. 

I  have  met  one  case,  perhaps  two,  of  malignant  hemorrhagic  smallpox, 
as  described  by  Hebra,  among  the  rare  forms  of  this  malady.  The  second 
case  died  so  soon  that  we  were  undecided  whether  he  had  smallpox  or  scar- 
latina. A  man  aged  thirty-six  years,  previously  healthy,  became  suddenly 
and  severely  sick  in  June,  1881,  with  fever,  intense  headache  and  backache, 
great  depression  of  the  vital  powers,  sleeplessness,  and  a  sensation  of  sinking 
or  depression  in  the  epigastrium.  He  had  a  marked  foreboding  of  coming 
evil,  and  begged  almost  constantly  for  relief.  Within  forty-eight  hours  a 
heavy  and  continuous  dusky  scarlatiniform  eruption  covered  the  whole  sur- 
face, except  below  the  knees,  disappearing  on  pressure ;  fauces  at  first  but 
moderately  injected.  On  the  following  day,  the  third  of  his  sickness,  with  a 
temperature  of  104.5°,  the  efflorescence  became  a  dark  red,  numerous  small 
extravasations  of  blood  had  occurred  under  the  skin,  the  urine  contained 
blood,  and  finally  it  seemed  to  consist  almost  entirely  of  dark  blood ;  a  large 
effusion  of  blood  under  the  entire  conjunctiva  of  either  eye  prevented  closure 
of  the  eyelids,  and  probably  hemorrhages  had  occurred  within  the  eyes,  as 
the  sight  was  nearly  lost.  Death  took  place  on  the  following  day.  In  Hebra's 
article  on  smallpox  is  the  description  of  precisely  such  cases,  but  the  death  of 
my  patient  was  too  early  for  exact  diagnosis. 

Varioloid. — The  course  of  varioloid  is  similar  to  that  of  variola,  but  it 
is  somewhat  shorter.  It  commences  with  rigors,  followed  by  fever,  head- 
ache, pain  in  the  back,  vomiting,  drowsiness,  and  sometimes  delirium,  or 
even  convulsions.  The  symptoms  in  the  stage  of  invasion  are,  indeed,  the 
same  in  character,  and  often  nearly  as  severe  as  in  variola.  With  the  initial 
symptoms  there  is  also  sometimes  a  scarlatiniform  eruption,  so  that  the 
disease  may  at  first  be  mistaken  for  scarlatina.  On  the  third  or  fourth  day 
the  variolous  eruption  commences.  The  number  of  pocks  is  commonly  few, 
often  not  more  than  twelve  to  twenty.  In  the  mildest  form  of  varioloid,  if 
the  physician  be  not  summoned  in  the  stage  of  invasion,  he  may  not  be  called 
at  all,  so  that  the  patient  passes  through  the  disease  in  ignorance  of  its  nature. 
The  true  character  of  the  malady  is  not  ascertained  till  others  are  afiiected 
either  with  variola  or  varioloid. 

The  eruption  pursues  a  more  rapid  course  in  varioloid  than  in  the  unmod- 
ified disease.  By  the  fifth  or  sixth  day  the  pustules  are  fully  developed, 
though  often  smaller  and  less  likely  to  be  ruptured  than  in  variola.  Often 
in  varioloid  the  eruption  aborts.  It  remains  papular  two  or  three  days,  and 
then  declines,  or  it  may  reach  the  vesicular  stage  and  decline  without  pustu- 
lation. 

The  constitutional  symptoms  in  varioloid  abate  with  the  commencement 
of  the  eruptive  stage.     The  secondary  fever  is  slight  or  absent. 

Such  is  the  usual  mild  course  of  varioloid,  but  not  always.  If  several 
years  have  elapsed  since  the  vaccination,  its  protective  power  is  greatly 
impaired,  and  varioloid  may  then  exhibit  as  severe  a  form  as  ordinary  small- 
pox.    In  some  instances  it  is  fatal. 

The  term  varioloid  is,  as  has  been  stated,  applied  to  cases  of  variolous 
disease  if  there  have  been  previous  vaccination.  It  is  also  applied  by  writers 
to  second  attacks,  whether  the  first  occurred  from  infection  or  from  variolous 
inoculation,  but  such  cases  are  rare. 

Mode  of  Death. — Death  in  smallpox  occurs  in  several  different  ways. 
The  most  fatal  period  is  the  pustular.     Feeble  children  not  infrequently  die 


COMPLICATIONS.  341 

from  exhaustion  at  or  about  the  time  that  the  pustules  attain  their  greatest  size. 
The  eruption  appears  and  becomes  developed  as  usual,  but  there  are  evi- 
dences of  weakness  in  the  patient,  and  suddenly  the  progress  of  the  vesicle 
or  pustule  ceases.  It  begins  to  subside  and  its  walls  shrivel.  There  is  evi- 
dently absorption,  in  part,  of  the  liquid  contents.  These  phenomena  are  of 
the  gravest  character.  .Death  is  the  common  result,  and  within  twenty-four 
hours.  In  other  cases  death  occurs  from  apnoea.  The  pock,  increasing  in 
size  in  the  larynx  and  trachea,  obstructs  inspiration,  or  there  may  be  the 
formation  of  a  pseudo-membrane,  as  in  true  croup.  This  is  not  an  unusual 
mode  of  death  in  young  children,  in  whom  the  calibre  of  the  larynx  and 
trachea  is  small.  Sometimes  convulsions  and  coma  occur  in  the  last  hours 
of  life.  In  other  cases  the  stage  of  desquamation  is  reached,  but  convales- 
cence does  not  occur.  The  patient  each  day  becomes  more  anaemic  and 
feeble,  and  finally  death  results  from  failure  of  the  vital  powers.  Again, 
after  smallpox  has  run  its  course  purpura  haemorrhagica  may  be  developed. 
Hemorrhages  occur  from  the  gums,  throat,  nostrils.  Blood  is  vomited,  and 
evacuated  in  the  stools.  I  have  known  death  to  occur  in  all  these  ways,  but 
that  from  purpura  is  least  frequent.  Sometimes,  as  in  scai'let  fever,  death 
occurs  suddenly  and  unexpectedly  in  confluent,  and  even  in  discrete,  variola, 
when  the  previous  symptoms  had  apparently  been  favorable.  The  patient  is 
overpowered  by  the  intensity  of  the  virus. 

Anatomical  Characters. — In  those  who  have  died  of  variola  without 
inflammatory  or  other  complication  the  heart-clots  have  been  found  small, 
dark,  and  soft.  The  blood  is  dark  and  thin.  The  vessels  of  the  brain  and 
its  membranes  are  injected,  so  that  numerous  red  points  appear  on  the  ciit 
surface  of  this  organ.  The  vessels  of  the  lungs  and  the  abdominal  organs 
are  congested,  while  the  muscles  present  a  deep-red  color.  The  variolous 
eruption  penetrates  more  deeply  than  that  of  any  other  exanthematic  fever. 
It  has  been  stated  elsewhere  that  it  occurs  not  only  on  the  skin,  but  often 
on  the  surface  of  the  mouth,  fauces,  and  air-passages.  The  mucous  mem- 
brane in  these  situations  is  frequently  also  the  seat  of  catarrhal  inflammation, 
being  thickened  and  softened,  and  in  some  parts,  as  the  larynx,  a  pseudo- 
membrane  is  occasionally  produced,  as  in  croup. 

The  eruption  very  seldom,  perhaps  never,  appears  upon  the  gastro-intes- 
tinal  surface,  but  the  solitary  follicles  and  patches  of  Peyer  are  often 
enlarged,  as  in  some  other  zymotic  aff'ections.  The  liver,  spleen,  and  kidneys 
are  commonly  congested  in  those  who  have  died  of  variola.  The  spleen 
especially  is  increased  in  volume  and  softened  ;  the  kidneys  are  enlarged,  as 
from  commencing  nephritis,  and  sometimes  softened. 

The  minute  structure  of  the  pock  is  described  by  Rilliet  and  Barthez 
and  others.  The  vesicle  is  multilocular,  consisting  of  at  least  five  or  six  com- 
partments with  distinct  partitions.  Its  centre  is  united  by  fibrous  bands  to 
the  derm  beneath,  which  union  gives  rise  to  the  umbilicated  appearance. 
The  giving  way  of  these  minute  bands  in  the  pustular  stage  occurs  when 
the  form  changes  from  the  umbilicated  to  the  convex.  In  the  pustular  stage 
also,  according  to  some,  a  fibrous  formation  occurs  within  the  pustule ; 
according  to  others,  this  substance  is  of  the  nature  of  the  epidermis,  pre- 
senting the  appearance  of  the  cuticle  when  macerated.  Mixed  with  this 
epidermic  or  fibrinous  formation  are  pus-cells. 

Complications. — There  are  several  diff"erent  complications  of  variola. 
One  is  salivation.  This  is  common  in  the  adult,  but  rare  in  the  child. 
When  it  occurs  in  the  child  it  is  slight,  commencing  with  or  about  the  time 
of  the  eruption,  and  disappearing  in  from  one  to  four  or  five  days.  Oph- 
thalmia is  another  complication.  Simple  conjunctivitis,  often  quite  intense, 
may   occur   in    consequence    of   pustules    developed    under    the    lids.     This 


342  VARIOLA—  VABIOL  OID. 

inflammation  subsides  without  injury  to  the  eye  as  the  primary  disease 
abates.  A  more  serious  inflammation  occurs  at  an  advanced  stage  of  variola, 
commencing  in  or  near  the  desquamative  period.  This  produces  more  or 
less  chemosis,  and  sometimes  opacity  or  ulceration  of  the  cornea.  A  similar 
inflammation  may  occur  in  the  ear,  giving  rise  to  otorrhoea,  and  even,  in  some 
patients,  to  rupture  of  the  drum  of  the  ear.  Abscesses  in  the  subcutaneous 
connective  tissue  have  been  occasionally  observed,  especially  in  the  confluent 
form.  Subcutaneous  infiltration  and  feebleness  of  constitution  favor  their 
occurrence.  Suppuration  within  the  joints  is  a  somewhat  rare  complication 
or  sequel,  rendering  convalescence  protracted,  if,  indeed,  the  case  be  not 
fatal. 

M.  Beraud  has  published  a  memoir  to  show  that  orchitis  in  the  male  and 
ovaritis  in  the  female  may  complicate  variola.  These  inflammations  are 
believed  to  be  accompanied  by  a  small  and  imperfect  variolous  eruption 
upon  the  tunica  vaginalis  and  the  peritoneal  covering  of  the  ovary.  Trous- 
seau states  that  he  has  often  met  this  complication  in  the  male  since  his 
attention  was  called  to  it.  It  is  mild,  and  subsides  with  the  disappearance 
of  the  eruption.  Laryngitis,  simple  or  diphtheritic,  bronchitis,  pneumonia, 
pharyngitis,  purpuric  hemorrhages,  gangrene  of  the  mouth  or  other  parts, 
oedema  pulmonum,  and  oedema  glottidis  are  occasional  complications,  some 
of  which  are  frequent,  others  rare. 

Prognosis. — This  depends  on  the  age,  vigor  of  system,  form  of  the 
disease,  and  the  presence  or  absence  of  complications.  The  younger  the 
child  the  greater  the  danger.  Trousseau  says :  "  Confluent  variola,  and  even 
discrete  variola,  are  almost  always  fatal  in  individuals  less  than  two  years 
old."  Above  the  age  of  three  or  four  years  discrete  variola  usually  ends 
favorably,  but  the  confluent  form  is  still,  as  a  rule,  fatal.  Varioloid  in  the 
child  is  a  mild  disease,  terminating  favorably  in  a  large  proportion  of  cases. 
It  is  milder  at  this  age  than  in  the  adult,  on  account  of  the  more  recent 
period  of  vaccination.  If  varioloid  be  severe  and  the  eruption  abundant 
in  a  child  who  has  been  vaccinated,  it  is  probable  that  the  vaccination  was 
spurious. 

It  is  not  necessary,  from  what  has  been  said,  to  specify  the  favorable 
prognostic  signs.  The  unfavorable  prognostics  are — great  violence  of  the 
initial  symptoms ;  early  appearance  of  the  eruption ;  an  abundant  eruption, 
especially  if  pale  and  without  swelling  of  the  surface ;  rapid  decline  of  the 
eruption  in  the  vesicular  or  pustular  stage  ;  hemorrhagic  eruption  or  hemor- 
rhages from  the  surfaces  ;  fever  continuing  after  the  appearance  of  the  erup- 
tion ;  diarrhoea  persisting  beyond  the  third  or  fourth  day  ;  delirium  or  great 
drowsiness  ;  a  frequent  and  feeble  pulse  ;  and,  finally,  obstructed  respiration 
— if  slow,  indicating  a  pseudo-membrane  or  variolous  eruption  in  the  larynx 
or  trachea ;  if  rapid,  indicating  bronchitis  or  pneumonia. 

Diagnosis. — The  diagnosis  cannot  be  made  with  certainty  prior  to  the 
eruptive  stage.  If,  however,  smallpox  be  prevalent,  if  the  patient  have  not 
been  vaccinated,  and  the  symptoms  which  pertain  to  the  period  of  invasion 
be  present,  as  headache,  pain  in  small  of  back,  repeated  vomiting,  drowsiness, 
and  perhaps  convulsions,  there  is  ground  for  the  gravest  suspicion.  If  in 
addition  to  these  symptoms  reddish  points  begin  to  appear  on  the  second  or 
third  day,  the  diagnosis  may  be  made  with  confidence.  At  this  early  period, 
even  before  there  is  any  distinct  cutaneous  eruption,  ash-colored  spots  may 
sometimes  be  observed  on  the  buccal  or  faucial  surface,  the  commencement 
of  the  variolous  eruption  ;  these  possess  considerable  diagnostic  value. 

The  scarlatiniform  efilorescence  in  the  first  stage  of  variola  sometimes 
leads  to  the  belief  that  the  disease  is  scarlet  fever.  The  absence  of  the 
pharyngitis   and   the   appearance   of   the  variolous    eruption  soon  after  the 


TREATMENT.  343 

efflorescence  correct  the  diagnosis.  Smallpox  has,  in  the  beginning  of  the 
eruptive  period,  sometimes  been  mistaken  for  measles.  The  points  involved 
in  the  differential  diagnosis  have  been  presented  in  treating  of  that  disease. 
After  the  development  of  the  eruption  it  may  be  mistaken  for  varicella.  The 
eruption  of  varicella  is,  however,  preceded  by  symptoms  which  are  milder 
and  of  shorter  duration,,  and  its  appearance  is  different.  It  is  irregular, 
instead  of  round,  is  not  umbilicated,  and  it  does  not  have  the  round,  inflamed, 
and  indurated  base  which  characterizes  the  variolous  eruption.  The  eruption 
of  ecthyma  is  sometimes  umbilicated,  but  the  symptoms  of  ecthyma  and  variola 
and  the  progress  of  the  eruptions  in  the  two  diseases  are  very  different. 

Treatment. — Smallpox,  like  the  other  essential  fevers,  is  self-limited, 
and  therefore  the  constitutional  treatment  should  be  sustaining  and  pal- 
liative. In  the  first  stages  of  the  disease  the  diet  should  be  simple ;  gentle 
laxatives  and  refrigerant  drinks  are  required  if  there  be  much  febrile  excite- 
ment. Lemonade  is  a  grateful  drink,  and  may  be  given  in  moderate  quantity. 
Spiritus  mindereri  in  carbonic-acid  water  may  be  allowed.  As  the  disease 
advances  more  nutritious  food  should  be  recommended,  and  in  severe  cases 
carbonate  of  ammonium,  and  even  alcoholic  stimulants,  are  required. 

As  confluent  smallpox  is  nearly  always,  and  the  discrete  form  often,  fatal 
in  infancy,  the  physician  should  carefully  watch  the  progress  of  the  case  in 
the  infant.  By  judicious  treatment  some  in  this  period  of  life  may  be  saved 
who  otherwise  would  perish.  In  the  infant  depressing  measures  should  be 
avoided.  A  laxative  may  be  given  at  first  if  there  be  much  fever  and  the 
bowels  are  constipated;  but  the  diet  should  be  nutritious,  and  many  soon 
require  tonics  and  stimulants.  If  the  pulse  become  more  frequent  and 
feeble,  or  if,  with  frequency  of  the  pulse,  the  face  and  extremities  become 
cool,  or  in  the  vesicular  or  pustular  stage  the  eruption  suddenly  subside, 
alcoholic  stimulants  must  be  immediately  employed  or  the  patient  dies. 

Such  is  an  outline  of  the  constitutional  treatment  required  in  smallpox. 
Sydenham  inculcated  a  mode  of  treatment  which  experience  has  shown  to  be 
injurious  in  infancy  and  childhood.  He  had  observed  that  the  severity  of  the 
disease  was  ordinarily  proportionate  to  the  amount  of  eruption,  and  concluded 
from  this  fact  that  measures  which  retarded  the  development  of  the  eruption 
were  salutary :  cold  drinks,  a  cold  apartment,  scanty  covering  of  the  body, 
cathartics  that  caused  derivation  of  the  blood  from  the  surface,  even  some- 
times the  abstraction  of  blood,  were  considered,  according  to  Sydenham's 
theory,  to  be  useful  as  means  of  preventing  full  development  of  the 
eruption. 

Sydenham's  treatment,  however  appropriate  it  might  sometimes  be  in  case 
of  robust  adults,  is  unsuitable  for  children,  because  they  do  not,  as  a  rule, 
tolerate  in  this  disease  measures  which  reduce  the  strength.  Moreover, 
smallpox  is  rendered  more  dangerous  by  what  Killiet  and  Barthez  designate 
perturbating  treatment — treatment  which  renders  it  abnormal.  The  regular 
appearance  and  development  of  the  eruption  are  requisite  in  order  that  the 
case  may  progress  favorably.  On  the  other  hand,  the  opposite  plan  of  treat- 
ment, which  families,  if  left  to  themselves,  frequently  adopt — to  wit,  the 
employment  of  measures  to  promote  perspiration,  as  hot  drinks  and  confine- 
ment in  a  heated  room — is  also  injurious. 

The  patient  should  be  kept  in  a  temperature  such  as  he  has  been  accus- 
tomed to  and  such  as  is  agreeable  to  him — a  temperature  at  G6°  to  70°  ;  his 
diet  should  be  simple  and  nutritious ;  laxative  medicine  should  only  be  given 
to  procure  the  natural  evacuations.  In  smallpox,  as  in  all  infectious  dis- 
eases, free  ventilation  of  the  apartment  is  required.  The  room  should  be 
dark,  for  a  strong  light  perhaps  increases  the  pitting. 

While  the  general  eruption  should  not,  as  a  rule,  be  interfered  with,  it  is 


344  VARIOLA— VARIOLOID. 

proper  to  endeavor  to  diminish,  so  far  as  possible,  the  size  of  the  pocks  on 
parts  exposed  to  view,  so  as  to  prevent  disfigurement.  Professor  Flint,  in  his 
Treatise  on  the  Practice  of  Medicine,  has  published  an  excellent  summary  of 
the  various  measures  which  have  been  recommended  for  accomplishing  this 
end.  First :  The  opening  and  breaking  up  of  the  vesicle  by  means  of  a  fine 
needle.  This  is  tedious  practice  in  confluent  variola,  but  it  can  readily  be 
performed  in  the  discrete  form — at  least  as  regards  the  vesicles  upon  the  face. 
This  treatment  was  proposed  by  Rayer,  and  it  is  recommended  by  many  who 
have  tried  it.  Secondly :  After  the  evacuation  of  the  liquid  the  cauteriza- 
tion of  the  vesicle  by  a  pointed  stick  of  nitrate  of  silver.  Eilliet  and  Bar- 
thez  say,  in  reference  to  this  mode  of  treatment,  "  Individual  cauterization 
of  the  pustules  is,  on  the  other  hand,  an  almost  infallible  means  of  causing 
them  to  abort.  To  be  successful,  it  is  necessary  to  penetrate  into  the  interior 
of  the  pustule  with  a  pointed  crayon  of  nitrate  of  silver  in  order  to  cauterize 

the  derm It  is  only  the  first  or  second  day  of  the  eruption  that  it 

(cauterization)  has  certain  success  ;  nevertheless,  we  have  often  seen  it  suc- 
ceed the  third  or  the  fourth  day,  or  even  the  fifth."  Thirdly :  The  appli- 
cation of  tincture  of  iodine  once  or  twice  daily  over  the  eruption  when  in 
the  papular  stage.  Some  writers  who  have  employed  iodine  state  that  it 
does  not  prevent  pitting,  but  diminishes  it.  Its  favorable  effects  are  pro- 
duced by  coagulating  the  contents  of  the  papule.  Fourthly  :  The  exclusion 
of  light  and  air  by  means  of  a  plaster.  A  mixture  containing  tannate  of 
iron  has  been  employed  for  this  purpose  in  one  of  our  hospitals.  This 
produces  a  black  mask.  Light  and  air  may  also  be  excluded  by  smearing 
the  face  with  sweet  oil  and  dusting  twice  daily  upon  the  oiled  surface  a 
powder  containing  equal  parts  of  subnitrate  of  bismuth  and  prepared  chalk. 
Fifthly  .  The  application  of  mild  mercurial  ointment  upon  the  face  or  other 
parts  of  the  surface  where  it  is  desirable  to  render  the  eruption  abortive. 
This  mode  of  treatment  does  diminish  the  size  of  the  vesicles  and  the  pitting, 
but  I  should  not  recommend  it  for  children.  I  have  known  in  the  adult 
severe  mercui'ialization  from  its  employment  for  four  or  five  days,  and,  though 
young  children  do  not  exhibit  so  readily  the  effects  of  mercury,  the  use  of 
the  ointment,  unless  for  a  very  limited  period,  increases,  in  my  opinion,  their 
feebleness  and  diminishes  the  chance  of  their  recovery.  Calamine  made  into 
a  paste  with  sweet  oil  is  said  to  be  equally  effectual  with  mercurial  ointment, 
and  it  produces  no  constitutional  effect.  Its  effect  is  obviously  similar  to  that 
of  the  bismuth  and  chalk  employed  with  sweet  oil  as  stated  above.  Also,  I 
have  employed  pulverized  charcoal  made  into  a  thin  paste  with  sweet  oil  or 
glycerin,  and  applied  daily  or  twice  daily  to  the  face.  It  effectually  excludes 
the  light,  and  the  result  appeared  to  be  good  as  regards  pitting,  but  it  is  a 
disagreeable  application.  Curschmann  recommends  as  preferable  to  any  of 
these  methods  the  use  of  iced  compresses  to  the  face  and  hands.  The  pain, 
redness,  and  swelling  are  diminished  by  their  use,  but  without  change  in  the 
copiousness  of  the  eruption  (^Ziemssenh  Encyclop.').  If  fissures  or  excor- 
iations occur,  an  application  may  be  made  of  oxide  or  carbonate  of  zinc  in 
glycerin,  one  drachm  to  the  ounce. 

Dr.  Tomkyns  of  the  Fever  Hospital,  Manchester,  England,  states  that  he 
has  used  with  good  results  the  following  mixture,  applied  from  time  to  time 
over  the  surface  : 

IJ.  Glycerini,  gss; 

Tine,  iodini,  ^ij  ; 

Sol.  amyli,  Oss.     Misce. 

The  intense  itching  and  the  fetor  are,  according  to  my  observations,  best 
relieved  by  frequent  bathing  with  the  following  wash : 


Shake  bottle  before  using. 


VACCINIA.  345 


B(.  Acidi  carbolic,  .^j  ; 

Tine,  caiuplior.,  .^ij  ; 

Aquie,  Oj.      Misce. 


The  prevention  of  smallpox,  so  far  as  practicable,  is  one  of  the  important 
incidental  duties  of  the  physician.  Isolation  of  the  patient  and  precautious 
in  reference  to  his  clothes  and  bcddinj^  are  imperatively  required,  so  great  is 
the  contagiousness  of  this  disease.  The  only  certain  means  of  prevention  is 
vaccination,  and  providentially  the  incubative  period  of  the  vaccine  disease 
is  less  than  that  of  variola.  Therefore,  smallpox  may  be  prevented  after  the 
virus  is  received  in  the  system  by  timely  and  successful  vaccination.  Vac- 
cination, at  any  period  between  the  time  of  exposure  and  the  commencement 
of  the  symptoms  of  invasion,  will  either  prevent  the  occurrence  of  smallpox 
or  modify  it.  If  the  symptoms  of  invasion  have  already  commenced,  it  is 
uncertain  whether  it  produces  any  modifying  effect. 

Variola  is  so  very  contagious  that  there  is  danger  that  the  phy.sician  and 
attendants  may  communicate  it  through  their  persons  or  clothing.  The  virus 
adheres  tenaciously  to  objects,  and  may  be  conveyed  by  them  long  distances. 
Therefore  the  room  occupied  by  the  patient  should  contain  no  unnecessary 
articles,  as  books  or  writing  material,  and  the  physician  attending  a  case 
should  bathe  and  change  his  clothing  before  going  elsewhere.  A  disinfectant 
should  also  be  constantly  used  in  the  room,  as  the  following,  which  I  have 
recommended  in  the  treatment  of  diphtheria  and  scarlet  fever  : 

K.  01.  eucalypti, 

Acidi  carbolic,         da.  Jj  ; 
Spts.  terebinth.,  H^iij.      Misce. 

Two  teaspoonfuls  in  a  quart  of  water,  placed  in  a  tin  vessel,  shallow  and  with  broad 
surface,  and  maintained  in  a  state  of  constant  simmering. 


CHAPTER    V. 

VACCINIA. 

Vaccinia  is  a  mild  eruptive  disease  which  occasionally  occurs  among 
cattle  and  has  been  propagated  from  them  to  man.  It  is  characterized  by 
the  appearance  upon  the  surface  of  one  or  more  papules,  which  soon  become 
vesicular  and  then  pustular.  It  is  communicable  by  contact,  but,  unlike  the 
other  eruptive  fevers,  it  is  not  contagious  through  the  air.  It  is  inoculable, 
both  by  the  liquid  contained  in  the  vesicle,  which  is  designated  vaccine  lymph, 
and  by  the  scab  which  results  from  the  desiccation  of  the  pustule. 

To  Gloucestershire,  England,  the  honor  belongs  of  discovering  and  utiliz- 
ing the  fact  that  vaccinia,  a  mild  and  comparatively  harmless  disease,  is  trans- 
missible from  the  cow  to  man,  and  that  it  affords  protection  from  smallpox. 
It  appeai-s  that  a  vague  opinion  prevailed  among  the  farmers  of  this  dairyin;^ 
section  that  a  disease  which  has  since  been  designated  vaccinia  was  occasion- 
ally received  from  the  cow  in  milking,  the  virus  passing  from  a  pustule  on 
the  teat  to  a  sore  or  chap  on  the  hand  of  the  milker,  and  that  those  who  thus 
conti'acted  the  disease  received  immunity  from  smallpox.  As  usually  happens 
with  important  discoveries,  so  slow  of  apprehension  is  the  human  intellect, 
these  people,  to  whom   Providence  had  revealed  a  most  important  fact,  were 


346  VACCINIA. 

blind  to  its  real  value.  Finally,  in  the  year  1724,  Benjamin  Jesty,  whom  the 
world  has  not  sufficiently  honored,  '-an  honest  and  upright  man,"  according 
to  his  epitaph,  a  farmer  of  Gloucestershire,  had  the  courage  to  vaccinate  his 
wife  and  two  children.  His  excellent  moral  character  did  not  shield  him. 
He  was  regarded  by  his  neighbors  as  an  inhuman  brute,  who  had  performed 
an  experiment  on  his  own  family  the  tendency  of  which  might  be  to  trans- 
form them  into  beasts  with  horns. 

This  first  essay  in  vaccination  appears  to  have  been  entirely  successful,  but 
the  prejudice  against  the  operation  continued.  A  fifth  of  a  century  passed, 
during  which  there  was  no  extension  of  the  benefits  of  this  great  discovery. 
At  last,  toward  the  close  of  the  last  century,  Dr.  Edward  Jenner,  a  physician 
of  Gloucestershire,  an  inoculator  of  his  district,  began  to  investigate  this  dis- 
ease of  the  cow,  about  which  little  was  known,  and  the  grounds  for  the  belief 
that  it  afforded  protection  from  smallpox.  Fortunately  for  the  world,  Jenner 
had  been  educated  under  John  Hunter,  and  had  learned  from  his  great  mas- 
ter to  study  nature  rather  than  books — to  be  guided  by  experience  and  obser- 
vation rather  than  by  the  dogmas  of  his  predecessors  or  of  the  schools. 

Jenner  performed  his  first  vaccination  on  the  14th  of  May,  1796,  twenty- 
two  years  after  Benjamin  Jesty  had  lost  his  good  name  among  his  neighbors 
by  vaccinating  his  own  family.  The  popularizing  of  vaccination,  mainly 
through  Jenner's  perseverance,  affords  one  of  the  most  interesting  and  in- 
structive chapters  in  the  history  of  medical  science — how  he  went  to  London 
full  of  the  importance  of  the  discovery,  and  was  there  advised  by  his  medical 
friends  to  desist  from  his  wild  schemes,  lest  he  should  injure  the  reputation 
which  he  had  gained  from  a  ci'editable  paper  on  the  habits  of  the  cuckoo ; 
how  he  was  finally  allowed  to  vaccinate  in  hospital  wai'ds,  and  gained  some 
adherents  to  the  new  faith  among  the  leading  physicians  of  the  metropolis; 
and,  finally,  how,  as  the  claims  of  vaccination  began  to  be  recognized  at  the 
close  of  the  last  century  and  commencement  of  the  present,  a  most  acrimo- 
nious discussion  arose  which  filled  all  the  medical  journals  of  that  period. 
The  opponents  of  vaccination  resorted  to  every  device  to  prevent  the  accept- 
ance of  Jenner's  views.  They  attempted  to  prejudice  the  people  against 
them  by  specious  arguments,  by  ridicule,  and  even  by  caricatures.  One  of 
the  leading  journals  contained  the  picture  of  a  cow  covered  with  sores  and 
devouring  children,  and  it  was  urged  that  vaccination  was  a  bestial  operation, 
degrading  man  to  the  level  of  the  brute.  But  the  truth  had  gained  a  firm 
hold  and  the  practice  of  vaccination  extended. 

The  discovery  of  vaccinia  and  of  its  protective  power  cannot  be  too 
highly  appreciated.  It  has  probably  done  more  to  relieve  human  suffering 
than  any  other  discovery  of  the  last  one  hundred  years,  unless  we  except 
that  of  anassthetics,  and  more  to  save  human  life  than  any  other  instrument- 
ality of  a  purely  physical  kind. 

The  fact  was  established  in  the  time  of  Jenner  that  the  virus  of  small- 
pox inoculated  in  the  cow  produces  vaccinia,  which  in  its  propagation  back 
to  man  never  returns  to  its  original  form,  but  always  remained  vaccinia. 
Moreover,  Jenner  believed  that  the  disease  known  in  the  horse  as  the  grease 
was  identical  in  nature  with  vaccinia  in  the  cow.  He  failed,  however,  in  his 
experiment  to  communicate  vaccinia  from  the  horse,  but  other  experiments 
have  been  more  successful.  In  1801  a  Dr.  Loy  of  the  county^of  York,  Eng- 
land, met  two  cases  of  vaccinia  in  persons  who  had  taken  care  of  a  horse 
affected  with  the  grease,  and  from  the  lymph  which  he  obtained  was  able  to 
produce  vaccinia  in  the  cow.  In  1805,  Viborg,  a  Danish  veterinary  surgeon, 
after  many  failures,  succeeded  also  in  communicating  vaccinia  to  the  cow  by 
means  of  the  virus  taken  from  a  horse. 

From  this  time  little  light  was  thrown  on  this  subject  till  within  the  last 


VACCINIA.  347 

twenty  years.  Although  Loy  ami  Vihorj^,  and  perhaps  a  few  others,  hud 
recorded  their  success,  other  experiinenters  had  failed  to  communicate  vac- 
cinia from  the  horse.  In  the  absence  of  additional  cases  the  profession  began 
to  question  whether  there  might  not  have  been  some  error  in  the  observations 
of  the  gentlemen  whose  names  I  have  mentioned,  and  whether  a  disease  iden- 
tical witii  vaccinia,  or  a  dificase  which  may  communicate  vaccinia  to  the  cow 
or  to  man,  occurs  in  the  horse. 

Observations  confirmatory  of  those  of  Loy  and  Viborg  were  at  length, 
however,  made,  which  must  be  regarded  as  conclusive.  In  1856,  in  the 
department  of  L'Eurc-et-Loir,  France,  M.  Pichot  was  consulted  by  a  boy 
who  had  on  the  back  of  his  hands  vaccine  pustules  which  had  apparently 
reached  the  eighth  or  ninth  day.  He  had  not  taken  care  of  nor  been  in  con- 
tact with  a  cow,  but  had  a  few  days  befoi'e  taken  care  of  a  horse  affected  with 
the  grease.  Vaccination  was  performed  by  means  of  the  lymph  taken  from 
the  pustules,  and  genuine  vaccinia  was  produced. 

Again,  in  1860  an  epidemic  prevailed  among  the  horses  in  Riemes  and 
Toulouse,  France.  A  mare  sickened  with  the  disease,  and  there  was  swell- 
ing of  the  hough,  with  discharge  of  sanious  matter.  M.  Delafosse  vacci- 
nated two  cows  with  this  matter  and  communicated  genuine  vaccinia.  This 
epidemic  was  believed  by  the  veterinary  sui'geons  to  be  an  eruptive  fever, 
differing  in  its  nature  somewhat  from  the  disease  or  diseases  which  have  ordi- 
narily been  designated  the  grease.  It  has  been  conjectured  that  two  or  more 
distinct  affections  of  the  horse  have  the  same  appellation — one  of  which,  it  is 
now  admitted,  is  identical  with  vaccinia  of  the  cow  and  may  communicate  it; 
and  the  reason  why  so  many  experimenters  have  failed  to  vaccinate  the  cow 
from  the  horse  is  that  they  have  used  the  virus  of  the  wrong  disease,  or  have 
taken  virus  from  horses  which  had  been  affected  with  true  disease,  but  from 
ulcers  which  had  lost  their  specific  character. 

Prior  to  the  time  of  Jenner  variolous  inoculation  was  practised  in  most 
civilized  countries,  since  variola  produced  in  this  way  was  found  to  be  milder 
than  when  arising  from  infection.  This  practice  is  now  obsolete,  forbidden 
in  some  places  by  legislative  enactments.  It  is  superseded  by  vaccination. 
Vaccination,  or  the  introduction  of  vaccine  lymph  into  the  system,  is  quickly 
and  conveniently  performed  by  scarifying  with  a  lancet  and  rubbing  into  the 
incisions  the  lymph  or  a  little  of  the  scab  pulverized  and  dissolved  in  a  drop 
of  cold  water.  It  may  also  be  performed  by  scraping  off  the  epidermis  with 
the  edge  of  the  instrument  till  the  blood  begins  to  ooze ;  and  also,  though 
with  less  certainty  of  success,  by  puncturing  the  skin  with  the  point  of  the 
lancet  or  by  an  instrument  called  the  vaccinator.  The  scab  should  never  be 
employed  when  it  is  possible  to  obtain  pure  lymph,  since  it  contains  animal 
matter  apart  from  the  virus,  and  may  be  the  medium  through  which  other 
diseases  may  be  communicated.  Besides,  it  is  much  less  active  than  pure 
lymph. 

If  the  child  have  a  vascular  ngevus,  this  may  be  selected  as  the  point  of 
vaccination.  Unless  of  large  size,  it  can  usually  be  cured  by  the  inflammation 
which  vaccinia  produces.  Statistics  collected  by  Simon,  as  well  as  Marson, 
show  that  in  those  who  contract  varioloid  the  larger  the  number  of  vaccine  cic- 
atrices the  milder  the  disease  and  the  less  the  proportionate  number  of  deaths. 
In  Simon's  statistics  of  those  who  stated  that  they  had  been  vaccinated,  but 
who  presented  no  cicatrix,  21 1  per  cent,  died  ;  of  those  who  had  one  cicatrix, 
l-i  per  cent,  died  ;  of  those  who  had  two,  4i  per  cent,  died  ;  of  those  who  had 
three,  I4  per  cent,  died;  while  of  those  who  had  four  or  more  cicatrices,  only 
f  per  cent.  died.  These  statistics  would  seem  to  indicate  the  propriety  of 
vaccinating  in  several  places.  But,  so  far  as  appears,  when  two  or  more 
cicatrices  were  observed  the  patients  may  have  been  vaccinated  at  different 


348  VACCINIA. 

times,  at  intervals  of  several  years ;  and  if  so  the  inference  would  not  follow 
that  more  complete  protection  is  produced  by  vaccinating  in  several  places 
than  in  one.  Moreover,  if  vaccination  be  performed  in  the  usual  manner  by 
several  incisions  on  the  arm,  and  the  virus  be  fresh  and  active,  usually  two 
or  more  distinct  vesicles  arise,  which  unite  in  their  development  and  probably 
protect  the  system  as  much  as  if  they  were  separated  by  a  wider  space. 

Appearances  ;  Sympto^is. — In  genuine  vaccination  no  effect  is  ob- 
served, except  the  slight  inflammation  due  to  the  operation,  till  the  close  of 
the  third  day.  Then  the  specific  inflammation  commences.  This  is  indi- 
cated by  a  small  red  point,  at  first  scarcely  visible,  indurated  and  slightly 
elevated,  as  determined  by  the  touch  rather  than  by  the  eye.  This  increases, 
and  on  the  fifth  day  the  cuticle  over  the  inflamed  part  begins  to  be  raised  by 
a  transparent  and  thin  liquid.  The  vesicle  increases  in  diameter,  and  by  the 
sixth  day  presents  an  umbilicated  appearance  and  is  surrounded  by  a  faint 
and  narrow  red  zone.  At  the  close  of  the  eighth  day  the  vesicle  is  fully 
developed.  Its  size  varies  considerably.  It  is  usually  from  a  sixth  to  a 
third  of  an  inch  in  diameter,  and  oval  or  circular.  If  the  vaccination 
have  been  performed  by  incisions,  the  size  of  the  matured  vesicle  may 
be  considerably  larger  and  its  shape  irregular,  in  consequence  of  the  union 
of  two  or  more  vesicles.  The  eruption  now  presents  a  whitish  or  pearl- 
colored  appearance,  due  to  the  whiteness  of  the  cuticle  and  the  transparence 
of  the  liquid  underneath.  If  the  vaccination  be  performed  by  incisions,  it 
is  not  unusual  to  observe  over  the  centre  of  the  vesicle,  and  adhering  to  it, 
a  small  yellowish  scab,  which  has  resulted  from  the  scarification  and  which 
contains  none  of  the  virus. 

The  vaccine  vesicle,  like  that  of  variola,  consists  of  compartments,  com- 
monly eight  or  ten,  with  complete  partitions,  so  that  there  is  no  intercom- 
munication. On  the  ninth  day  the  inflamed  areola  becomes  more  distinct 
and  its  diameter  rapidly  increases.  Its  color  is  deep  red,  its  temperature  is 
considerably  elevated,  and  it  is  accompanied  by  more  or  less  induration  of 
the  subcutaneous  tissue,  and  it  is  tender  to  the  touch.  On  the  tenth  day 
the  pock  has  reached  its  full  development.  The  areola  extends  from  one  to 
two  inches  away  from  the  vesicle,  becoming  fainter  at  its  outer  circumfer- 
ence and  gradually  disappearing  in  the  healthy  skin.  The  shape  of  the 
outer  circumference  of  the  areola  is  irregular,  projecting  farther  at  one  point 
than  another,  though  its  general  form  is  circular. 

On  the  tenth  day,  when  the  inflammation  has  reached  its  maximum,  the 
heat,  itching,  and  tenderness  in  and  around  the  pock  are  such  that  the  child 
is  often  feverish  and  restless.  Occasionally  the  glands  of  the  axilla  become 
swollen  and  tender.  In  other  cases,  in  which  there  is  but  a  moderate  amount 
of  inflammation,  the  constitutional  disturbance  is  slight. 

At  the  close  of  the  tenth  day  or  on  the  eleventh  the  inflammation  begins 
to  decline  ;  the  areola  becomes  narrower  and  then  disappears  ;  the  induration 
and  tenderness  abate ;  and  with  this  change  the  pustule  desiccates,  its  liquid 
is  absorbed,  and  there  results  a  brownish  or  dark  mahogany-colored  scab, 
which  is  detached,  ordinarily,  between  the  fourteenth  and  twenty-first  days. 
The  cicatrix,  at  first  reddish  like  all  recent  cicatrices,  gradually  becomes  paler, 
and  remains  whiter  than  the  surrounding  integument.  It  presents  several 
minute  depressions  or  pits,  which  indicate  the  genuineness  of  the  vaccination. 

The  theory  that  smallpox  becomes  vaccinia  by  passing  through  the  heifer, 
as  we  have  given  it  above,  has  for  many  years  been  undisputed.  But  recent- 
ly the  theory  has  been  promulgated  that  vaccinia  and  variola,  instead  of 
being  forms  of  the  same  disease,  are  essentially  distinct — that  when  the  heif- 
er is  inoculated  with  the  virus  of  smallpox,  the  disease  which  is  produced  is 
a  modified  smallpox,  but  not  vaccinia,  which  occurs  as  a  spontaneous  disease 


ANOMALIES,   COMPLICATIONS,    AND  SEQUELS.  349 

among  cattle.  It  may  be  that  the  old  theory,  which  no  one  doubted  until 
recently,  is  wrong,  but  that  vaccination  prevents  smallpox  just  as  a  mild 
attack  of  scarlet  fever  prevents  a  severe  attack  of  the  same  disease,  shows, 
in  my  opinion,  a  close  relationship  between  vaccinia  and  the  severe  malady 
which  it  prevents.  We  wait  for  more  conclusive  facts  in  support  of  the 
new  theory  before  accepting  it. 

Anomalies,  Complications,  and  Sequels.  —  The  vesicle  is  often 
broken  accidentally  or  by  the  nails  of  the  child.  If  the  top  of  the  vesicle 
be  destroyed  or  most  of  the  compartments  be  opened,  the  inflammation  is 
commonly  increased,  considerable  suppuration  occurs,  and  there  results  a 
large,  irregular,  yellowish  scab  consisting  of  the  virus  mixed  with  desiccated 
pus.  The  scab  is  entirely  unreliable  and  unfit  for  the  purpose  of  vaccina- 
tion, though  the  protective  power  of  the  disease  is  not  diminished  by  injury 
of  the  vesicle  even  if  it  be  totally  destroyed.  The  cicatrix  which  results 
from  extensive  injury  to  the  vesicle  is  usually  large  and  without  the  indented 
points  which  characterize  the  normal  cicatrix. 

In  rare  cases,  when  the  inflammation  which  surrounds  the  vesicle  is 
intense  and  deep  seated,  suppuration  occurs  in  the  subjacent  connective 
tissue,  giving  rise  to  an  abscess.  This  abscess  is  commonly  of  small  size, 
but  it  increases  the  fretfulness  and  constitutional  disturbance  which  attend 
vaccinia.  This  subcutaneous  suppuration  occurs  most  frequently  in  those 
who  have  a  scrofulous  or  vitiated  state  of  system.  Inflammation  of  the 
lymphatic  glands  of  the  axilla  I  have  spoken  of  as  not  infrequent  in  vaccinia. 
This  sometimes  pi'oceeds  to  suppuration,  pi'oducing  an  unpleasant  though  not 
serious  complication. 

It  sometimes  happens  that  vesicles  appear  in  other  parts  besides  the 
points  where  the  virus  was  inserted.  These  supernumerary  vesicles  com- 
monly occur  where  the  cuticle  has  been  removed  by  scalds  or  injuries. 

Trousseau  relates  the  case  of  an  infant  whom  he  had  vaccinated.  On  the 
eleventh  day  he  was  astonished  to  find  twenty-seven  vaccine  pustules  on  the 
face,  ti'unk,  and  limbs.  This  infant  had,  however,  before  the  vaccination  a 
simple  non-specific  eruption  over  the  whole  body,  and  it  was  believed  that  it 
had  produced  these  vaccinations  by  transferring  the  lymph  with  its  nails  to 
the  various  parts  where  the  cuticle  was  denuded. 

It  is  not  unusual,  also,  to  observe  minute  papules  appearing  on  parts  of 
the  surface  simultaneously  with  or  soon  after  the  vesicle,  and  in  a  few  days 
declining.     These  seem   to  be  abortive  vaccine  eruptions. 

One  of  the  most  serious  complications  is  erysipelas.  This  may  occur 
directly  from  the  operation  or  from  the  inflammation  caused  by  the  vesicle 
when  the  virus  possesses  no  deleterious  property ;  and,  again,  it  may  result 
from  some  unknown  element  in  the  virus.  It  may  occur  immediately  after 
the  operation,  when  it  commonly  prevents  the  working  of  the  virus,  or  during 
the  vesicular  or  pustular  stage,  or,  again,  after  desiccation  and  separation  of 
the  scab.     I  have  observed  it  at  all  these  periods. 

Erysipelas,  occurring  as  a  complication  of  vaccinia,  is  invariably  referred 
by  the  friends  to  the  virus  employed,  and  the  physician  who  has  had  the  mis- 
fortune to  vaccinate  is  often  unjustly  blamed.  In  many  of  these  cases  there 
is  a  strong  predisposition  to  erysipelas  at  the  time  of  the  vaccination,  and 
the  operation  or  the  inflammation  which  accompanies  the  normal  develop- 
ment of  the  vesicle  serves  simply  as  an  exciting  cause.  Erysipelas  would 
occur  as  soon  from  a  non-specific  sore  ;  indeed,  we  not  infrequently  are  called 
to  cases  of  this  disease  in  young  children  which  commence  from  non-specific 
sores  upon  the  genitals  or  on  one  of  the  limbs.  That  the  fault  is  not  in  the 
virus  employed  is  evident  from  the  fact  that  other  children,  vaccinated  with 
the  same,  have  simple  uncomplicated  vaccinia. 


350  VACCTNIA. 

Sometimes,  on  the  other  hand,  the  cause  of  erysipelas,  whatever  it  may  be, 
exists  in  the  virus,  (For  further  facts  in  reference  to  this  subject  the  reader 
is  referred  to  our  remarks  on  erysipelas.)    . 

The  fact  is  established  by  many  observations  that  syphilis  is  communi- 
cable by  vaccination.  The  symptoms  of  it  may  not  appear  till  vaccinia  has 
terminated  or  for  a  little  time  subsequently,  but  it  then  constitutes  a  very 
serious  sequel.  A  physician  of  this  city,  well  known  in  this  community  as 
skilful  in  the  diagnosis  and  treatment  of  skin  diseases,  and  therefore  not 
likely  to  be  mistaken  as  regards  the  nature  of  the  diseases,  states  that  he 
communicated  syphilis  to  two  infants  by  vaccinating  with  the  same  scab. 
Both  had  the  characteristic  syphilitic  eruption.  In  January,  1868,  an  infant 
was  brought  to  Prof.  Alonzo  Clark's  clinique  in  this  city  having  syphilitic 
rupia,  which  in  the  opinion  of  the  physicians  present  was  undoubtedly  the 
result  of  vaccination. 

Trousseau  relates  the  case  of  a  young  woman  eighteen  years  old  who  was 
vaccinated  with  virus  taken  from  an  infant  apparently  in  perfect  health.  The 
vaccination  was  unsuccessful,  but  twenty-three  days  subsequently  his  atten- 
tion was  called  to  an  eruption  which  had  appeared  in  two  places  on  the  woman's 
arm  corresponding  with  the  points  where  the  virus  had  been  inserted.  The 
eruption  was  that  of  ecthyma,  which  by  the  next  examination,  which  was 
five  days  subsequently,  had  been  transformed  into  rupia.  The  axillary  lym- 
phatic glands  were  tumefied  and  indolent ;  finally  roseola  appeared,  which 
removed  all  doubts  as  to  the  syphilitic  character  of  the  disease.  There  was 
syphilitic  infection,  which  first  manifested  itself  in  the  points  where  vaccina- 
tion had  been  performed  (Article  de  la  'Vaccine').  It  is  not  ascertained  in 
Professor  Clark's  case,  nor  is  it  stated  in  Trousseau's,  whether  the  lymph  or 
scab  was  employed  for  vaccination.  There  can  be  little  doubt  that  the  pure 
lymph  never  communicates  anything  but  vaccinia,  and  if  by  vaccination  any 
other  disease  be  imparted,  a  little  blood  has  mingled  with  the  lymph  or  the 
scab  has  been  employed. 

The  vesicle  in  genuine  vaccinia  is  sometimes  very  small,  not  having  a 
diameter  of  more  than  two  lines.  Occasionally  the  development  of  the 
vesicle  is  retarded.  It  does  not  appear  till  two  or  three  days  later  than 
the  usual  time,  or  even  a  longer  period. 

Vaccinia  is  modified  by  certain  diseases.  It  is  arrested  by  measles  and 
scarlet  fever,  pursuing  its  course  after  the  subsidence  of  the  exanthem.  On 
the  other  hand,  it  sometimes  modifies  the  paroxysmal  cough  of  pertussis,  but 
only  during  the  time  when  the  pock  is  maturing.  Ec^ematous  eruptions 
occasionally  occur  after  vaccinia,  as  they  often  do  after  the  other  eruptive 
fevers,  or  if  already  present  they  may  be  aggravated. 

Subsequent  Vaccinations. 

A  second  vaccination,  performed  prior  to  the  ninth  day  after  the  first  vac- 
cination, is  successful.  A  genuine  vaccine  eruption  results,  which  is  smaller 
the  more  advanced  the  primary  disease.  This  second  eruption  overtakes  the 
first.  On  the  ninth  day  the  susceptibility  to  vaccinia  is,  in  most  cases,  lost, 
so  that  vaccination  performed  on  the  tenth  or  subsequent  days  is  unsuc- 
cessful. 

As  a  rule,  an  acute  contagious  disease  occurs  only  once  in  the  same 
individual.  Vaccinia  is  an  exception.  In  most  people,  after  a  few  years  it 
can  be  produced  a  second  time,  and  cases  of  a  third  or  fourth  successful  vac- 
cination at  intervals  of  a  few  years  are  not  uncommon.  Now,  subsequent 
cases  of  vaccinia  difier  from  the  first,  which  has  been  described  above.  The 
period  of  incubation  is  shorter,  and  the  vesicular,  pustular,  and  desiccative 


PROTECTION  FROM    VACCINATION— REVACCINATION.        351 

stages  succeed  each  other  more  rapidly,  so  tliat  tlie  whole  period  of  the  dis- 
ease is  less.  The  variation  from  the  appearance  and  course  of  the  first  ves- 
icle is  proportionate  to  the  degree  of  protection  which  the  first  vaccination 
still  affords  both  as  regards  smallpox  and  vaccinia.  If  several  yeajs  have 
elapsed  since  the  first  vaccination,  and  the  protective  power  which  it  affords 
is  nearly  lost,  the  second  vaccinia  differs  but  little  from  tlie  first.  If,  on  the 
other  hand,  the  first  vaccination  still  affords  nearly  complete  protection,  the 
result  of  the  second  is  slight ;  the  eruption  is  insignificant,  lacking  the  cha- 
racteristic appearance  of  the  vaccine  vesicle,  resembling  a  common  sore,  and 
disappearing  within  a  week.  It  is  not  accompanied  by  the  inflamed  areola  or 
any  appreciable  constitutional  disturbance. 

Vaccination  often  produces  no  result.  This  is  sometimes  due  to  the  fact 
that  the  lymph  or  scab  employed  is  useless.  It  has  spoiled  by  keeping  or 
never  has  been  good.  In  other  cases  it  is  due  to  a  lack  of  susceptibility  in  the 
person.  Some  take  vaccinia  with  difficulty  and  only  after  several  vaccinations  ; 
just  as  children,  though  fully  exposed,  often  fail  to  take  measles  or  scarlet 
fever,  on  account  of  a  condition  of  the  system  which  prevents  the  reception 
of  the  virus  or  antagonizes  and  controls  its  action.  In  some  instances  after 
vaccination  an  eruption  is  produced  which  may  or  may  not  be  genuine,  but  it 
immediately  becomes  purulent  and  is  soon  broken.  A  large  yellow,  uneven 
scab  results,  having  none  of  the  appearance  and  containing  little  or  none  of 
the  vaccine  virus.  This  scab,  as  w^ell  as  the  liquid  matter  which  preceded  the 
formation  of  the  scab,  is  utterly  useless  for  the  purpose  of  vaccination,  and 
if  so  employed  will  probably  cause  a  sore  from  its  irritating  eflect,  but  not  of 
a  specific  character.  If,  in  place  of  the  true  vaccine  vesicle,  the  eruption 
presents  the  appearance  which  I  have  described — namely,  that  of  a  pustule, 
soon  breaking  and  forming  a  large  irregular,  yellowish  scab — the  vaccinia  (if 
it  be  correct  so  to  designate  it)  must  be  considered  spurious.  A  sore  has 
been  produced  by  the  animal  matter  which  was  employed  in  the  vaccination 
along  with  the  virus,  which  has  modified  the  action  of  the  virus,  and  prob- 
ably has  rendered  it  useless  as  a  means  of  protection ;  or  there  may  have 
been  no  virus  inserted  with  this  animal  matter.  The  physician  should  in 
such  cases  insist  on  a  second  vaccination. 

Cases  like  the  above  are  of  frequent  occurrence,  and  the  parents  of  the 
child  are  often  satisfied  with  the  result.  They  see  an  eruption  following 
vaccination,  accompanied  by  considerable  inflammation  and  leaving  a  cicatrix. 
Unless  undeceived  by  the  physician,  they  probably  remain  in  the  belief  of 
the  child's  security  until,  perhaps,  it  takes  smallpox.  Such  cases  obviously 
tend  to  diminish  the  confidence  which  the  public  should  have  in  vaccination 
as  a  means  of  protection  from  smallpox,  and  on  account  of  their  frequent 
occurrence  it  is  important  in  every  case  that  the  physician  should  see  the 
result  of  his  vaccination.  It  has  been  proposed,  as  a  means  of  determining 
the  genuineness  of  vaccinia,  to  revaccinate  when  the  eruption  begins,  and  if 
the  first  be  genuine  the  second  will  overtake  it.  This  is  called  Brice's  test, 
but  it  is  not  necessary,  since  the  physician,  familiar  with  the  appearance  of 
the  true  vesicle,  can  determine  at  once  its  genuineness  by  the  sight. 

Protection  from  Vaccination — Revaccination. 

It  was  believed  by  the  early  advocates  of  vaccination  that  the  general 
performance  of  this  operation  would  soon  eradicate  smallpox  from  the  com- 
munity, so  that  it  would  be  interesting  only  to  the  medical  historian  as  a 
scourge  of  past  ages.  This  result,  however,  is  only  partially  achieved.  As  a 
rule,  the  greater  the  benefit  of  any  measure  designed  to  ameliorate  the  condition 
of  mankind,  the  greater  and  more  numerous  are  the  obstacles  which  diminish 


352  VACCINIA. 

its  effectiveness.  Science  is  full  of  examples  of  this.  Fortunately,  these 
obstacles  as  regards  vaccination  are  not  such  as  to  impair  the  confidence  of 
physicians  in  its  protective  power,  and  it  is  not  too  much  to  expect  that  this 
simple  operation  will  yet  be  the  means  of  rendering  smallpox  a  disease  almost 
unknown,  unless  in  its  modified  form. 

Vaccination  should  be  performed  in  the  first  year  of  life.  In  rural  dis- 
tricts, where  there  is  little  danger  of  exposure  to  smallpox,  it  may  deferred 
till  the  age  of  ten  or  twelve  months.  In  the  city,  on  the  other  hand,  where 
there  is  constant  intercourse  of  people  and  where  contagious  diseases  are 
often  contracted  in  ignorance  of  the  time  and  place  of  exposure,  an  earlier 
vaccination  is  advisable.  Some  physicians  recommend  performance  of  the 
operation  as  early  as  the  age  of  four  or  six  weeks.  The  objection  to  this  is 
that  if  erysipelas  occur  so  young  an  infant  is  likely  to  perish  from  it,  whereas 
an  infant  three  or  four  months  old  ordinarily  recovers.  For  this  reason  I 
believe  that  the  most  suitable  age  is  about  four  months  for  the  city  infant  in 
ordinary  times  ;  but  if  smallpox  be  epidemic,  vaccination  should  be  performed 
at  an  earlier  age.  I  have  vaccinated  even  the  new-born  infant  when  smallpox 
had  broken  out  in  adjoining  apartments. 

Vaccinia  usually  extinguishes,  for  a  time,  the  susceptibilitj'  to  smallpox. 
According  to  Mr.  Gintrac,  varioloid  does  not  occur  within  two  years  in  those 
who  have  been  vaccinated.  It  may,  however,  in  exceptional  instances,  occur 
in  a  mild  form  within  a  few  months  after  vaccination.  The  protection  afforded 
by  vaccination  gradually  diminishes  by  time,  but  it  does  not  probably,  as  a 
rule,  entirely  cease.  Varioloid,  however,  occurring  thirty  or  forty  years 
after  a  successful  vaccination  is  likely  to  be  severe,  and  it  may  even  be  fatal, 
showing  that  it  has  been  but  slightly  modified.  In  other  cases,  even  after  so 
long  an  interval,  the  symptoms  present  a  degree  of  mildness  which  indicates 
that  the  protective  power  of  the  vaccination  is  not  entirely  lost. 

If  a  second  vaccination  be  practised  soon  after  the  scab  from  the  first 
vaccination  has  fallen,  it  will  usually  produce  no  result,  but  in  other  cases  it 
gives  rise  to  a  little  redness,  swelling,  and  induration,  which  show  that  vaccinia 
has  been  reproduced,  though  in  a  very  mild  and  insignificant  form.  It  is 
probable  that  in  these  cases  varioloid  might  also  occur  by  exposure,  though 
with  a  mildness  corresponding  with  that  of  the  vaccinia.  The  longer  the 
period  after  the  first  vaccination,  the  greater  the  number  of  those  in  whom  a 
second  vaccination  is  effective,  and,  as  has  already  been  stated,  the  greater 
also  the  liability  to  the  variolous  disease  until  the  system  is  protected  by  a 
second  vaccination.  A  second  vaccination  should  be  performed  about  the 
sixth  or  eighth  year,  and  a  third  between  the  fifteenth  and  twentieth  years. 
If  smallpox  be  epidemic,  it  is  proper  to  vaccinate  all  who  have  not  been 
vaccinated  within  three  or  four  years. 

Selection  of  Virus. 

The  lymph  is  preferable  to  the  scab  for  vaccination,  provided  that  it  can 
be  obtained  fresh.  The  scab  is  more  easily  preserved,  and  therefore,  if  the 
lymph  and  the  scab  be  old,  the  latter  is  to  be  preferred.  The  lymph  should 
be  taken  on  the  fifth  day  if  the  vesicle  be  sufficiently  developed.  It  may  also 
be  taken  on  the  sixth,  seventh,  or  even  eighth  day,  provided  that  the  areola 
has  not  formed.  The  lymph  of  the  fifth  day  acts  with  greater  energy, 
though  that  of  the  sixth  or  seventh  day  is  not  much  inferior.  Lymph 
obtained  after  the  formation  of  the  areola  is  less  efiicient,  though  it  may 
communicate  the  genuine  disease. 

There  is  no  mode  of  vaccination  so  reliable  as  the  use  of  lymph  taken 
<lirectly  from  the  arm  and  immediately  inserted — the  arm-to-arm  vaccination. 


VARICELLA.  353 

Lymph  can  be  preserved  for  a  few  days  on  a  flattened  surface  of  whalebone 
or  the  segment  of  a  quill,  and  if  employed  within  a  week  it  will  usually  com- 
municate vaccinia.  Lymph  may  be  preserved  a  longer  period  between  two 
surfaces  of  glass,  but  the  best  way  of  preserving  it  is  in  capillary  glass  tubes. 
The  end  of  the  tube  is  placed  within  the  vesicle,  and  the  lymph  ascends  by 
capillary  attraction.  Wh^n  a  sufficient  quantity  is  received,  the  ends  are 
sealed  by  holding  them  for  a  moment  in  a  flame.  Care  is  requisite  in  doing 
this  so  as  not  to  heat  the  lymph,  as  it  is  spoiled  by  a  temperature  much  above 
that  of  the  body.  When  the  lymph  is  used,  the  ends  of  the  tube  are  broken, 
and  by  blowing  gently  through  it  a  sufficient  quantity  is  received  on  the  point 
of  a  lancet. 

If  the  scab  be  genuine,  it  presents  a  dark-brown  or  mahogany  color,  and 
has  a  circular,  oval,  or  at  least  a  rounded  form  ;  it  is  firm  or  compact,  and  has 
a  lustre.  Soft,  yellowish,  and  irregular  scabs  are  not  genuine,  and  those  of  a 
dull  appearance  or  without  lustre  have  usually  spoiled  in  the  keeping.  The 
scab  is  best  preserved  in  soft  beeswax,  which  excludes  the  air,  and  it  should 
be  kept  in  a  cool  place.  It  is  the  belief  of  many  that  the  vaccine  virus  grad- 
ually becomes  weaker  by  passing  successively  through  the  human  system 
(Condie,  American  Journal  of  the  Medical  Sciences,  Api-il,  1865),  and  that 
therefore  different  specimens  of  virus  work  with  different  energy  according 
to  the  degree  of  removal  from  the  cow.  To  what  extent  this  view  is  correct 
is  not  fully  ascertained,  but  certainly  if  the  virus  employed  continue  to  pro- 
duce a  small  vesicle  attended  only  by  a  little  inflammation,  there  is  reason  to 
believe  that  the  protection  which  it  imparts  is  less  than  that  from  virus  which 
works  with  greater  energy,  and  it  should  be  exchanged  for  such.  In  New 
York  we  are  able  to  obtain  at  any  time  lymph  directly  from  the  heifer.  It 
has  never  passed  through  human  blood,  for  the  original  lymph  came  from 
cattle  in  one  of  the  provinces  of  France,  where  vaccinia  was  prevailing  epi- 
demically. The  popular  objection  to  vaccination  is  obviated  by  the  use  of 
this  lymph,  but  it  works  with  great  energy,  producing  a  large  pock  and  a 
sore  which  is  often  a  month  in  healing.  I  have  found  it  very  reliable,  and 
prefer  to  use  it  in  ordinary  cases. 


CHAPTER   VI. 

VARICELLA. 

Varicella,  chickenpox,  or  swinepox  Jis  the  shortest  and  mildest  of  the 
eruptive  fevers.  It  is  highly  contagious,  so  that  few  children  escape  who  are 
exposed  to  it.  Its  period  of  incubation  is  from  fifteen  to  seventeen  days. 
Hutchinson  (Brif.  Med.  Jour.,  1881)  and  Le  Gendre  {L'  Concours  Med.,  1887) 
state  that  varicella  is  inoculable,  but  some  years  ago  inoculations  which  I 
performed  with  the  lymph  of  the  varicellar  vesicle  were  without  result. 
It  attacks  the  same  individual  but  once,  and  it  occurs  as  an  epidemic.  It 
has  been  thought  by  some  to  prevail  most  immediately  before,  during,  or 
after  epidemics  of  smallpox,  and  it  has  been  conjectured  that  it  is  a  modified 
form  of  variola,  and  hence  its  name,  which  signifies  little  variola.  This  idea 
is,  however,  entertained  by  few,  and  it  is  opposed  by  the  following  facts  :  ^'ari- 
cella  may  occur  after  variola  or  variola  after  varicella  without  any  modifica- 
tion, and  the  two  diseases  are  very  dissimilar  as  regards  gravity  of  symptoms 
and  duration.     The  variolous  disease,  whether  smallpox  or  varioloid,  often 

23 


354  VABICELLA. 

occurs  in  the  adult ;  varicella,  on  the  other  hand,  is  a  disease  of  infancy  and 
childhood.  I  have  seen  one  adult  case,  which  I  recall  to  mind,  and  Professor 
Flint  states  that  he  has  also  observed  it,  but  its  occurrence  at  this  period  of 
life  is  rare.  Senator  relates  a  case  that  occurred  at  the  age  of  eleven  days. 
In  584  cases  observed  by  Baader  the  ages  were  as  follows : 

Cases.  Age. 

382 1-5  years. 

191 6-10      " 

7  11-15      " 

2  16-20     " 

2  21-40     " 

Moreover,  varicella  and  variola  have  been  known  to  occur  simultaneously  in 
the  same  individual.  Such  a  case  was  reported  by  M.  Delpech  in  a  memoir 
published  in  1845. 

Symptoms. — Varicella  usually  commences  with  such  symptoms  as  usher 
in  ordinary  mild  febrile  attacks — namely,  headache,  languor,  chilliness,  and 
sometimes  aching  in  the  back  and  limbs.  Fever  supervenes,  which  is  usually 
moderate,  the  pulse  rising  perhaps  to  100  or  112,  and  the  thermometer  show- 
ing an  increase  of  temperature,  but  less  than  occurs  in  the  other  eruptive 
fevers.  These  symptoms  which  precede  the  eruption  are  sometimes  absent 
or  are  so  mild  as  to  escape  notice.  The  fever  usually  ceases  on  the  second 
day,  but  it  may  return  on  the  following  night.  The  appetite  is  rarely  lost, 
and  most  children  continue  more   or  less  at  their  amusements. 

When  the  above  symptoms  have  continued  about  twenty-four  hours  the 
eruption  appears  first  over  the  trunk,  and  soon  afterward  over  the  face  and 
limbs.  It  consists  of  minute  disseminated  papules  which  become  vesicular 
in  the  course  of  a  few  hours.  The  occurrence  of  the  vesicular  stage  is  nearly 
simultaneous  on  all  parts  of  the  surface,  and  commonly  fresh  vesicles  appear 
during  the  first  three  or  four  days.  The  vesicles  lack  the  hard,  indurated 
base  of  the  variolous  eruption,  though  they  are  sometimes  surrounded  by  a 
faint  zone  of  redness.  They  differ  also  from  the  variolous  eruption  in  the 
absence  of  umbilication  and  in  irregularity  of  shape.  Some  are  small  and 
acuminate,  some  hemispherical  and  of  medium  size,  and  others  oval  or  elon- 
gated and  of  large  size.  The  inflammation  is  quite  superficial,  not  involving 
the  subcutaneous  tissue  and  scarcely  affecting  the  deepest  layer  of  the  skin. 

The  vesicles  vary  in  size  from  the  diameter  of  half  a  line  to  that  of  even 
three  lines.  They  occasionally  give  rise  to  slight  itching.  On  the  second 
day  of  the  eruption  or  third  day  of  the  disease  they  are  still  fully  developed,, 
their  liquid  contents  being  nearly  transparent.  At  the  close  of  this  day  the 
liquid  begins  to  be  somewhat  cloudy  and  its  absorption  commences.  On  the 
fourth  day  of  the  disease  desiccation  progresses  rapidly,  and  by  the  fifth  the 
liquid  has  for  the  most  part  disappeared,  and  a  scab  results,  small,  thin,  and 
of  a  yellowish-brown  color.  The  scabs  are  soon  detached,  the  redness  which 
indicated  their  seat  disappears,  the  epiderm  which  had  been  raised  and 
removed  by  the  eruption  is  reproduced  in  its  normal  state,  and  in  a  few  days 
■all  evidence  of  varicella  is  effaced.  A  cicatrix  occasionally  results,  but  it  is 
due  not  to  the  simple  varicellar  eruption,  but  to  a  sore  produced  from  the 
eruption  by  the  scratching  of  the  child. 

The  number  of  vesicles  varies  considerably  in  different  cases.  They  are 
never,  so  far  as  I  have  observed,  confluent ;  but  they  are  sometimes  so  abun- 
dant in  young  children  that  if  the  disease  were  variola  it  would  be  called 
severe  discrete.  They  occur  also  on  the  buccal  and  faucial  surfaces,  where 
they  soon  break,  forming  small  ulcers.  The  duration  of  the  disease  from 
the  first  symptoms  until  the  disappearance  of  the  crusts  is  eight  or  ten  days.. 


COM  PLICA  TIONS—TREA  TMENT.  355 

Mr.  J.  Hutchinson  of  London  has  descnbcd  a  rare  form  of  varicella  in 
which  the  eruption  becomes  gangrenous.  It  occurs  most  frequently  in  feeble, 
ill-conditio!ied  children,  but  sometimes  in  those  who  are  well  nourished.  Only 
a  portion  of  the  vesicles  become  gangrenous.  Where  the  gangrene  occurs  a 
deep  and  unhealthy  ulcer  forms  underneath  the  scab,  which  does  not  heal  or 
heals  slowly.  This  rare  form  of  varicella  is  very  fatal,  death  sometimes 
occurring  from  pyiiemia  and  secondary  abscesses.  Crocker  states  (London 
Lancet^  May  30,  1885)  that  the  gangrene  sometimes  occurs  upon  a  part  of 
the  surface  which  is  not  the  seat  of  the  eruption. 

Complications  ;  Sequelae. — Complicating  maladies  which  sometimes 
supervene  in  varicella  do  not,  for  the  most  part,  occur  in  consequence  of 
this  disease,  but  are  independent  of  it.  Erysipelas  has  in  rare  instances 
supervened  on  the  varicellar  eruption,  but  its  occurrence  is  attributable  to 
the  ordinary  causes  of  this  disease,  rather  than  to  varicella.  Various  seque- 
lae of  varicella  have  been  mentioned  by  writers,  among  which  we  may 
mention  an?eraia,  pemphigus,  urticaria,  bronchitis  or  bronchi-pneumonia 
(Meigs  and  Pepper),  ulcers  leading  to  glandular  enlargements  and  tuber- 
culosis,  and   nephritis   (Henoch,   Janssen,   Oppenheim). 

Diagnosis. — Obviously,  the  only  diseases  with  which  varicella  is  liable 
to  be  confounded  are  such  as  present  vesicles  at  some  stage  of  their  course. 
From  the  local  vesicular  eruptions  this  disease  is  diagnosticated  by  the  fact  that 
the  vesicles  appear  on  all  parts  of  the  surface.  It  is  sometimes  mistaken  for 
variola  or  varioloid,  or  vice  versa — a  mistake  very  damaging  to  the  reputation 
of  the  physician.  The  points  of  differential  diagnosis  are  the  symptoms  of 
invasion — severe  and  lasting  three  or  four  days  in  the  one,  mild  and  continu- 
ing only  one  day  in  the  other ;  an  eruption  passing  slowly  through  its  stages 
from  the  papular  to  the  pustular,  umbilicated,  with  circular,  raised  and 
inflamed  base,  appearing  first  on  the  face  and  neck,  and  not  till  a  day  later 
on  the  legs,  in  the  one  disease ;  while  in  the  other  the  evolution,  shape,  and 
course  of  the  eruption,  as  described  above,  are  materially  different.  By 
proper  attention  to  these  distinctive  features  it  is  rarely  difficult  to  diagnosti- 
cate varicella. 

Prognosis. — In  ordinary  uncomplicated  varicella  this  is  always  good. 
Gangrenous  varicella,  which  is  very  rarely  seen  in  America,  may  be  fatal, 
and   complications   may  render  a   case   grave. 

Treatment. — On  account  of  the  general  mildness  of  varicella,  prophy- 
lactic measures,  as  isolation  of  the  patient,  are  seldom  enforced  in  America, 
and  the  disease,  when  not  complicated  or  gangrenous,  requires  little  treat- 
ment ;  but  the  patient  should  be  quiet  and  indoor  during  its  continuance. 
Large  vesicles  upon  the  face  should  be  punctured  early  and  irritation  by 
rublDing  should  be  avoided.  Complications  and  gangrenous  varicella  require 
appropriate  treatment,  especially  supporting  remedies.  Anaemia  or  gland- 
ular swellings  remaining  after  varicella  require  tonics,  especially  cod-liver  oil 
and  syrup  of  the  iodide  of  iron. 


356  DIPHTHERIA. 


CHAPTER   yil. 

DIPHTHEEIA. 

Diphtheria  is  one  of  the  most  dreaded,  one  of  the  most  fatal,  and 
unfortunately  one  of  the  most  common,  maladies  of  childhood.  It  is  believed 
to  be  produced  by  a  micro-organism.  It  is  characterized  by  the  occurrence 
of  a  grayish-white  pellicle  upon  the  mucous  surface  or  the  skin  deprived  of 
its  protecting  epithelium.  The  specific  principle  is  ordinarily  received  by  the 
inspiration  of  infected  air,  but  it  is  sometimes  received  by  direct  contact  of 
infected  matter  with  one  of  the  surfaces  not  lying  in  the  respiratory  tract. 

Diphtheria  is  a  disease  of  antiquity.  M.  Sanne  mentions  the  following 
names  by  which  it  has  been  known  in  different  countries  and  at  different 
periods  :  ulcus  Syriacum,  ulcus  JEgyptiacum,  garrotillo,  morbus  suffocans, 
affectus  strangulatorius,  pestilentis  gutturis  affectio,  pedancho  maligna,  angina 
maligna,  anginosa  passio,  mal  de  gorge  gangreneux,  ulcere  gangreneux, 
angina  polyposa,  angine  maligna,  croup,  diphtheritis,  diphtheria.  These  terms, 
expressing  the  prominent  characteristics  of  diphtheria,  render  it  probable  that 
this  was  the  disease  alluded  to. 

It  is  impossible  to  state  or  form  a  probable  conjecture  in  regard  to  the 
time  when  diphtheria  originated,  but  its  origin  probably  antedated  the  Chris- 
tian era.  According  to  Aurelianus,  Asclepiades,  who  lived  one  hundred 
years  before  Christ,  scarified  the  tonsils  and  performed  laryngotomy  for  the 
relief  of  respiration,  and  it  is  supposed  that  he  treated  cases  of  membranous 
croup,  and  probably  diphtheria.  Aretaeus,  a  Greek  physician  of  Cappadocia 
at  the  commencement  of  the  Christian  era,  gives  in  writings  still  extant  a 
clear  and  accurate  description  of  mild  and  severe  diphtheria.  After  describ- 
ing what  he  designates  ulcers  upon  the  tonsils,  "  covered  with  a  white,  livid, 
or  black  concrete  product,"  he  adds :  "  If  the  malady  invades  the  chest  by 
the  trachea,  it  causes  suffocation  on  the  same  day.  Children  up  to  the  age 
of  puberty  are  most  exposed  to  this  disease."  He  gives  also  a  graphic  and 
truthful  description  of  the  suffering  of  the  child  when  the  disease  extends  to 
the  larynx,  and  croup  results.  Galen,  in  the  second  century,  apparently 
alludes  to  diphtheria  when  he  describes  a  fatal  disease  prevalent  in  his  time 
in  which  fragments  of  "  membranous  tunic  "  are  expelled.  He  states  that  he 
is  able  to  determine  by  the  manner  in  which  the  fragments  are  expelled,  by 
coughing  or  spitting  (hawking),  whether  they  are  detached  from  the  larynx 
or  the  pharynx.  Coelius  Aurelianus,  a  Latin  physician  who  is  supposed  by 
some  to  have  lived  in  the  second  century,  and  by  others  as  Sate  as  the  fifth 
century,  describes  a  grave  angina  in  which  the  symptoms  which  sometimes 
arise  correspond  with  those  in  diphtheritic  croup  and  diphtheritic  paralysis  as 
observed  at  the  present  time.  In  the  fifth  century  Aetius  of  Amida  described 
a  disease  accompanied  by  "  crusty  and  pestilential  ulcers,"  sometimes  having 
a  whitish  and  in  other  instances  an  ashy  or  rusty  color,  and  not  preceded  by 
a  discharge.  Aetius  alludes  to  the  hoarseness  which  he  says  sometimes  super- 
venes and  is  a  source  of  danger  up  to  the  seventh  day. 

From  the  close  of  the  fifth  century  until  the  sixteenth  the  record  of 
diphtheria  is  broken.  It  is  probable  that  during  the  long  period  embraced 
in  the  Dark  Ages  every  decade  witnessed  epidemics  of  this  fatal  disease, 
but  if  they  were  observed  and  recorded  the  records  were  lost,  the  literature 


DIPHTHERIA.  357 

of  diphtheria  sharing  the  fate  of"  general  literature  during  this  time  of  intel- 
lectual darkness. 

In  the  sixteenth  century  epidemics  of  diphtheria  occurred  in  various 
parts  of  Europe,  and  clear  and  unmistakable  descriptions  of  them  have  been 
preserved.  From  the  sixteenth  century  until  the  present  time  diphtheria  has 
continued  to  be  one  of  the  -most  frequent  and  fatal  of  the  epidemic  diseases 
upon  the  European  continent,  and  it  is  apparently  permanently  established  in 
its  great  cities. 

It  is  a  remarkable  fact  that  those  pestilential  diseases  which  desolate 
families  and  communities  in  modern  times  originated  in  the  P]astern  hemi- 
sphere, chiefly  in  Asia  or  Africa,  and  extended  to  the  Western  nations  through 
commerce  or  navigation.  The  aborigines  of  America  had  in  their  primitive 
state  no  ailments,  so  far  as  we  can  ascertain,  except  such  as  occurred  from 
vicissitudes  of  temperature  or  were  incident  to  age  and  their  wild  and  exposed 
nomadic  life.  Pernicious  to  them  was  the  discovery  of  America  by  Europeans 
for  various  reasons,  but  especially  because  it  led  to  the  introduction  of  the 
contagious  and  pestilential  maladies.  The  cruel  and  rapacious  gold-hunters 
under  Cortez  introduced  smallpox  into  Mexico,  and  for  ages  afterward 
throughout  Central  America  heaps  of  skeletons  of  those  who  perished  of 
this  disease  were  found  in  shaded  and  out-of-the-way  localities  where  they 
had  been  taken  by  their  friends.  Adventurers  from  the  Old  World  intro- 
duced the  eruptive  fevers  and  the  loathsome  contagious  diseases  of  vice  and 
immorality  into  the  islands  and  upon  the  continent  of  North  America.  The 
medicine-men  of  the  Indians  had  by  their  incantations  gained  great  repute  in 
the  management  of  the  diseases  with  which  they  were  familiar  in  their  wild 
life  in  the  forests,  but  they  were  unable  to  cope  with  the  new  diseases  which 
the  vessels  of  the  foreigner  had  brought  to  this  Western  World. 

Of  all  the  diseases  which  America  has  received  from  Europe,  the  one 
most  dreaded,  because  of  its  highly  contagious  character,  the  great  mortality 
which  attends  it,  and  the  extreme  suffering  which  certain  forms  of  it  produce, 
is  diphtheria.  It  is  to  be,  from  appearance,  above  all  other  maladies  the 
scourge  of  America  in  the  future.  It  is  probable  that  the  first  cases  of 
diphtheria  in  America  occurred  in  or  near  Boston.  Josselyn  made  two  voy- 
ages to  New  England  in  1638  and  1663,  remaining  eight  years  in  this  country 
after  his  second  arrival.  He  states  that  the  Europeans  residing  in  New 
England  are  greatly  afflicted  by  a  disease  "  which  hath  proved  mortal  to  some 
in  a  very  short  time,  quinsies  and  impostumations  of  the  almonds,  with  great 
distempers  of  colds."  ^  At  Roxbury,  Massachusetts,  in  1659,  three  children 
in  a  family  were  attacked  by  the  "  malady  of  bladders  in  the  windpipe,"  all 
dying  within  two  weeks.^ 

At  the  close  of  the  seventeenth  century  and  in  the  first  half  of  the 
eighteenth  century  epidemics  of  diphtheria  occurred  in  various  parts  of  New 
England.  At  Kingston,  New  Hampshire,  in  March,  1735,  a  child  died  of 
three  days'  sickness  of  a  throat  affection.  A  week  subsequently  three  chil- 
dren in  another  family,  four  miles  distant  from  the  first  case,  also  died  of  a 
three  days'  sickness.  The  malady  continued  to  spread  and  the  first  forty 
cases  all  perished.  They  died  of  a  disease  located  in  the  throat,  neck,  and 
air-passages,  attended  in  many  of  them  by  swelling  of  the  cheek  or  neck. 
The  disease  from  Kingston  spread  to  other  townships,  but  in  its  subsequent 
course  it  was  milder  than  at  first.  We  recognize  in  this  nameless  disease  the 
characteristics  of  diphtheria. 

In  August,  1735,  in  Boston,  a  child  had  a  disease  of  the  fauces  attended 
by  white  spots.  In  the  following  month  several  similar  cases  occurred  in 
different  parts  of  Boston.  In  October  of  the  same  year  a  young  man  lately 
^  Wm.  Veazie,  Boston,  1865.  *  Historical  Researches  of  Dr.  Elsuorlh  Eliot. 


358  DIPHTHERIA. 

arrived  from  Exeter,  New  Hampshire,  where  a  brother  had  died  of  this  new 
disease,  himself  sickened  with  it  in  a  more  severe  form  than  had  yet  occurred 
in  Boston.  Diphtheria,  thus  established  in  Boston,  was  epidemic  during  the 
following  winter  and  spring  months.  At  the  height  of  the  epidemic,  in  the 
second  week  of  March,  1736,  the  burials  increased  from  an  average  of  ten  to 
twenty-four  through  the  prevalence  and  severity  of  the  new  disease.  Two 
years  later  (1738),  a  monograph  appeared  from  the  pen  of  I.  Dickinson,  A.  M., 
Boston,  bearing  the  title,  "  Observations  on  that  Terrible  Disease  vulgarly 
called  the  Throat  Distemper,  with  Advices  as  to  the  Method  of  Cure,  in  a 
letter  to  a  friend."  The  writer  of  this  epistle,  though  a  clergyman,  appears 
to  have  been  a  close  observer.  He  probably,  as  was  not  unusual  at  that 
period,  practised  both  as  physician  and  clergyman.  Dickinson's  graphic 
description  shows  that  the  disease  in  his  day  presented  the  same  character- 
istics as  at  present. 

Diphtheria,  thus  established  in  Eastern  New  England,  spread  westward 
through  the  intercourse  of  the  inhabitants,  reaching  New  York  in  about  two 
years.  Dr.  Cadwallader  Golden,  writing  in  1753,  had  already  carefully 
observed  diphtheria.  He  remarks  :  "  When  the  disease  first  appeared  it  was 
treated  in  the  usual  way  for  a  common  angina,  and  no  plague  was  more 
destructive The  orifices  made  by  the  lancet  in  bleeding  and  the  adja- 
cent parts  were  apt  to  become  diseased  ;  so  likewise  the  places  where  blisters 
were  applied."  He  recognized  the  fact,  now  well  known,  that  in  exceptional 
cases  the  throat  remains  unaffected,  while  the  diphtheritic  inflammation  and 
exudate  appear  upon  other  surfaces  :  "  A  girl  about  ten  years  of  age,  while  the 
throat  distemper  was  prevailing,  had  sores  on  her  private  parts,  like  those  on 
the  tonsils  of  others,  but  no  symptom  of  the  disorder  appeared  in  her  throat." 
Dr.  Jacob  Ogden,  writing  from  Jamaica,  Long  Island,  in  1769.  and  again  in 
1774,^  described  diphtheria  as  it  occurred  in  his  practice  and  in  the  adjacent 
townships.  He  recommended  the  use  of  senega  and  calomel.  But  the 
American  physician  of  this  period  whose  writings  contributed  most  to  a 
correct  understanding  of  diphtheria  was  Samuel  Bard  of  New  York  (1771). 
He  possessed  a  mind  admirably  qualified  for  scientific  investigations,  and 
especially  for  study  of  an  obscure  disease,  basing  his  opinions  upon  accurate 
clinical  examinations.  A  recent  appreciative  reviewer,  Dr.  John  C.  Peters, 
says :  "  Bard's  article  is  among  the  calmest,  wisest,  and  most  accurate  that 
has  ever  been  written  on  diphtheria,  both  before  and  since  his  time."  He 
recognized  the  fact  that  the  various  forms  of  diphtheritic  inflammation  were 
identical  in  nature,  and,  however  differing  in  appearances,  had  the  same 
underlying  cause. 

In  the  first  half  of  the  present  century  diphtheria  was  regarded  as  a  very 
important  disease  in  Europe,  and  was  made  the  subject  of  investigation  by 
the  most  renowned  clinical  teachers,  among  whom  we  may  mention  Jurine 
(1807),  Bretonneau  (1821),  Bourgeoise  (1823),  Gendron  (1825),  Billard 
(1826),  Deslandes  (1827).  Blanquin  (1828),  Broussais  (1829),  Trousseau 
(1830),  Cheyne  (1833),  Fricout  and  Burley  (1836),  Boudet  (1842),  Guersant 
and  Blache  (1844),  Moland  (1845),  Damot  (1846),  and  Heine  (1849).  During 
this  half  century,  ending  with  1850,  which  witnessed  such  an  augmentation 
of  the  literature  of  diphtheria  in  Europe,  this  disease  attracted  but  little 
attention  in  America.  It  appears  to  have  been  much  less  prevalent  on  this 
continent  than  in  the  Old  World.  It  may  have  occurred  in  small  epidemics 
in  various  localities  from  the  time  of  Dr.  Bard  until  1850,  but  they  attracted 
so  little  notice  from  American  physicians  that  no  monograph  or  communica- 
tion to  medical  journals  relating  to  diphtheria,  which  was  worthy  of  preserva- 
tion, appeared  during  this  long  period. 

^  See  Medical  Report,  vol.  v.,  1802. 


DIPHTHERIA. 


359 


Since  1850  epidemics  of  diphtheria  have  occurred  in  numerous  localities 
in  North  America,  not  only  in  the  cities  with  their  sewers  and  crowded 
tenement-houses  rendering  the  air  impure,  but  also  in  the  sparsely-settled 
and  mountainous  sections,  where  no  impurities  in  the  air  exist.  But  dii)h- 
theria  is  most  prevalent  and  fatal  in  the  cities.  During  the  last  quarter 
century  it  has  become  established  in  most  of  the  larger  cities  in  the  Northern 
and  Western  States  from  the  Atlantic  to  the  Pacific  coast,  along  the  line  of 
commerce  and  travel.  The  permanent  establishment  of  diphtheria  in  the 
centres  of  trade  and  travel,  and  the  fact  that  many  have  this  subtle  malady 
in  so  mild  a  form  that  they  are  not  aware  of  it,  and  mingle  with  others  in 
places  of  resort,  inevitably  tend  to  disseminate  the  disease  throughout  the 
country.  Hence  in  rural  localities  intervening  between  the  cities  outbreaks 
of  diphtheria  of  unknown  origin  are  common  in  at  least  all  the  ea.stern, 
northern,  central,  and  western  portions  of  the  United  States  and  in  Canada. 
Consequently,  in  the  last  two  decades  in  America  diphtheria  has  been  the 
subject  of  discu-ssion  at  numerous  meetings  of  medical  societies,  many  cases 
of  interest  have  been  reported,  and  histories  of  epidemics  and  statistics  of 
treatment  have  been  published  in  the  medical  journals.  Therefore,  the 
American  literature  on  diphtheria  is  abundant  and  rapidly  accumulating, 
and  to  the  genius  and  perseverance  of  an  American  (O'Dwyer)  the  world 
is  indebted  for  the  means  of  combating  more  successfully  than  in  former 
times  the  most  painful,  most  dreaded,  and  most  fatal  form  of  diphtheritic 
inflammation. 

In  Europe  diphtheria  is  established  in  the  centres  of  medical  education, 
as  Paris,  Berlin,  London,  and  more  recently  Vienna.  It  has  in  these  cities, 
and  in  smaller  cities  and  towns  where  it  has  occurred,  been  the  subject  of 
much  discussion  and  investigation.  In  Europe,  therefore,  as  well  as  in 
America,  the  literature  of  diphtheria  has  been  greatly  increased  during  the 
last  decade  by  reports  of  cases,  histories  of  epidemics,  and  statistics  of  treat- 
ment. In  six  consecutive  months  in  1888  the  deaths  from  diphtheria  in  ten 
of  the  principal  cities  of  Europe  were  as  follows : 


Deaths.  Population. 

Paris 1047  2,260,945 

London 852  4,282,921 

Berlin 523  1,414,980 

St.  Petersburg    ....    341  928,016 

Vienna 251  1,212,232 


Deaths.  Population. 

Buda-Pesth 207  442,787 

Copenhagen 210  300,000 

Christiania 196  135,600 

Prague 161  300,828 

Amsterdam 136  390,016' 


In  Madrid,  with  a  population  increasing  from  136,663  in  1880  to  157,965 
in  1885,  the  deaths  from  diphtheria  during  the  six  years  ending  with  1885 
were  as  follows : 


In  1880 
"  1881 
"  1882 


242  I  In  1883 1027 

799       "   1884 1079 

587  !    "   1885 1350' 


Among  the  American  physicians  who  have  recently  advanced  our  know- 
ledge of  diphtheria  are  Drs.  Curtis  and  Satterthwaite  of  New  York,  in  their 
"  Report  on  the  Pathology  of  Diphtheria,"  made  to  the  New  York  Board  of 
Health ;  Drs.  Wood  and  Formad  of  Philadelphia,  in  their  "  Memoir  on  the 
Nature  of  Diphtheria,"  prepared  and  published  by  the  National  Board  of 
Health  in  1882 ;  and  Drs.  A.  Jacobi  and  C.  E.  Bellington  in  their  treatises  on 
diphtheria  (1880,  1889).  In  Europe  during  the  same  period  interesting  and 
instructive   monographs   have   been  published   by  Peters.   Birch-Hirschfeld, 

1  Bull.  fjm.  de  Ther.,  October  30,  1888. 
^  La  Higiene,  October,  18S8. 


360  DIPHTHERIA. 

Rosenbach,  Leyden,  Wagner,  Fiirbringer,  Fischl,  Weigert,  Meyer,  and 
others. 

Etiology. — During  the  last  twenty  years  numerous  experiments  and 
microscopic  examinations  have  been  made  in  order  to  elucidate  the  cause 
and  nature  of  diphtheria.  Each  year  of  investigation  has  strengthened 
the  belief  that  the  cause  is  a  microbe,  but  it  is  still  a  matter  of  doubt  which 
microbe  is  the  causal  agent,  or  whether  there  may  not  be  more  than  one 
species  of  bacteria  which  by  their  action  upon  and  in  the  tissues  produce 
diphtheria. 

Between  the  years  1868  and  1873  many  of  the  leading  pathologists  of 
Europe  believed  that  the  cause  of  diphtheria  had  been  discovered — that  it 
was  the  micrococcus  or  spherical  bacterium.  During  the  decade  commencing 
with  1868  no  subject  in  pathology  attracted  so  much  attention  as  the  relation 
of  the  micrococcus  to  diphtheria.  Oertel  (1868)  discovered  micrococci  in 
the  diphtheritic  pseudo-membrane  and  in  the  blood,  lymphatic  vessels,  and 
kidneys  in  severe  diphtheria,  appearing  as  "  point-like,  dark-contoured,  round 
or  oval  little  bodies  isolated,  and  in  zoogloea."  In  later  investigations  (1874) 
he  found  a  larger  or  smaller  number  of  the  bacterium  termo  accompanying 
the  micrococcus,  and  he  expresses  more  firmly  the  belief  that  micrococci 
lodging  on  the  mucous  surface  cause  the  diphtheritic  inflammation.  He  pro- 
duced croup  in  rabbits  by  applying  ammonia,  and  found  few  or  no  micrococci 
in  the  false  membrane,  and  never  in  the  blood  or  internal  organs.  He  inocu- 
lated the  trachea  of  rabbits,  pigeons,  and  chickens  with  the  diphtheritic 
membrane,  and  produced  local  lesions  apparently  identical  with  those  of 
diphtheria  in  man,  and  the  blood  of  the  animals  subjected  to  the  experiment 
contained  micrococci  in  abundance.  Nassilof  states  as  the  result  of  his 
observations  that  fungi,  not  designating  the  species,  are  always  present  in 
diphtheritic  membranes  and  precede  their  development,  and  that  they  pene- 
trate the  tissues  by  the  blood-vessels  and  lymphatics  before  any  observable 
change  occurs  in  the  tissues.  Therefore  he  believes  that  they  cause  the 
diphtheritic  imflammation.  Hueter  and  Tommasi  inserted  particles  of  the 
diphtheritic  membrane  in  the  back  of  the  rabbit.  Death  occurred  in  forty 
hours.  Micrococci  were  found  at  the  seat  of  the  injury  and,  before  death,  in 
the  blood  of  the  animal.  Similar  experiments  and  observations  made  by 
other  pathologists  of  renown  strengthened  the  belief  that  the  cause  of  diph- 
theria had  at  last  been  discovered  in  the  micrococcus.  Cohn  (1872  and  1873) 
classified  this  organism,  which  had  now  assumed  great  importance,  with  the 
schizophytes,  tribe  sphaero-bacteria,  and  he  designated  it  micrococcus  diph- 
theriticus. 

On  the  other  hand,  Eberth  (1872)  and  Krebs  (1871)  expressed  the 
opinion  that  the  diphtheritic  micrococci  are  the  same  as  septic  micrococci. 
Senator  (1874)  states  that  other  diseases  of  the  mouth  and  pharynx  are 
accompanied  by  the  same  micrococci  as  those  in  diphtheria.  They  are 
also,  he  says,  found  in  the  mucus  between  the  teeth  and  in  normal  urine, 
and  the  micrococci  of  diphtheria  do  not  differ  in  cultures  from  those  occur- 
ring in  other  conditions.  Billroth  (1874)  also  dissented  from  the  opinion 
that  micrococci  caused  diphtheria.  He  made  the  broad  statement  that  "  the 
so-called  pathogenic  bacteria  of  diseases  are  positively  identical  with  those 
found  in  putrefying  dead  tissues."  Therefore  the  theory  that  micrococci 
alighting  upon  one  of  the  surfaces  caused  diphtheria  met  with  strong  opposi- 
tion soon  after  it  was  announced,  and  as  time  went  on  facts  and  observations 
which  militated  against  it  multiplied. 

In  1877,  Drs.  Curtis  and  Satterthwaite  were  employed  by  the  New  York 
Health  Board  to  investigate  the  etiology  and  pathology  of  diphtheria.     After 

^  Virchovfs  Archiv,  1870. 


ETIOLOGY.  361 

many  experiments  they  reported  "  tliut  tlie  bacteria  of  diphtheritic  membranes 
do  not  differ  in  optical  or  chemical  behavior  from  those  found  in  putrescent 
but  non-diphtheritic  animal  material."  They  also  found  that  "  scrapings  from 
the  upper  surface  of  a  somewhat  furred  tongue  from  a  healthy  person  "  cause, 
when  inserted  in  the  cellular  tissue  of  the  rabbit,  an  effect  exactly  similar  to 
that  produced  by  inoculations  with  diphtheritic  membrane.  Putrid  (John's, 
fluid  (an  a({ueous  solution  of  ammonic  tartrate,  potassic  and  calcic  phosphates, 
and  magnesic  sulphate)  also  caused  the  same  result.  They  were  enabled, 
after  many  carefully-conducted  experiments,  to  enunciate  the  following  prop- 
ositions :  "  Thorough  trituration  of  proven  virulent  diphtheritic  membrane 
and  tongue-scrapings  with  a  high  percentage  of  salicylic  acid  fails  not  only 
to  remove,  but  even  markedly  to  modify,  the  intensity  of  the  infectious  (jual- 
ity  of  those  substances.  Hence,  since  salicylic  acid  in  even  a  minute  per- 
centage is  capable  of  permanently  suspending  the  vital  activity  of  bacteria,. 
the  inference  is  that  the  infectious  quality  of  diphtheritic  membrane  upon 
the  system  of  the  rabbit  is  not  correlated  to  the  vital  activity  of  the  bacteria 
present  in  such  membrane."  Therefore  if,  as  is  probable,  the  agent  in  the 
pseudo-membrane  which  causes  the  noxious  effects  in  the  inoculated  rabbit 
be  the  same  as  that  which  causes  diphtheria  in  man,  it  follows  "  that  there  is 
no  theoretical  ground  for  assuming  that  preventing  the  bacteria  of  a  diphtheritic 
patch  from  making  their  way  through  the  underlying  mucous  membrane  ujilly 
per  se,  prevent  general  diphtheritic  infection  of  the  system.'^ 

These  important  observations  and  opinions,  expressed  by  Curtis  and  Sat- 
terthwaite  in  1877,  evidently  prepared  the  way  for  the  theory  that  the  bacteria 
themselves  are  not  the  cause  or  the  infectious  principle  of  diphtheria,  but 
chemical  substances  or  ptomaines  produced  by  the  agency  of  the  bacteria 
may  be. 

In  1882,  Drs.  Wood  and  Formad,  employed  by  the  National  Board  of 
Health  to  investigate  the  nature  of  diphtheria,  after  many  microscopic  exam- 
inations and  experiments  declared  their  belief  that  the  micrococcus  diphthe- 
riticus  and  m.  septicus,  inasmuch  as  they  responded  alike  to  optical,  chemical, 
and  vital  tests,  are  identical.  They  found  the  same  micrococcus  in  the 
unhealthy  pus  of  erysipelatous  cellulitis,  and  in  21  instances  in  which  death 
resulted  from  inoculations  with  this  pus  they  found  the  same  micrococci  in 
the  blood  of  the  victims.  The  blood  of  22  cases  of  erysipelas  was  examined 
for  micrococci,  with  the  following  result:  "In  13  of  these  the  oi'ganisms 
were  found  in  the  blood,  whilst  in  the  other  9  there  were  none.  Of  measles, 
29  eases  were  studied  :  in  6  only  were  micrococci  detected,  whilst  in  8  cases  of 
rbtheln,  or  German  measles,  there  were  no  organisms.  We  have  also  inves- 
tigated 4  cases  of  malignant  fatal  scarlet  fever,  in  all  of  which  we  found  the 
blood  a  few  hours  before  death  loaded  with  micrococci,  both  free,  attacking 
the  white  corpuscles,  and  in  zoogloea  masses,  and  in  one  of  which  micrococci 
emboli  were  abundant  in  the  kidneys.  We  have  also  studied  4  cases  of  '  puer- 
peral fever,'  probably  septic  metritis,  in  all  of  which  micrococci  existed  in 
the  blood  before  death." 

It  soon  became  apparent  to  pathologists,  from  experiments  and  observa- 
tions like  the  above,  that  the  so-called  micrococcus  diphtheriticus  is  not 
peculiar  to  diphtheria — that  it  occurs  in  all  pestilential  and  putrid  diseases, 
in  decomposing  animal  tissues  in  various  diseases,  and  even  upon  the  tongue 
and  gums  in  health.  Hence  it  was  necessary  to  look  elsewhere  for  the  cause 
of  diphtheria. 

In  1883,  Klebs  made  extended  and  thorough  examinations  of  the  microbes 
of  diphtheria,  and  formed  the  opinion  that  a  bacillus  which  he  had  observed 
in  the  pseudo-membi'ane  and  upon  the  inflamed  tissue  merited  special  atten- 
tion.    Subsequently,   Loefl3er  pursued  the  investigation,  and   the  organism 


362  DIPHTHERIA. 

known  as  the  Klebs-Loeffler  bacillus  became  a  prominent  object  of  study  as 
perhaps  the  causal  agent  in  diphtheria.  Loeffler,  in  the  published  statement 
of  his  investigations,  remarks  that  all  observers  have  found  bacteria  in  the 
diphtheritic  exudate,  micrococci  most  frequently,  existing  in  colonies,  and 
especially  abundant  in  superficial  portions  of  the  pseudo-membrane.  At 
times  bacteria  have  been  found  in  the  lymphatics  in  the  vicinity  of  the 
inflamed  tissues.  Every  diphtheritic  patch  contains  many  species  of  bacteria 
which  have  been  cultivated,  but  as  they  have  not  been  isolated  the  specific 
germ  of  diphtheria  has  not  been  determined.  The  rejection  of  the  theory 
that  micrococci  are  the  causal  agent  of  diphtheria,  on  the  ground  that  they 
occur,  presenting  the  same  optical,  chemical,  and  vital  characteristics,  in  other 
distinct  diseases  and  conditions,  led  to  a  more  careful  examination  of  other 
bacteria  present  in  the  diphtheritic  exudate  and  upon  and  in  the  underlying 
tissues.  The  bacillus  described  by  Klebs,  and  later  by  Loeffler,  is  motion- 
less, partly  straight,  partly  curved,  of  the  length  of  the  tubercle  bacillus, 
but  double  its  thickness.  It  is  abundant  in  the  pseudo-membrane,  but  is  not 
found  in  the  blood-vessels,  lymphatics,  or  internal  organs  ;  so  that  its  path- 
ogenic action  must  be  localized  on  the  surface.  If  it  be  the  specific  principle 
or  germ  of  diphtheria,  it  must  act  by  producing  a  ptomaine  or  chemical  poi- 
son where  it  is  lodged,  which  poison,  entering  the  lymphatics  and  blood-ves- 
sels, causes  systemic  infection.  In  some  typical  cases  of  diphtheria  Loeffler 
was  unable  to  find  the  bacillus — which  of  course  militates  against  the  theory 
that  it  is  the  specific  germ — but  he  suggests  that  it  might  have  died  and  been 
eliminated  before  the  death  of  the  patients.  Such  an  explanation  seems  very 
improbable  ;  it  is  making  a  stubborn  antagonistic  fact  yield  to  a  theory  ;  and 
yet  without  such  an  explanation  we  must  look  for  some  other  cause  of  diph- 
theria. The  Klebs-Loeffler  bacillus  was  found  by  Loeffler  in  the  exudate  in 
thirteen  cases  of  diphtheria,  and  cultures  to  the  twenty-fifth  generation  inoc- 
ulated in  guinea-pigs  and  birds  caused  a  whitish  exudation  at  the  point  of 
inoculation. 

W.  Watson  Cheyne^  recognizes  the  importance  of  Klebs  and  Loeffler's 
researches,  and  thinks  it  probable  that  the  micro-organism  which  causes 
diphtheria  is  a  bacillus,  which,  lodging  upon  the  surface  of  the  throat,  is 
propagated  there.  Having  upon  the  mucous  membrane  a  favorable  nidus, 
it  not  only  lies  upon,  but  penetrates,  the  superficial  portion  of  the  mucous 
layer  and  causes  the  exudation  of  fibrin.  The  pseudo-membrane  thus 
produced  consists,  according  to  Cheyne,  of  the  fibrinous  exudate  and  dead 
epithelial  cells.  As  the  bacilli  multiply  and  extend,  the  exudate  enlarges. 
Cheyne  believes  it  probable,  though  demonstration  is  lacking,  that  the 
bacilli  cause  very  poisonous  ptomaines,  which,  entering  the  lymphatics 
and  the  blood,  give  rise  to  systemic  infection  and  render  the  disease 
■constitutional. 

But  since  the  observations  of  Klebs,  Loeffler,  and  Cheyne  the  bacillus 
which  they  consider  the  specific  principle  of  diphtheria  has  been  subjected 
to  a  more  thorough  examination,  with  the  result  of  apparently  demon- 
strating that  the  same  bacillus  occurs  in  non-diphtheritic  cases,  and  even 
in  healthy  persons,  as  well  as  in  diphtheria.  Thus,  Von  Hofman-Wellenhof '■' 
detected  this  bacillus  in  26  of  45  cases  in  various  conditions  of  the  buccal 
and  faucial  surfaces.  He  discovered  it  in  7  cases  of  diphtheria,  in  3  of 
measles,  in  6  of  19  cases  of  scarlet  fever,  and  in  4  of  11  normal  cases.  In 
cultures  and  experiments  the  bacilli  from  difi"erent  sources  appeared  to  be 
identical.  Therefore  in  the  light  of  recent  investigations  the  Klebs-Loeffler 
bacillus  has  no  more  significance  as  a  cause  of  diphtheria  than  the  micro- 
coccus of  Oertel. 

^  Brit.  Med.  Jour.  "  Wiener  med.  Wochenschr..  1888,  Nos.  3  and  4. 


ETIOLOGY.  3G3 

Prof.  Oertel,  who  was  one  of  tlic  earliest  advocates  of  the  theory  of  the 
microbic  origin  of  diphtheria,  and  whose  monograph  in  1868,  published  in 
Zinnssens  Cgclojjxdia^  led  to  the  belief  in  the  profession  that  the  micro- 
coccus was  the  cause,  now  admits  that  the  theory  that  diphtheria  is  due  to 
the  action  of  bacteria,  though  plausible,  is  not  proved.  He  has  endeavored 
to  elucidate  the  pathogeny  of  the  disease  by  a  careful  and  minute  study  of 
its  anatomical  characters.'  After  an  elaborate  study  of  its  histology,  he 
remarks :  "  In  the  earliest-formed  membranes  many  varieties  of  microbes 
can  be  isolated  ;  but  practically  there  are  two  chief  kinds — chain-forming 
cocci  (streptococcus)  and  rod-shaped  bacteria  with  rounded  extremities 
(bacilli)."-^ 

Oertel  remarks  that  in  the  septic  form  of  diphtheria  the  cocci  are  abun- 
dant. In  a  pseudo-membrane  of  twelve  hours'  continuance  micrococci 
abounded  mostly  on  the  surface,  but  in  the  fibrinous  network  the  bacilli, 
often  in  colonies,  preponderated.  In  a  specimen  of  twenty-four  hours'  dura- 
tion the  upper  surface  was  full  of  cocci,  and  between  them  were  bacilli.  In 
another  specimen  of  membrane  detached  after  six  days  these  two  forms  of 
microbes  were  also  intermixed.  As  regai'ds  the  tissues  and  organs,  the  micro- 
cocci and  bacilli  occurred  upon  the  mucous  membranes,  not  penetrating  them 
to  any  great  depth.  They  were  not  found  in  the  "  necrobiotic  foci,"  nor 
were  they  observed  in  any  of  the  sections  of  the  kidneys  which  were  exam- 
ined. This  is  a  noteworthy  fact,  because  in  the  examinations  made  between 
1865  and  1871,  the  results  of  which  were  published  in  Oertel's  article  in 
Ziemssens  CycJnpsexlia^  micrococci  were  found  in  the  kidneys.  He  attributes 
their  presence  in  the  kidneys  during  this  period  to  the  fact  that  the  cases 
under  observation  were  septic,  whereas  in  those  recently  examined  septic 
infection  was  not  common,  on  account,  he  thinks,  of  the  employment  of  dis- 
infecting and  antiseptic  measures  in  place  of  the  escharotic  treatment  and 
forcible  detachment  of  the  membrane,  in  use  during  the  time  of  his  former 
observations. 

The  purpose  of  Oertel  in  his  recent  investigations  has  been  to  ascertain, 
if  possible,  the  nature  of  the  diphtheritic  virus  by  a  close  and  minute  study 
of  the  lesions  or  anatomical  changes  which  it  produces.  It  appears  from  his 
examinations  that  the  primary  lesion  is  cell-change.  "  Necrobiotic  pro- 
cesses" and  "necrobiotic  areas"  commencing  in  the  cells  are  observed  in  the 
tonsils,  the  mucous  membrane  of  the  fauces,  uvula,  epiglottis,  larynx,  tra- 
chea, in  the  cervical  submaxillary,  bronchial,  and  mesenteric  glands,  in  the 
spleen,  and  in  the  follicles  and  agminate  glands  in  the  intestines.  In  differ- 
ent cases  these  structural  changes  vary  according  to  the  intensity  of  the 
virus  and  the  duration  of  its  action.  The  morbific  process  extends  by 
propagation  through  an  organ  or  from  one  part  to  another,  the  virus  being 
carried  by  the  lymph-stream  or  blood,  disintegrating  products  being  the 
carrier. 

The  following  is  a  summary  of  Oertel's  views  in  regard  to  the  virus  of 
diphtheria.  They  express  all  that  is  at  present  known  of  the  etiology  of 
this  disease.  The  nature  of  the  virus,  says  Oertel,  is  still  obscure.  It  acts 
upon  cells,  causing  their  death  and  disintegration,  and  the  infected  particles 
convey  the  virus  to  other  cells.  The  virus  causes  hyaline  degeneration  in 
the  tissues.  The  hyaline  degeneration  in  the  walls  of  the  blood-vessels 
causes  them  to  rupture,  producing  hemorrhages.  The  unequal  amount  of 
hyaline  change  in  different  parts  of  the  vascular  apparatus  may  be  attrib- 
uted to  difference  in   resisting   power   or  unequal   exposure   to   the   infected 

'  Die  Pathogenese  d.   epidemischen  Diphtherie,   nach    ihrer  histologischen   Begriindiing, 
Leipzig,  1887. 

'  London  Lancet,  March  31,  1888. 


364  DIPHTHERIA. 

blood.  Secondary  inflammatory  processes  in  the  lungs,  heart,  liver,  kidneys, 
and  in  the  central  and  peripheral  nerve-tissues  must  arise  from  the  infectious 
property  of  the  blood  circulating  in  them.  After  enumerating  at  length  and 
with  much  detail  the  results  of  his  examinations,  Oertel  expresses  the  opinion 
that  bacterial  organisms  cause  diphtheria,  and  that  they  produce  this  result 
not  by  their  direct  action,  but  by  producing  a  ptomaine  which  infects  the 
system  and  causes  the  disease  to  be  constitutional.  The  microbe  itself  is 
mostly  confined  to  the  surface,  whereas  the  action  of  the  virus  is  "  wide- 
spread and  deep.'"  The  most  eminent  pathologists  of  the  present  time  do 
not  express  any  more  positive  opinions  in  reference  to  the  specific  principle 
or  germ  of  diphtheria  than  is  contained  in  the  above  summary  of  Oertel's 
views. 

Dr.  Prudden  has  recently  made  systematic  studies  on  a  series  of  cases  of 
diphtheria,  which  would  seem  to  indicate  that  a  streptococcus  which  is  almost 
constantly  present  in  the  pseudo-membrane  may  stand  in  a  causal  relation 
to  diphtheria.^ 

At  a  recent  meeting  of  the  London  Epidemological  Society,  Dr.  M.  W. 
Taylor  ^  expressed  the  opinion  that  common  mould  might  cause  diphtheria  in 
persons  exposed  to  it.  The  walls  of  a  sleeping  apartment  became  wet  and 
sodden  on  July  12th.  On  the  22d  a  fungus  appeared  on  the  plaster,  and  in 
the  beginning  of  August  the  three  children  who  occupied  the  room,  and  who 
had  not  been  exposed  in  any  other  way,  so  far  as  could  be  ascertained,  sick- 
ened with  diphtheria.  The  aspergillus  and  coprinus  grew  abundantly  in  the 
mould.  In  another  instance,  in  which  the  child  died  in  three  days,  there 
was  a  great  development  of  penicilium  moulds.  A  young  man  had  diphthe- 
ria severely  four  days  after  cleaning  out  a  pigeon-loft  where  the  exuviae, 
debris,  and  rotten  wood  were  covered  with  mould.  But  the  theory  that 
organisms  which  are  commonly  present  in  ordinary  mould  can  produce  diph- 
theria is  improbable,  for  mould  is  common  in  all  damp  localities,  where  there 
is  no  diphtheria  as  well  as  where  diphtheria  is  present.  We  shall  see  in  our 
remarks  on  the  propagation  of  diphtheria  that  there  can  be  little  doubt  that 
pigeons  and  other  feathered  animals  frequently  have  this  disease,  and  in  the 
instance  referred  to  by  Dr.  Taylor  it  is  probable  that  exuviae  and  debris  in 
the  pigeon-loft  had  been  infected  by  sick  pigeons.  The  specific  principle 
must  be  introduced  from  without,  but  if  it  obtain  a  lodgment  upon  the  wet 
and  mouldy  surface  of  any  filthy  accumulation,  it  may  find  there  a  nidus 
favorable  for  its  development.  We  shall  see  that  the  fact  appears  to  be 
fully  established  that  the  diphtheritic  virus  is  frequently  propagated  in  foul 
and  damp  localities,  apart  from  the  animal  tissues  and  independently  of  the 
sick.  We  repeat,  therefore,  that  the  theory  in  reference  to  the  causation  of 
diphtheria  which  is  gaining  acceptance  throughout  the  world  is  that  it  is 
produced  by  a  microbe  or  microbes  whose  action  is  chiefly  on  the  surface 
or  at  no  gnat  depth,  and  that  blood-poisoning  occurs  mainly  from  a  ptomaine 
or  ptomaines  produced  by  microbic  agency.  In  order  to  obtain  a  know- 
ledge of  the  ptomaine  chemistry  must  aid  microscopical  investigation. 

Mode  of  Propagation. — No  fact  is  better  established  than  that  diph- 
theria does  not  originate  de  novo.  Like  the  eruptive  fevers,  it  is  produced 
by  the  reception  in  or  upon  some  part  of  the  system  of  the  pre-existing 
specific  poison.  The  extreme  contagiousness  of  diphtheria  from  person  to 
person  is  well  known  ;  a  moment's  exposure  to  the  breath  of  a  patient,  or  in 
the  infected  room  where  he  is  under  treatment  or  has  been  weeks  or  perhaps 
months  previously,  has  in  numberless  instances  communicated  the  disease. 
The  virus  adheres  tenaciously  to  objects  on  which  it  happens  to  alight.  The 
clothing  of  a  patient,  even  when  the   disease  is  in  its  mildest  form,  his  bed- 

'  See  Araer.  Jour.  Med.  ScL,  1889.  ^  ^.^^  ]\fgfj^  j^^^.^ 


MODE   OF  PROPAGATIOX.  365 

ding,  the  furniture  of  his  room,  and  the  objects  which  he  handles  may  for 
weeks  afterward  communicate  tlie  disease,  and  even  when  transported  to  a 
distance.  A  child  with  malignant  diphtheria  seen  by  me  in  consultation 
apparently  contracted  it  by  embracing  a  school-mate  who  was  in  the  street 
for  the  first  time  after  an  attack  of  diphtheria.  In  another  instance  a  child 
was  for  a  brief  period  iu  a  room  where  diphtheria  had  occurred  two  months 
previously,  and  after  the  usual  incubative  period  sickened  with  the  disease. 

Although  diphtheria  is  often  contracted  in  the  manner  mentioned  above — 
that  is,  by  exposure  to  a  diphtheritic  patient  or  to  a  room  or  some  object 
infected  by  such  patient — there  is  another  mode  of  infection  common  in  the 
cities.  Dr.  Sternberg,  in  his  recent  Lomb  Prize  Essay,  published  by  the 
American  Public  Health  Association,  refers  to  the  fact  that  damp,  foul 
places,  such  as  sewers,  cellars,  ill-ventilated  spaces  under  floors  where  the 
sun  never  enters  and  where  refuse  collects,  afford  conditions  favorable  for 
the  development  and  propagation  of  the  diphtheritic  virus.  The  virus,  what- 
ever its  nature,  once  received,  may  be  propagated  in  such  a  place  for  an 
indefinite  time,  and,  ascending  in  the  vapors  which  arise  from  this  culture- 
bed,  it  is  liable  to  communicate  the  disease  to  any  one  who  inhales  it.  Thus, 
in  New  York  City  prior  to  1850,  although  foul  sewers  and  insanitary  con- 
ditions existed,  there  was  no  diphtheria,  but  in  the  decade  following  1850 
diphtheria  was  introduced.  Its  germ  made  its  way  into  the  sewers  under- 
ground, and  now  wherever  sewer-gas  escapes  into  the  domiciles  of  this  city, 
it  carries  with  it  the  diphtheritic  virus.  The  amazing  vitality  and  power  of 
propagation  of  the  diphtheritic  poison  are  apparent  when  we  reflect  that  it 
permanently  infects  the  filthy  but  constantly-flowing  and  constantly-renewed 
currents  of  the  sewers  of  a  great  city.  In  all  the  wards,  and  apparently  in 
every  street,  in  New  York  City  children  are  constantly  falling  sick  with  this 
disease,  contracted  by  inhaling  sewer-gas,  which,  notwithstanding  "  sanitary 
plumbing,"  often  escapes  from  unsuspected  sources,  even  in  houses  con- 
structed with  all  the  modern  improvements.  It  is  chiefly  by  exposure  of 
children  to  infected  sewer-gas  which  ascends  from  this  widely-extending 
underground  culture-bed,  and  to  walking  cases  often  so  mild  that  there  is 
little  or  no  complaint  of  the  throat  or  impairment  of  the  general  health, 
that  this  disease  is  so  prevalent.  Most  of  the  contagious  diseases  of  chil- 
dren are  quickly  detected  by  characteristic  symptoms  or  appearances  which 
the  most  ignorant  families  are  to  a  certain  extent  familiar  with,  but  mild 
diphtheria  possesses  so  few  subjective  symptoms  that  it  is  often  not  detected 
or  suspected,  even  in  intelligent  families  who  are  watchful  of  their  children. 
Children  with  mild  diphtheria  sit  among  other  children  in  the  schools,  in 
the  city  conveyances,  in  the  churches  and  dispensaries,  and  frequently  com- 
municate to  those  who  are  near  them  a  malignant  form  of  the  disease  from 
which  the  unfortunate  victims  quickly  perish.  The  diphtheritic  virus  is  so 
subtle,  and  its  vitality  and  power  of  propagation  so  great,  that  when  it  is 
established  in  a  sewered  city  it  can  probably  never  be  stamped  out,  as  cholera 
and  yellow  fever  may  be,  by  measures,  however  stringent  and  active,  employed 
by  health  boards  or  by  legislative  enactments. 

Commonly,  diphtheria  is  communicated  by  the  inhalation  of  infected 
air — the  inhalation  of  air  containing  the  specific  principle,  whether  derived 
directly  from  a  patient  or  from  some  infected  inanimate  object,  as  the  walls 
of  a  room,  furniture,  apparel,  an  article  of  merchandise,  or  sewer-gas.  More 
rarely,  diphtheria  is  communicated  by  direct  contact  with  some  infected  solid 
substance,  as  a  particle  of  the  diphtheritic  exudate,  muco-purulent  secretion 
from  an  infected  surface,  or  the  blood  of  a  patient.  A  considerable  number 
of  instances  has  been  reported  in  which  instruments  infected  by  use  upon 
a  patient,  and  not  properly  cleaned  and  disinfected  subsequently,  have  been 


366  DIPHTHERIA. 

the  means  of  communicating  the  disease.  In  these  instances  of  communi- 
cation by  direct  contact  the  poison  is  received  either  upon  one  of  the  mucous 
surfaces  or  upon  the  skin  denuded  of  its  protecting  epidermis. 

Diphtheria  contracted  from  Animals. — Observations  are  accumulating  which 
show  that  diphtheria  or  a  disease  closely  resembling  it  occurs  among  animals, 
and  is  sometimes  communicated  from  them  to  man.  The  feathered  tribe 
especially  appear  to  be  susceptible  to  this  disease.  On  the  island  of  Skiathos, 
off  the  north-eastern  coast  of  Greece,  no  diphtheria  had  occurred  during  at 
least  thirty  years  previously  to  1884,  according  to  Dr.  Bild,  the  medical 
practitioner  of  the  island.  In  that  year  a  dozen  turkeys  were  introduced 
from  Salonica.  Two  of  them  were  sick  at  the  time,  and  died  soon  afterward ; 
the  others  became  affected  subsequently,  and  of  the  whole  number  seven 
died,  three  recovered,  and  two  were  sick  at  the  time  of  the  inquiry.  The 
two  had  a  pseudo-membrane  upon  the  larynx,  difficult  breathing,  and  swell- 
ing of  the  glands  of  the  neck.  As  further  evidence  that  the  disease  was 
true  diphtheria,  one  of  the  turkeys  that  had  survived  had  paralysis  of  the 
feet.  The  turkeys  were  in  a  garden  on  the  north  side  of  the  town,  and  the 
prevailing  winds  upon  the  island  are  from  the  north.  When  this  sickness 
was  occurring  among  the  turkeys  an  epidemic  of  diphtheria  commenced  in 
the  houses  in  proximity  to  the  garden  and  spread  through  the  town.  It 
lasted  five  months,  and  of  125  cases  in  a  population  of  four  thousand,  36 
died.  Diphtheria  was  from  this  time  established  upon  the  island,  and  fre- 
quent epidemics  of  it  have  occurred  since. ^  M  Menzies  ^  states  that  diph- 
theria is  common  among  the  poultry  in  Italy,  in  which  country  the  flat  roofs 
of  the  houses  afford  a  resting-place  for  turkeys,  fowls,  pigeons,  and  rabbits,, 
and  their  evacuations  are  carried  by  the  rain  into  the  cisterns  and  wells.  A 
physician  at  Posilippo,  near  Naples,  had  directed  his  servant  not  to  obtain 
drinking-water  from  the  well  next  to  his  house,  but  from  a  well  at  a  distance. 
As  long  as  the  instruction  was  obeyed  his  family  was  well ;  but  the  servant,, 
yielding  to  his  indolence,  finally  disobeyed  the  command  and  obtained  water 
from  the  infected  well.  Four  of  the  children  who  drank  this  water  soon  took 
diphtheria  and  died.  The  fifth  child,  who  did  not  drink  the  water,  escaped. 
In  1878-79,  Nicati  of  Marseilles  observed  cases  which  seemed  to  show  that 
diphtheria  is  sometimes  contracted  from  fowls.^  The  Journal  de  Medicine  de 
Paris,  February  19,  1888,  contains  an  instructive  paper  by  Dr.  Delthil  on  the 
transmission  of  diphtheria  from  animals  to  man,  in  which  a  considerable 
number  of  apparent  instances  is  related.  Dr.  F.  T.  Wheeler  *  states  that  while 
in  a  nesting  of  wild  pigeons  he  found  many  sick  with  a  pseudo-membranous, 
sore  throat.  He  dissected  some  of  them  with  his  pocket-knife,  which  he  was 
obliged  to  throw  away  on  account  of  the  offensive  odor.  There  were  millions- 
of  pigeons  in  the  nesting,  and  they  were  hunted  and  eaten  by  the  inhabitants. 
The  same  year  diphtheria  broke  out  in  a  most  malignant  form,  causing  many 
deaths  among  the  children.  Several  years  previously  pigeons  nested  in  the 
same  locality  or  near  by,  and  fully  half  of  the  children  living  in  the  vicinity 
had  diphtheria.  Dr.  George  Turner^  states  that  a  pigeon  was  brought  to- 
him  for  dissection.  The  whole  of  its  windpipe  was  covered  by  pseudo-mem- 
brane, as  in  the  croup  of  a  child.  Pigeons  were  inoculated  in  the  fauces 
with  this  membrane,  and  a  similar  disease  was  produced,  which  extended  to^ 
their  eyes  through  the  nostrils.  An  epidemic  of  diphtheria  occurred  in  the 
village  of  Braughing,  Hertfordshire,  England,  the  first  cases  appearing  on  a 
farm  where  the  fowls  were  dying  of  a  disease  similar  to  that  in  the  pigeon  ;. 
and  on  other  farms  where  diphtheria  appeared  it  was  preceded  by  a  similar 

^Bulletin  Med.,  January  22, 1888.  ^  Thesis,  Paris,  1881. 

'  Marseille  Med.,  1879,  p.  105.  *  American  Practitioner  and  News. 

^  Journal  of  Laryngology  and  Rhinology. 


MODE  OF  PROPAGATION.  367 

disease  in  the  fowls.  Dr.  Turner  also  mentions  several  other  epidemics  of 
diphtheria  in  different  localities  where  the  poultry,  turkeys,  pigeons,  and  in 
one  locality  the  pheasants,  perished  of  a  disease  attended  by  this  membranous 
exudation.  At  Tougham  a  man  bought  a  chicken  at  a  low  price,  as  it  was 
affected  by  the  prevailing  disease,  and  cared  for  it  at  his  home.  Soon  after 
diphtheria  broke  out  in  his  family,  and  this  case  was  the  first  in  the  village. 
Instances  are  also  cited  by  Dr.  Turner  showing  that  cats,  sheep,  and  pigs 
have  suffered  from  a  severe  disease  of  the  throat,  probably  diphtheritic,  in 
several  localities  where  diphtheria  was  prevailing  among  children. 

According  to  the  observations  of  various  experimenters,  diphtheria  can  be 
transmitted  from  man  to  animals ;  and,  if  this  be  true,  it  seems  probable  that 
it  can  likewise  be  transmitted  from  animals  to  man.  Trendelenburg  inoculated 
68  rabbits,  introducing  diphtheritic  pseudo-membrane  into  the  trachea  through 
an  artificial  opening:  11  of  the  rabbits  died  with  the  symptoms  and  appear- 
ances of  diphtheria.  In  control  experiments  he  introduced  various  foreign 
bodies  into  the  larynx  of  rabbits,  and  was  unable  to  produce  any  results  or 
lesions  resembling  those  in  diphtheria.  Oertel  performed  12  similar  experi- 
ments, and  5  of  the  rabbits  died  after  the  production  of  pseudo-membranes. 
Zahn,  Gerhard,  Labadie-Lagrave,  Francotte,  and  Vulpian  obtained  similar 
results  from  their  experiments.  Such  observations  and  experiments  render 
it  probable  that  genuine  diphtheria,  equally  fatal  and  attended  by  the  same 
anatomical  characters  and  symptoms  as  in  man,  does  occur  in  birds,  whether 
wild  or  domesticated,  and  in  certain  quadrupeds,  as  the  rabbit.  Nevertheless, 
we  should  add  that  certain  eminent  pathologists,  among  whom  we  may  men- 
tion the  honored  name  of  Virchow,  have  doubted  the  identity  of  animal  and 
human  diphtheria.  With  our  present  light  on  the  subject  it  is  evident  that, 
since  our  relations  to  the  domestic  animals  are  so  close,  if  they  are  sick  with 
any  disease  resembling  diphtheria  the  same  precautionary  measures  should 
be  taken  to  prevent  infection  of  the  family   as  in  human   diphtheria. 

Mr.  Cole,  a  veterinary  surgeon  of  Hinckley,  Australia,  published  in  the 
Australian  Veterinary  Journal,  February,  1882,  copied  into  the  New  York 
Medical  Record,  the  account  of  an  epidemic  of  diphtheria  that  was  appa- 
rently traced  to  the  milk  obtained  from  a  diseased  cow.  In  1879,  Mr.  W. 
H.  Power,  health  inspector,  investigated  an  outbreak  of  diphtheria,  and 
believed  that  he  traced  it  to  the  milk-supply.  The  cows  which  furnished 
the  milk  that  seemed  to  communicate  the  disease  had  what  the  veterinary 
surgeons  designate"  garget,"  or  ''infectious  mammitis."^  Another  similar 
history  of  an  epidemic  is  related  by  the  same  journal  that  published  Mr. 
Power's  report.  Prof.  Damman  of  the  Hanover  Veterinary  School  reported 
in  the  Deutsche  Zeifschrift  fiir  Thiermedicin,  1877,  an  epidemic  of  what  seemed 
to  be  diphtheria  in  calves.  He  directed  the  attendant  to  make  applications  to 
the  mouths  and  throats  of  the  affected  calves.  This  was  on  April  29.  On 
May  5  the  attendant  became  sick,  complained  of  his  throat,  and  was  confined 
to  bed.  A  pseudo-membrane  appeared  on  his  tonsils,  which  were  highly 
inflamed ;  he  had  fever  and  enlargement  of  both  the  submaxillary  and  cer- 
vical glands.  A  dairy-maid  who  now  took  charge  of  the  calves  also  had  a 
similar  but  less  severe  attack.  Milk  is  a  culture-medium  of  various  microbes, 
and  that  it  may  be  the  medium  of  communication  of  diphtheria  as  well  as  of 
scarlet  fever  seems  probable. 

The  fact  that  the  diphtheritic  virus  may  be  conveyed  long  distances  with- 
out losing  its  virulence  is  now  admitted  from  the  many  observations  that  have 
been  made.  Prof.  C.  W.  Earle  of  Chicago  read  before  the  Ninth  Interna- 
tional Medical  Congress  an  interesting  statistical  paper  on  the  occurrence  of 
diphtheria,  often  severe  and  fatal,  in   salubrious  rural   localities,  free  from 

'■  Med.  Times  and  Oaz.,  Jan.,  1879. 


368 


DIPHTHERIA. 


sewage-gas  and  water-pollution,  in  the  newly-settled  and  mountainous  States 
and  Territories  of  the  North-west.  Dr.  Earle's  statistics  render  it  probable 
that  the  diphtheritic  infection  is  transported  long  distances  to  these  localities, 
being  carried  in  articles  of  clothing  and  merchandise.  The  well-known  tena- 
cious adherence  of  the  virus  to  objects  renders  it  highly  important  that 
thorough  disinfection  should  be  employed  before  articles  are  removed  from 
an  infected  room. 

Age. — Trousseau  has  said  that  diphtheria  does  not  spare  any  age,  but  is 
most  common  between  the  ages  of  two  and  five  or  six  years.  Guersant  believes 
that  the  age  of  greatest  frequency  is  between  the  second  and  seventh  years, 
and  Barthez  and  Rilliet  agree  with  Guersant.  Bouillon-Lagrange  in  63  cases 
occurring  in  one  epidemic  treated — 


Under  2  years 14  cases. 

From    2  to    6      "  18     " 

"       6  to  12      "  10     " 

"     12  to  18     "  9     " 


From  1 8  to  30  years 15  cases. 

"     30  to  40      "  4     " 

"     40  to  50      "  1  case. 

Above  50     "  2  cases. 


According  to  M.  Barthez,  in  Sainte-Eugdnie  Hospital  during  twenty  years 
the  ages  of  the  diphtheritic  patients  were  as  follows,  adults  being  excluded 
from  this  institution : 


Under  1  year 81  cases. 

From   1  to  2  years 314     " 

2  to  3     "  319      " 

"       3  to  4     "  292     " 

"       4  to  5     "  200     " 

"       5  to  6     "  103     " 


From    6  to    7  years   .    . 

...  59  cases 

"        7to    8     "       .    . 

...  36     " 

"        8to    9     "       .    . 

...  24     " 

9  to  15     "       .    . 

...  82     " 

"      15  to  17     "       .    . 

...    2     " 

Louis  has  shown  that  diphtheria  may  occur  at  an  advanced  age,  but  it 
is  rare  over  the  age  of  forty  years,  and  very  rare  after  the  age  of  sixty  years. 

Oertel  says,  "  In  the  first  half  year  the  infant  organism  seems  to  be  not 
at  all  susceptible  to  the  disease."  As  in  scarlet  fever,  so  in  diphtheria,  cases 
are  infrequent  under  the  age  of  six  months,  but  a  considerable  number  of 
cases  are  on  record  showing  that  it  does  occur  even  in  the  newly-born.  Dr. 
A.  Jacobi  has  collated  the  following  cases :  A  child  of  fourteen  days  treated 
by  Tigri,  one  of  fifteen  days  by  Bretonneau,  one  of  seventeen  days  by  Bed- 
nar,  one  of  eight  days  by  Bouchut,  one  of  seven  days  by  Weikert,  several 
cases  by  Parrot,  and  eighteen  cases  observed  by  Siredey  in  the  Hopital  Lari- 
boisiere  in  the  spring  of  1877.  Dr.  Jacobi  adds :  "  I  have  met  with  three 
cases  of  diphtheria  of  the  pharynx  and  larynx  in  the  newly-born  myself. 
One  of  these  became  sick  on  the  ninth  day  after  birth,  and  died  on  the  thir- 
teenth day ;  the  other  died  on  the  sixteenth  day  after  birth ;  the  third  was 
taken  when  seven  days  old,  and  died  on  the  ninth   day."^ 

Certain  physicians  having  charge  of  maternity  wards  have  observed  a  dis- 
ease occurring  in  newly-born  infants  which  bears  some  resemblance  to  diph- 
theria, but  which,  if  it  be  true  diphtheria,  presents  anomalous  features. 
Thus,  Dr.  W.  S.  Bigelow  reports  in  the  Boston  Medical  and  Surgical  Journal 
for  March  11.  1875,  10  cases  occurring  between  September  and  December, 
1873,  in  the  Boston  Lying-in  Asylum,  all  fatal  but  2.  The  prominent  symp- 
toms and  anatomical  characters  were  dark  hue  of  skin,  hsematuria,  pseudo- 
membranous exudation  upon  certain  mucous  surfaces,  dark-green  stools, 
spleen  enlarged  and  dark,  kidneys  engorged,  in  some  of  the  cases  eifusion 
of  blood  into  the  pelves  of  the  kidneys  and  along  the  urinary  tract.  Dr. 
Bigelow  refers  to   what  appear   to  have  been   similar  cases   in   one  of  the 

^  Treatise  on  Diphtheria,  New  York,  1880. 


AGE.  369 

European  asylums.  The  presence  of  pseudo-membranous  exudations  on  the 
mucous  surfaces,  and  renal  casts,  raises  the  suspicion  that  the  disease  which 
gave  such  strong  evidence  of  infectiousness  was  diphtheria.  That,  so  far  as 
appears  from  the  records,  the  mothers  remained  well,  does  not  preclude  the 
belief  that  the  disease  of  these  ini'ants  had  a  diphtheritic  origin  ;  for  in  cases 
which  we  will  presently  relate  the  mothers  with  one  exception  remained  well, 
although  their  infants  a  few  days  old  undoubtedly  had  diphtheria. 

A  case  in  some  respects  similar  to  those  observed  by  Dr.  Bigelow  came 
under  my  notice.  Malignant  diphtheria  occurred  in  a  family  in  West  Fifty- 
third  street,  New  York,  in  October,  1880.  The  patient,  a  boy  of  ten  years, 
died,  and  the  remaining  two  children,  as  soon  as  the  nature  of  the  malady 
was  apparent,  were  sent  from  the  house.  Nevertheless,  one  of  those  pre- 
cisely seven  days  after  the  removal  was  attacked  by  diphtheria  of  the  hemor- 
rhagic form,  and  died  in  less  than  a  week.  Blood  escaped  from  the  nostrils, 
fauces,  under  the  skin  in  numerous  places,  causing  purpuric  spots,  and  from 
the  kidneys  or  urinary  tract,  causing  haematuria.  The  mother,  who  was  at 
this  time  in  the  sixth  month  of  pregnancy,  continued  greatly  depressed  by 
the  occurrence,  although  her  general  health  seemed  to  be  good.  She  had 
been  in  constant  attendance  upon  her  children.  Her  infant,  born  three 
months  subsequently  to  the  occurrence  of  diphtheria  in  her  family  (Febru- 
ary 6,  1881),  was  well  developed,  but  it  presented  a  similar  hemorrhagic 
cachexia  to  that  in  the  second  case  of  diphtheria.  Blood  escaped  from  the 
vessels  under  the  skin,  causing  blotches  and  prominences,  and  from  the 
mucous  surfaces.  The  bleeding  was  persistent  and  copious  from  the  umbil- 
icus, so  that  death  occurred  in  less  than  a  week.  The  diphtheritic  virus  is 
subtle  and  penetrating,  causing  the  specific  inflammation  in  the  uterine  walls 
of  the  parturient  woman  even  when  her  fauces  are  not  affected.  Neverthe- 
less, whether  diphtheria  sustains  a  causal  relation  to  cases  like  the  above  is 
uncertain,  and  can   be  determined  only  by  more  numerous  observations. 

The  admitted  infrequency  of  diphtheria  in  the  newly-born,  and  the  state- 
ment by  some  writers  that  they  have  an  immunity  from  it,  induce  me  to  relate 
the  following  cases,  in  which  the  diagnosis  of  diphtheria  was  established 
beyond  doubt  by  carefully-conducted  necropsies  and  microscopic  examina- 
tions : 

The  New  York  Foundling  Asylum  at  Sixty-First  street  and  Tenth  avenue 
has  during  the  twenty-three  years  of  its  existence  been  remarkably  free  from 
contagious  and  infectious  maladies,  but  from  September  1,  1887,  to  April, 
1888,  an  epidemic  of  diphtheria  occurred  in  the  institution.  During  this 
time  five  new-born  infants  had  diphtheria,  the  pseudo-membrane  appearing 
in  its  usual  situation  on  the  pharyngeal,  nasal,  and  laryngo-tracheal  surfaces, 
and  in  one  of  the  cases  also  lining  the  oesophagus.  Two  of  these  infants 
(Cases  1  and  2)  had  umbilical  phlegmons  in  addition  to  diphtheria,  and  their 
cases  are  related  in  our  remarks  on  Sepsis  of  the  New-born,  pages  137  and 
138,  to  which  the  reader  is  referred. 

Case  3. — Olivia  G ,  born  January  8th,  and  wet-nursed  by  her  mother,  was 

apparently  well  until  January  14th,  when  she  became  restless.  On  the  15th, 
when  she  was  seven  days  old,  she  was  carefully  examined,  and  diphtheritic 
patches  were  observed  on  the  faueial  surface ;  rectal  temperature  100°  F,  respi- 
ration 36,  pulse  120.  She  had  commencing  nasal  catarrh,  with  the  usual  infil- 
tration and  muco-purulent  discharge,  which  so  obstructed  the  nostrils  that  she 
could  not  take  the  breast,  and  she  was  fed  with  the  mother's  milk  from  a  spoon. 
Probably  patches  of  pseudo-membrane  were  present  in  the  nostrils,  but  none 
were  observed  upon  the  visible  parts  until  the  17th,  when  the  characteristic  pel- 
licle occluded  the  right  nostril.  Daily  notes  of  the  case  have  been  preserved, 
and  the  symptoms  as  regards  temperature,  respiration,  pulse,  and  the  cyanosis 
bore  a  close  resemblance  to  those  in  the  above  cases.  Death  occurred  on  the 
24 


370  DIPHTHERIA. 

18th.  At  the  autopsy,  in  addition  to  the  diphtheritic  patches  already  mentioned 
occurring  upon  the  faucial  and  nasal  surfaces,  a  pseudo-membrane  was  found 
covering  the  larynx,  trachea,  and  oesophagus  to  within  one  inch  of  the  stomach. 
No  notable  change  was  observed  in  the  appearance  of  the  internal  organs,  with 
the  exception  of  numerous  points  of  extravasation  in  the  lungs. 

Case  4. — Victor  K ,  born  December  7, 1887,  appeared  to  be  in  usual  health 

until  January  13th,  when  at  the  age  of  thirty-seven  days  the  mother  called  the 
attention  of  the  resident  physician.  Dr.  Davis,  to  him,  as  he  appeared  to  be  seri- 
ously sick.  His  temperature  was  103.2°  F.,  and  his  breathing  indicated  acute 
nasal  catarrh.  On  the  following  day,  the  14th,  the  grayish-white  exudate  of 
diphtheria  was  observed  covering  the  left  side  of  the  uvula.  The  inability  to 
remove  it  by  the  brush  or  washing  demonstrated  its  diphtheritic  nature.  His 
subsequent  history  resembled  those  given  above.  Death  occurred  on  the  15th. 
At  the  autopsy  no'  pseudo-membrane  was  observed  except  that  already  described. 

Case  5. — Vincent  B ,  born  December  31,  1887,  was  well  until  January  17, 

1888,  when  symptoms  of  a  catarrhal  nature  attracted  attention.  The  nostrils 
seemed  to  be  unaffected,  but  upon  the  posterior  portion  of  the  fauces  was  a  gray- 
ish-white patch  of  the  usual  diphtheritic  appearance.  By  antiseptic  and  solvent 
inhalation  this  pellicle  became  smaller,  and  on  the  21st  had  disappeared.  The 
infant  recovered. 

Diphtheria  of  the  newly-born  is  sometimes  wrongly  diagnosticated.  Thus, 
in  the  New  York  Foundling  Asylum,  where  diphtheria  was  occurring,  the 
tonsils  of  an  infant  a  few  days  after  birth  presented  a  grayish-white  appear- 
ance, suspected  to  be  diphtheritic.  After  its  death  the  curator,  Dr.  Northrup, 
discovered  a  pultaceous  state  of  the  surface  of  the  tonsils,  but  no  pseudo- 
membrane.  The  disease  was  apparently  not  diphtheritic ;  but,  as  regards 
the  cases  related  above,  diphtheria  was  undoubtedly  present  in  the  first  three, 
and  there  can  be  little  doubt  that  this  was  also  the  disease  in  the  remaining 
two.  The  occurrence  of  these  cases  in  so  short  a  time  in  a  small  maternity 
service  shows  that  under  certain  circumstances  the  newly-born  infant  exhibits 
considerable  susceptibility  to  diphtheria. 

Incubation. — The  duration  of  the  incubative  stage  in  experimental  inoc- 
ulation is  short,  varying  from  twelve  hours  to  three  days.  In  Trendelen- 
burg's experiments  the  incubation  was  mostly  from  one  to  three  days ;  in 
Lagrave's,  about  twenty  hours.  In  Duchamp's  inoculations  the  animals 
died  after  forty-eight  hours  with  the  larynx  and  trachea,  upon  which  the 
infectious  material  was  applied,  covered  with  pseudo-membrane.  Oertel  says 
that  the  rabbits  upon  which  he  experimented  by  inoculation  of  the  muscles 
perished  in  from  thirty  to  thirty-six  hours,  rarely  after  forty-two  hours,  the 
disease-process  extending  rapidly  to  neighboring  tissues.  When  diphtheria 
is  contracted  by  a  child  upon  an  excoriated  or  wounded  surface,  as  after  cir- 
cumcision, ablation  of  the  tonsils,  or  upon  a  leech-bite  or  a  burn,  the  incuba- 
tive period  is  short,  but  it  may  be  as  long  as  four  days.  Thus,  the  British 
Medical  Journal,  and  subsequently  the  Archives  of  Pediatrics,  published  the 
following  interesting  case,  contributed  by  Mr.  Phillips:  A. few  hours  after 
the  performance  of  tracheotomy  for  diphtheritic  croup  the  same  instruments 
were  employed  for  performing  circumcision  in  a  child  of  eighteen  months. 
Four  days  later  a  false  membrane  appeared  upon  the  wound  of  the  prepuce, 
which  by  the  following  day  had  extended  over  the  glans,  with  much  cedema 
of  the  prepuce  and  retention  of  urine. 

When  diphtheria  is  contracted  in  the  usual  manner — that  is,  by  the 
inspiration  of  air  containing  the  specific  principle — the  period  of  incubation 
appears  to  be  on  the  average  somewhat  longer  than  when  it  is  communicated 
by  direct  contact.  My  observations  lead  me  to  believe  that  when  the  incu- 
bative period  is  short  the  disease  is  likely  to  be  severe,  and  mild  when  the 
incubative  period  is  long.  I  was  enabled  to  ascertain  very  nearly  the  incu- 
bative period  in  the  following  cases :  A  boy  of  nine  years  was  in  the  same 


NATURE.  371 

room  about  one  hour  on  Saturday  \Tith  a  child  who  had  fatal  diphtheria. 
On  the  following  Tuesday,  without  any  other  exposure,  he  sickened  with  a 

severe  and  fatal  form  of  the  disease.    Mrs.  E as.sisted  in  nursing  a  severe 

case  of  diphtheria  from  November  11  to  13,  1874,  after  which  she  returned 
home,  several  blocks  away.  On  the  evening  of  the  15th  she  complained  of 
sore  throat,  and  on  the  following  day  the  diphtheritic  pseudo-membrane  was 
observed  upon  her  tonsils.  On  the  19th  the  exudation  had  disappeared  and 
she  was  convalescent.  On  the  20tli  her  sister,  who  resided  with  her,  and 
who  had  not  been  elsewhere  exposed,  was  also  attacked.  The  only  other 
ca.se  in  the  family,  a  boy,  sickened  with  diphtheria  on  December  2d.  In  the 
first  of  these  cases  the  incubative  period  seems  to  have  been  from  two  to 
four  days,  while  in  the  last  it  was  longer.  In  April,  187C,  a  little  girl  died 
of  malignant  diphtheria  in  West  Forty-first  street.  New  York  City.  Her 
sister,  aged  one  year,  remained  with  her  from  April  14th  to  17th,  when  she 
was  removed  to  a  distant  part  of  the  city  and  placed  in  a  family  where  there 
had  been  no  diphtheria.  On  April  24th,  seven  days  after  her  removal,  this 
infant  was  observed  to  be  feverish,  and  on  the  following  day,  when  I  was 
called  to  examine  her,  the  characteristic  diphtheritic  patch  had  begun  to 
form  over  the  left  tonsil.  In  April,  1875,  two  sisters,  aged  five  and  seven 
years,  resided  with  their  parents  in  a  boarding-house  in  West  Twenty-second 
street.  A  playmate  in  the  same  house  had  symptoms  which  were  supposed 
to  be  due  to  a  cold,  but  which  were  diphtheritic,  when  one  night  severe  lar- 
yngitis occurred  and  ended  fatally  the  following  day.  The  physician  who 
had  been  summoned  diagnosticated  diphtheria,  and  the  two  sisters  were 
immediately  removed  to  a  hotel.  Seven  days  subsequently  diphtheria  com- 
menced in  the  older  child.  The  younger  sister  was  then  removed  to  a  dis- 
tant part  of  the  same  hotel,  but  six  or  seven  days  later  she  also  was  attacked. 
Sanne  says  that  in  98  cases  the  incubative  period  appears  to  have  been  as 
follows : 

From  1  to     2  days 7  cases.  I  From  13  to  15  days 6  cases. 

"      2to     8     "       48     "  "      15  to  20    "      14     " 

"      8  to  13     "       23     "       I 

But  diphtheria  is  so  insidious  and  the  modes  of  exposure  so  many  that 
in  some  of  the  cases  of  an  apparently  long  incubation  there  may  have  been 
a  second  exposure.  The  above  statistics  show  that  the  incubative  period 
varies,  but  is  most  frequently  from   two  to  eight  days. 

Nature. — Diphtheria  resembles  scarlet  fever  in  certain  particulars :  in 
its  incubative  period,  varying  from  two  to  eight  days,  with  occasional  cases 
outside  of  these  limits ;  in  its  variability  of  type,  from  a  very  mild  to  a 
malignant  form  ;  in  the  common  seat  of  its  inflammations — to  wit,  upon  the 
fauces  and  nasal  passages  ;  in  the  profound  prostration  and  blood-poisoning  in 
the  graver  cases ;  and  in  the  frequent  occurrence  of  nephritis  as  a  compli- 
cation or  sequel.  It  resembles  both  scarlet  fever  and  smallpox  in  the  fact 
that  it  has  the  twofold  mode  of  communication  through  the  air  and  by  con- 
tact or  inoculation.  It  resembles  erysipelas  in  the  variableness  of  its  dura- 
tion, and  in  the  fact  that  one  attack  does  not  prevent  the  occurrence  of 
another.  In  its  etiology  it  resembles  typhoid  fever ;  for  it  is  not  only  com- 
municable from  person  to  person,  but  it  is  communicated  by  foul  exhalations, 
as  sewer-gas,  in  which  the  poison  lurks.  But  while  there  are  certain  resem- 
blances, it  is  distinguished  from  all  these  infectious  diseases  by  marked  pecu- 
liarities. 

Diphtheria  is  primary  or  secondary.  The  secondary  form  most  frequent- 
ly occurs  during  epidemics  of  the  other  infectious  diseases  and  as  a   com- 


372  DIPHTHERIA. 

plication  of  them.  Those  infectious  maladies  which  are  accompanied  by 
inflammation  of  the  fauces  and  air-passages  are  most  liable  to  this  complica- 
tion if  they  occur  in  a  locality  where  diphtheria  prevails.  In  these  instances 
of  secondary  diphtheria  the  diphtheritic  inflammation  supervenes  upon  the 
inflammations  which  pertain  to  the  primary  diseases.  Scarlet  fever  beyond 
any  other  malady  appears  to  furnish  the  conditions  which  are  most  favoi'able 
for  the  occurrence  of  diphtheria  in  the  latter  part  of  the  first  week  or  in  the 
second  week  of  its  continuance.  If  scarlet  fever  and  diphtheria  be  epidemic 
in  the  same  locality,  not  infrequently  toward  the  close  of  the  first  week  of  the 
former  disease  a  sudden  aggravation  of  symptoms  occurs,  and  the  cause  is 
soon  rendered  apparent  by  the  appearance  of  the  diphtheritic  exudate  upon 
the  faucial  surface,  usually  upon  its  tonsillar  portion.  The  discrimination 
under  these  circumstances  of  the  diphtheritic  inflammation  from  a  severe 
scarlatinous  angina  is  to  be  carefully  made,  and  is  sometimes  not  easy,  for 
the  scarlatinous  inflammation,  if  intense,  occasionally  becomes  gangrenous, 
so  as  to  present  an  appearance  resembling  that  of  a  pseudo-membrane.  The 
other  infectious  maladies  which  are  most  liable  to  the  diphtheritic  com- 
plication are  measles,  variola,  whooping  cough,  and  typhoid  fever,  the 
catarrhal  inflammation  of  these  diseases  changing  to  a  pseudo-membranous 
inflammation. 

It  is  an  interesting  and  important  fact  that  when  diphtheria  is  contracted 
by  a  person  having  inflammation  of  one  of  the  surfaces,  the  specific  inflam- 
mation with  the  pseudo-membrane  usually  occurs  upon  the  part  which  is 
already  inflamed.  A  catarrhal  inflammation,  however  produced,  is  liable 
under  the  influence  of  the  virus  to  become  diphtheritic  and  pseudo-mem- 
branous. Thus,  at  one  time  diphtheria  entered  the  eye  ward  of  the  New 
York  Foundling  Asylum,  and  three  children  who  were  under  treatment  for 
inflammation  of  the  eyelids  were  attacked  by  diphtheritic  conjunctivitis, 
exemplifying  the  remark  by  Billroth,  that  "  catarrhal  conjunctivitis,  which 
is  so  very  common,  may  become  diphtheritic."^  Catarrhal  inflammation 
from  abrasions,  burns,  wounds  however  produced,  are  liable  to  be  attacked 
by  the  diphtheritic  inflammation  and  become  covered  with  the  pseudo-mem- 
brane. In  Paris,  where  diphtheria  is  very  prevalent,  the  circumcised  prepuce 
has  so  often  become  the  seat  of  the  diphtheritic  exudate  that  the  distin- 
guished surgeon  Saint-Germain  considers  this  fact  a  strong  argument  in 
favor  of  stretching,  which  he  practises  instead  of  circumcision.  He  also 
for  the  same  reason  among  others  recommends  the  treatment  of  enlarged 
tonsils  by  galvano-cautery  instead  of  excision.  However,  in  one  instance  in 
which  I  was  employing  dilatation  of  the  prepuce,  and  in  which  the  mucous 
membrane  may  have  been  injured  by  the  operation,  a  severe  diphtheritic 
inflammation  set  in  on  the  following  day,  and  extended  from  the  tip  of  the 
prepuce  to  the  body,  with  intense  redness  and  swelling.  The  tonsils  at  the 
same  time  were  inflamed  and  covered  with  the  membranous  exudation. 
Although  severely  sick,  the  patient  recovered  in  a  few  days. 

This  general  fact  in  regard  to  the  nature  of  diphtheria  and  its  mode  of 
manifestation — to  wit,  that  in  one  afliected  by  it  the  diphtheritic  inflammations 
appear  by  preference  upon  such  surfaces  as  are  already  inflamed — has  an 
important  practical  bearing.  In  frequent  instances  during  epidemics  of  diph- 
theria inflammations  which  physicians  of  experience  believe  to  be  simple  or 
catarrhal,  and  have  diagnosticated  as  such  to  their  friends,  are  seen  in  a  few 
days  to  be  diphtheritic.  The  most  serious  error  of  this  kind,  if  it  be  one,  is 
to  diagnosticate  and  treat  diphtheritic  croup  as  a  simple  or  catarrhal  laryngitis 
until  the  increasing  dyspnoea  reveals  the  true  nature  of  the  disease.  This 
experience  always   places  the  physician  in  an  unfavorable  light.     But  is  it 

^  Encyc.  Pathol.,  translated,  p.  267. 


NATURE.  373 

not  probable  that  in  a  certain  proportion  of  such  cases  tlie  disease  was  at  first 
a  simple  catarrhal  inflammation,  and  that  it  became  diphtheritic  during  its 
progress,  just  as  scarlatinous  angina  or  rubeolous  laryngitis  becomes  a  diph- 
theritic inflammation   in  those  who  contract  diphtheria? 

The  frequent  occurrence  of  diphtheria  in  all  civilized  countries  during  the 
last  thirty  years,  and  the  great  mortality  which  attends  it,  have  awakened  an 
interest  in  this  malady  which  has  led  to  a  careful  study  of  its  causes  and 
nature.  At  first  these  inquiries  were  chiefly  clinical,  but  in  later  years  micro- 
scopic examinations  and  experiments  on  animals  have  furnished  important  aid 
in  elucidating  the  nature  of  the  disease.  The  importance  of  these  micro- 
scopic examinations  and  experiments  cannot  be  overestimated.  In  connection 
with  clinical  observations,  they  render  highly  probable  the  theory  which  has 
been  stated  above,  that  diphtheria  is  produced  by  micro-organisms,  which, 
coming  in  contact  with  the  mucous  membrane  or  the  cuticle  deprived  of  its 
epidermis,  adhere  to  it,  and,  multiplying  rapidly,  act  as  an  irritant  and  pro- 
duce the  characteristic  inflammation  ;  and  the  fact  that  since  antiseptic  treat- 
ment has  come  into  general  use  microbes,  in  at  least  many  instances,  have 
not  been  found  in  the  blood-vessels,  lymphatics,  or  internal  organs  in  those 
who  have  died  of  diphtheria,  has  led  to  the  belief,  as  we  have  already 
remarked  under  the  head  of  Etiology,  that  the  systemic  poisoning  occurs 
through  the  agency  of  chemical  products  or  ptomaines,  which,  produced  by 
microbic  action,  are  absorbed  into  the  system.  Whether  this  theory  be 
entirely  true  or  not  will  be  determined  by  future  investigations.  If  true, 
it  of  course  establishes  the  fact  that  diphtheria  is  primarily  a  local  disease. 
Whether  it  is  primarily  local  or  constitutional  has  been  and  is  still  much  dis- 
cussed. It  is  sufficient  for  the  wants  or  purposes  of  the  practising  physician 
to  be  assured  that  in  all  cases,  unless  of  the  mildest  type,  diphtheria,  if  not 
primarily  constitutional,  is  attended  by  systemic  blood-poisoning  very  early, 
even  on  the  first  day,  so  that  in  all  cases  of  average  severity  constitutional  as 
well  as  local  treatment  is  required.  The  following  facts  indicate  the  early 
blood-poisoning  in  diphtheria  : 

1.  It  is  a  law  in  pathology  that  those  diseases  which  have  or  may  have  a 
long  incubative  period — say  of  a  week  or  more — are  constitutional. 

2.  Another  fact  which  indicates  primary  blood-poisoning  in  diphtheria 
is  observed  in  certain  cases — namely,  the  occurrence  of  severe  constitution al 
symptoms  for  a  longer  or  shorter  time.,  perhaps  for  half  a  day.,  before  the 
appearance  of  the  usual  infamviation .  Thus,  a  girl  of  five  years,  having 
malignant  diphtheria,  whom  I  saw  in  consultation,  was  carefully  examined 
on  the  first  day  of  her  sickness  by  the  attending  physician,  and,  although 
he  closely  inspected  the  fauces,  there  was  no  appearance  which  indicated  the 
nature  of  the  malady  till  the  subsequent  day.  In  such  cases,  a  sufficient 
number  of  which  I  have  observed,  there  is  likely  to  be  complaint  of  soreness 
of  the  throat  or  difficulty  in  swallowing  almost  from  the  beginning  of  the 
general  symptoms,  but  the  pain  and  tenderness  seem  to  be  in  the  deeper  tis- 
sues of  the  neck. 

Again,  treatment  of  the  inflammations  by  the  most  reliable  and  efficient 
antiseptics  and  disinfectants  which  we  possess,  commenced  at  the  earliest 
possible  moment  and  repeated  at  short  intervals,  does  not  prevent  the  occur- 
rence of  indubitable  symptoms  of  blood-poisoning  in  cases  of  a  severe  type. 
Thus,  I  have  treated  every  portion  of  the  inflamed  surface,  so  far  as  it  was 
accessible,  every  second  or  third  hour  with  carbolic  acid  and  other  disinfect- 
ants almost  from  the  very  commencement  of  diphtheria,  and  so  thoroughly 
that  any  vegetable  or  animal  poison  with  which  the  remedies  had  come  in 
contact  would  probably  have  been  destroyed  or  rendered  inert,  and  yet,  except 
in  mild  cases,  symptoms  of  diphtheritic  blood-poisoning  have  occurred,  and 


374  DIPHTHERIA. 

as  early  and  uniformly  as  if  less  energetic  local  measures  had  been  employed. 
While,  therefore,  I  do  not  fail  to  recommend  local  treatment  as  calculated  to 
diminish  septic  poisoning  and  relieve  the  inflammations,  I  have  lost  con- 
fidence in  it  as  a  means  of  preventing  the  entrance  of  the  diphtheritic  poison 
into  the  blood.  Its  powerlessness  to  prevent  contamination  of  the  blood  by 
the  diphtheritic  virus  is  an  additional  evidence  that  this  contamination  occurs 
early. 

3.  The  quick  succumbing  of  the  system  in  certain  malignant  cases  is  evi- 
dently due  to  diphtheritic  toxaemia.  We  sometimes  observe  a  fatal  result  on 
the  second,  third,  or  fourth  day,  without  any  dyspnoea  or  sufficient  laryngitis 
to  compromise  life.  Cases  of  this  kind,  terminating  fatally  even  in  the  first 
day,  have  been  reported.  The  system  is  suddenly  overpowered  by  the  poison, 
struck  down,  as  it  were,  ~hy  the  profound  blood-change,  while  the  inflamma- 
tions are  still  in  their  incipiency. 

4.  Important  evidence  of  the  constitutional  nature  of  diphtheria  is  aflforded 
also  by  the  state  of  the  kidneys.  No  internal  organs  are  so  often  aff"ected  in 
diphtheria  as  the  kidneys,  and,  on  account  of  their  location  and  anatomical 
relation,  it  is  evident  that  the  poison  first  passes  through  the  system  before  it 
reaches  them.  Any  clinical  or  anatomical  fact,  therefore,  which  indicates 
that  the  diphtheritic  virus  has  reached  and  afiected  the  kidneys  affords  proof 
that  it  has  penetrated  the  system  and  poisoned  the  blood.  Now,  the  occur- 
rence of  albumen,  with  granular  or  hyaline  casts,  in  the  urine,  in  cases  unat- 
tended by  dyspnoea,  affords  proof  of  nephritis  caused  by  the  action  of  the 
poison  on  the  kidneys. 

Sir  John  Rose  Cormack  of  Paris,  in  a  series  of  interesting  and  useful 
papers  relating  to  diphtheria  published  in  the  Edinhurgh  Medical  Journal 
during  1876,  states  that  albuminuria,  and  of  course  the  nephritis  on  which 
it  depends,  sometimes  begin  as  early  as  the  first  day.  My  observations  con- 
firm this  statement,  as  in  the  following  cases : 

Case  1. — L.  McD ,  aged  three  years,  was  first  visited  by  me  on  February 

29,  1876.  I  learned  from  the  parents  that  she  had  been  feverish  during  the  pre- 
ceding forty-eight  hours  and  her  urine  very  scanty.  A  moment's  examination 
was  suflScient  to  show  that  the  case  was  one  of  malignant  diphtheria,  for  the  fauces 
were  already  nearly  covered  by  the  diphtheritic  pellicle ;  the  temperature  was 
103j°  F.,  and  the  pulse  140.  The  skin  was  hot  and  dry,  and  there  was  moderate 
swelling  under  the  ears  and  a  muco-purulent  discharge  from  the  nostrils.  On 
account  of  the  scantiness  of  the  urine,  the  amount  not  exceeding  f^iv-v  daily,  it 
was  impossible  to  obtain  sufficient  for  examination  till  the  following  day.  It  was 
then  found  to  have  a  specific  gravity  of  1032,  to  contain  a  deposit  of  urates  and 
hyaline  and  granular  casts,  a  diminished  amount  of  urea,  and  a  large  quantity  of 
albumen.  It  can  hardly  be  doubted,  from  the  scantiness  of  the  urine  and  the 
large  amount  of  albumen  found  when  the  urine  was  first  examined,  that  albu- 
minuria had  been  present  on  the  first  day. 

Case  2. — The  following  was  a  similar  case  :  K ,  aged  four  years,  living  in 

West  Thirty-sixth  street,  was  visited  by  me  in  consultation  on  January  29,  1875. 
Her  sickness  had  also  continued  forty-eight  hours  ;  her  fauces  were  swollen  and 
covered  with  the  diphtheritic  pellicle,  which  was  dark  and  offensive ;  respiration 
guttural ;  pulse  120 ;  temperature  101°  F.  ;  she  had  a  free  discharge  from  each 
nostril ;  urine  scanty,  its  specific  gravity  1030 ;  it  contained  a  small  amount  of 
albumen  with  casts,  aud  a  large  amount  of  urates,  with  no  apparent  diminution 
of  the  urea.     Death  occurred  on  the  fourth  day. 

In  such  severe  cases,  in  which  albumen  and  casts  are  found  in  the  urine 
at  the  first  visit  of  the  physician,  there  can  be  little  doubt  that  the  nephritis 
begins  nearly  or  quite  as  early  as  the  pharyngitis  ;  and  therefore,  since  poison- 
ing of  the  blood  must  antedate  the  renal  disease,  diphtheria  affects  the  system 
very  early,  probably  from  the  occurrence  of  the  first  symptoms. 


NATURE.  375 

Again,  there  are  cases,  though  nut  frequent — three  I  can  recall  to  mind 
during  the  last  two  years  in  my  practice — in  which  the  external  manifesta- 
tions of  diphtheria  are  very  mild,  even  insignificant,  and  quickly  cured,  but 
in  which  the  kidneys  are  early  and  severely  affected.  The  occurrence  of  such 
cases  is  best  explained  on  the  supposition  of  an  early  and  profound  blood- 
change.     The  following  are  histories  of  two  of  the  cases  alluded  to : 

The  house  229  West  Nineteenth  street,  New  York,  is  an  old  wooden  struc- 
ture, and  the  family  which  has  occupied  it  during  the  last  five  years  has  been 
three  times  visited  by  diphtheria,  the  first  case,  that  of  the  oldest  child, 
proving  fatal.  In  February,  187G,  one  of  the  children  had  diphtheria  in  a 
moderately  severe  form.  He  recovered,  and  after  my  visits  had  been  dis- 
continued his  sister,  aged  six  years,  who  had  had  scarlet  fever  when  eighteen 
months  old,  became  feverish  and  complained  of  her  throat.  No  rash  appeared 
on  her  skin,  and  there  was  apparently  no  coryza.  Inspection  of  the  fauces 
by  the  parents  revealed  a  small  diphtheritic  patch  over  each  tonsil.  Although 
diphtheria  was  so  frightful  a  malady  to  this  family  from  their  past  experience, 
the  case  seemed  so  mild  that  the  parents  treated  it  without  medical  attend- 
ance by  the  remedies  which  had  been  employed  for  the  boy.  A  mixture  of 
carbolic  acid,  subsulphate  of  iron,  and  glycerin  was  applied  to  the  fauces 
every  third  hour,  sufficiently  often,  apparently,  to  destroy  all  bacteria  or 
other  vegetable  or  animal  organisms  with  which  it  might  have  come  in  con- 
tact, and  within  two  or  three  days  the  inflammation  of  the  throat  seemed  to 
the  parents  to  be  cured.  Nevertheless,  with  this  insignificant  inflammation 
of  the  fauces,  so  quickly  subdued,  and  with  no  other  apparent  inflammation 
of  the  mucous  surfaces,  there  was  severe  internal  disease  going  on  as  the 
result  of  the  general  infection.  The  child  did  not  regain  her  former  appetite  ; 
she  had  increasing  pallor,  although  able  to  play  about  the  house ;  and  finally, 
in  the  the  third  week,  when  I  was  called  to  see  her,  slight  oedema  of  the  face 
and  limbs  was  observed.  Her  urine,  which  was  scanty,  was  found  to  contain 
pus  and  blood-corpuscles,  albumen,  and  granular  casts,  and  nearly  two  months 
elapsed  before,  under  treatment,  it  became  normal  and  her  health  was  restored. 

The  second  case  occurred  in  January,  1878,  in  West  Fifty-first  street.  A 
boy  aged  six  years,  in  a  family  where  diphtheria  was  occurring,  had  slight 
sore  throat,  which  abated  in  two  or  three  days.  It  was  attended  by  little  or 
no  exudation,  and  would  not  have  been  considered  diphtheritic  except  for  the 
circumstances  in  which  it  occurred  and  the  subsequent  history.  Still,  the 
boy  remained  ill  and  fretful,  and  four  days  subsequently  his  urine  was  found 
to  be  scanty  and  very  albuminous ;  and  three  days  later  death  occurred,  pre- 
ceded by  total  suppression  of  urine.  The  last  urine  passed,  which  was  not 
more  than  a  teaspoonful,  became  nearly  semi-solid  by  heat.  There  had  been 
no  scarlet  fever  in  the  family. 

Cases  like  the  above,  in  which  there  is  an  early  and  profound  systemic 
infection,  with  but  slight  evidence  of  lodgment  of  the  virus  upon  the  faucial 
or  other  exposed  surface,  are  interesting  as  showing  the  constitutional  nature 
of  the  malady,  even  when  the  symptoms  and  visible  lesions  have  extreme 
mildness.  Certain  clinical  observations,  therefore,  lend  support  to  the  theory 
that  diphtheria,  even  if  it  be  in  most  instances  local  at  first,  is  in  some  cases 
systemic  from  its  commencement,  and  seem  to  justify  the  remark  made  by 
Dr.  A.  Jacobi,  that  probably  in  some  instances  the  diphtheritic  virus  enters 
the  system  through  the  lungs — a  supposition  which  demands  consideration, 
notwithstanding  the  fact  that  many  pathologists  now  believe  that  the  specific 
germ  acts  only  upon  the  surface.  Whether  diphtheria  be  always  local  in 
its  commencement  or  sometimes  systemic,  it  answers  the  wants  of  the  prac- 


376  DIPHTHERIA. 

titioner  to  be  assured  that  in  cases  of  a  severe  type  diphtheria  is  systemic 
at  so  early  a  period  that  constitutional  remedies  are  required  at  the  first 
visit.  He  will  be  the  most  successful  practitioner  who  fully  recognizes  the 
fact  that  he  has  to  deal  with  a  malady  which  has  both  a  local  and  a  systemic 
character. 

Diagnosis. — It  is  very  important  that  the  diagnosis  of  a  case  of  diph- 
theria be  early  made,  so  that  proper  remedial  measures  may  be  employed  at 
the  beginning,  as  well  as  measures  designed  to  prevent  propagation.  In  a 
large  proportion  of  cases  the  diagnosis  is  easy  after  diphtheria  has  continued 
twenty-four  hours,  since,  in  addition  to  the  fever  and  pain  in  swallowing,  the 
characteristic  grayish-white  pellicle  has  begun  to  form  on  one  or  both  tonsils. 
Under  such  circumstances  the  nature  of  the  malady  is  apparent  on  inspecting 
the  fauces.  But  many  cases  are  not  so  quickly  and  readily  diagnosticated, 
even  by  experienced  physicians.  The  diagnosis  is  uncertain,  and  is  postponed 
until  two  or  more  days  have  elapsed.  One  reason  of  failure  to  diagnosticate 
early  is  the  fact  that  many  patients,  even  those  old  enough  to  express  their 
sensations,  do  not  complain  of  the  throat.  I  have  many  times  been  informed 
by  parents  or  nurses  that  there  was  no  need  of  examining  the  fauces,  as  there 
was  no  complaint  of  pain  in  the  throat,  and  yet  on  examination  have  observed 
unequivocal  evidence  of  diphtheria.  A  physician  practising  in  a  locality 
where  diphtheria  is  prevailing  should  at  his  first  visit  inspect  the  fauces  of  a 
child  to  whom  he  is  summoned,  especially  if  there  be  fever,  and  he  will  often 
discover  evidences  of  diphtheria  which  without  such  examination  would  not 
have  been  detected. 

When  diphtheria  has  continued  from  twelve  to  twenty-four  hours,  external 
examination  of  the  neck  usually  reveals  some  tenderness  as  well  as  fulness  in 
the  tonsillar  regions,  and  the  enlargement  of  the  tonsils  can  be  readily  detected 
on  palpation ;  but  in  some  instances  the  tenderness  and  swelling  are  so  slight 
as  to  be  scarcely  appreciable.  In  not  a  few  cases  it  is  impossible  to  make  a 
positive  diagnosis  until  the  disease  has  been  under  observation  some  days  and 
its  progress  and  character  have  been  carefully  noted,  the  difficulty  in  diagno- 
sis arising  from  the  fact  that  the  membranous  exudate  is  concealed  from  view. 
Thus,  in  nasal  diphtheria  the  pseudo-membrane  may  be  located  upon  the  supe- 
rior and  posterior  portions  of  the  Schneiderian  membrane,  and  therefore  be 
invisible,  while  the  anterior  and  visible  portions  of  the  nares  and  the  faucial 
surface  are  hyperaemic  and  secreting  muco-pus  in  abundance,  but  are  free 
from  the  pseudo-membranous  exudate.  The  pseudo-membrane  may,  and 
probably  will,  appear  upon  visible  parts  before  the  disease  terminates,  but 
not  early  enough  to  establish  a  diagnosis  in  the  first  days  of  the  sickness. 
Occasionally  in  the  milder  forms  of  pharyngeal  diphtheria  membranous 
patches  occur  in  the  depressions  of  the  faucial  surface,  and  are  not  visible 
on  cursory  inspection.  They  are  brought  into  view  when  the  patient  coughs 
or  by  firm  external  pressure  upon  the  side  of  the  neck,  which  elevates  the 
depressed  surfaces. 

In  laryngo-tracheal  diphtheria  diagnosis  is  not  infrequently  delayed  in  a 
similar  manner.  The  child,  without  known  exposure  to  the  diphtheritic  virus, 
becomes  hoarse,  and  the  hoarseness  with  fever  increases.  The  fauces  show  the 
characteristics  of  catarrhal  inflammation,  and  the  nostrils  are  not  aff'ected  or 
are  aff'ected  but  slightly.  The  diagnosis  between  catarrhal  croup,  non-specific 
membranous  croup,  and  diphtheritic  croup  is  uncertain.  The  patient  may 
die  without  any  visible  pseudo-membrane  unless  the  laryngoscope  be  used, 
and  without  a  diagnosis  except  the  general  one  of  croup.  The  occurrence  of 
albuminuria  with  casts  may  enable  us  to  make  the  probable  diagnosis  of  diph- 
theria, and  this  opinion  may  be  confirmed  by  the  contemporaneous  or  subse- 
quent occurrence  of  diphtheria  in  other  members  of  the  family  ;  but  in  other 


DIAGNOSIS.  377 

instances  no  such  aid  is  obtained,  and  the  nature  of  the  attack  continues  to 
be  a  matter  of"  probability  only.  Such  are  some  of  the  hindrances  in  the 
way  of  accurate  diaj^nosis. 

The  following  is  a  rt'sunii'  of  the  characteristics  of  the  white,  grayish,  or 
grayish-white  products  of  disease  which  occur  on  the  faucial  surface  and  which 
are  liable  to  be  mistaken  ibr  the  pseudo-membrane  of  diphtheria.  Let  us  first 
consider  the  characteristics  of  the  diphtheritic  exudate.  It  is  deeply  set  in 
the  mucous  membrane,  penetrating  it  and  being  incorporated  with  it.  It 
consists  of  necrosed  mucous  tissue  and  firm  fibrinous  material  exuded  from 
the  minute  vessels,  and  it  cannot  be  detached  from  the  faucial  surface,  except 
at  an  advanced  stage  of  the  disease,  without  producing  hemorrhage.  It  is 
surrounded  by  inflamed  and  swollen  mucous  membrane  as  the  crystal  of  a 
watch  is  surrounded  by  the  rim.  Compare  these  characteristics  of  the  diph- 
theritic pseudo-membrane  with  the  products  of  other  and  distinct  diseases  of 
the  pharynx.  First,  follicular  tonsillitis.  This  is  a  common  disease.  In 
New  York,  and  probably  elsewhere,  it  frequently  extends  through  families  as- 
if  contagious,  all  or  most  of  the  children  being  affected  by  it.  It  is  attended 
by  fever  and  dysphagia.  It  has  no  marked  premonitory  symptoms,  unless  of 
very  brief  duration,  and  commences  suddenly,  like  diphtheria,  with  headache^ 
chilliness,  heat  of  surface,  the  temperature  often  rising  to  103°  F.,  languor^ 
and  frequently  pain  in  the  back  and  extremities.  The  dysphagia  attract.^ 
attention  to  the  fauces,  the  surface  of  which  is  seen  to  be  hyperaemic,  espe- 
cially its  tonsillar  portion.  In  a  few  hours  a  whitish  material  exudes  from 
the  crypts  of  the  tonsils,  consisting  of  the  secretion  of  the  crypts  and  epi- 
thelial cells,  and  forming  rounded  masses  of  the  size  of  a  small  pin's  head. 
The  secretion,  occurring  as  small,  rounded,  salient  masses  distinct  from  one 
another,  is  distinguished  by  its  appearance  from  the  diphtheritic  pseudo-mem- 
brane, which  at  first  is  a  thin,  pellucid  film,  becoming  thicker  subsequently. 
Consisting  simply  of  epithelial  cells  held  together  by  the  secretion,  these 
small  rounded  masses  are  quickly  detached  by  the  swab  or  brush,  when  they 
are  found  to  be  friable,  readily  crushed  between  the  thumb  and  fingers,  and 
having  a  fetid  odor.  If  two  or  more  of  them  happen  to  unite,  forming  an 
appearance  like  that  of  the  diphtheritic  membrane,  they  still  present  the 
same  physical  characters,  and  are  readily  detached  from  the  tonsillar  surface 
without  hemorrhage.  This  peculiar  secretion  of  follicular  tonsillitis  is  usu- 
ally limited  to  the  tonsillar  portion  of  the  pharynx,  and  is  of  short  duration,, 
ceasing  to  appear  after  two  or  three  days.  The  inflammation  abates  soon. 
In  a  large  number  of  cases  which  I  have  observed  the  clinical  history  of 
this  disease  has  been  as  mentioned  above,  except  in  one  instance,  when  death 
occurred  apparently  from  a  sudden  extension  of  the  inflammation  to  the  larynx 
and  the  occurrence  of  oedema  glottidis.  The  diagnosis  of  follicular  tonsillitis 
from  diphtheria  is  easily  made,  except  as  regards  the  mildest  form  of  diphtheria. 

Pultaceous  Pharyngitis. — This  form  of  pharyngitis  usually  occurs  in  low 
or  debilitated  states  of  the  system.  It  occurs  most  frequently  in  the  old 
and  feeble  and  in  such  exhausting  diseases  as  scarlatina  and  typhoid  fever. 
As  the  term  "  pultaceous  "  indicates,  the  inflammatory  product  is  soft  and 
friable,  coming  away  in  fragments  when  touched  by  the  brush  or  sponge, 
without  bleeding  or  any  injury  to  the  mucous  membrane.  Under  the  micro- 
scope it  is  found  to  consist  of  epithelial  cells,  often  in  fragments,  nuclei  and 
nucleoli,  but  no  fibrin.  When  this  substance  is  removed,  as  it  readily  can 
be,  the  mucous  membrane  underneath  is  entire,  hyperfemic,  and  covered  by 
a  newly-formed  epithelial  layer.  The  appearance  of  the  pultaceous  product 
to  the  naked  eye  may  closely  resemble  that  in  diphtheria,  but  its  friable  cha- 
racter, its  epithelial  nature,  and  the  absence  of  fibrin  which  the  microscope 
reveals  render  the  diagnosis  certain. 


378  DIPHTHERIA. 

Scarlatinous  Pharyvgitis. — The  frequency  of  scarlet  fever  and  diphtheria, 
and  the  facts  that  epidemics  of  the  two  are  not  uncommon  at  the  same  time, 
and  that  diphtheria  often  attacks  a  scarlatinous  patient,  render  important 
the  differentiation  of  scarlatinous  pharyngitis  from  diphtheritic  pharyngitis 
supervening  upon  and  complicating  the  scarlatinous.  Very  commonly,  when 
the  pharyngitis  of  scarlet  fever  is  severe,  an  abundant  desquamation  of 
epithelial  cells  occurs,  which,  aggregating,  produce  the  pultaceous  pseudo- 
membrane  described  above.  This  membrane  resembles  the  diphtheritic  in 
appearance,  but  its  anatomical  character,  consisting  as  it  does  of  epithelial 
cells  as  stated  above,  suffices  to  show  that  it  is  not  a  diphtheritic  exudate. 
The  grayish-white  or  brown  product  of  scarlatinal  inflammation  seldom 
appears  upon  other  parts  than  the  tonsillar  or  lateral  pharyngeal  surfaces, 
whereas  the  diphtheritic  membrane  often  appears  upon  the  uvula,  upon  the 
posterior  faucial  surface,  and  in  the  nares,  in  addition  to  the  tonsillar  surface. 

Gangrenous  Pharyngitis. — This  variety  of  pharyngitis  occurs  oftener  in 
connection  with  scarlet  fever  than  with  any  other  malady  unless  diphtheria, 
and  when  it  complicates  scarlet  fever  the  appearance  resembles  very  closely 
that  in  advanced  cases  of  malignant  diphtheria.  The  diagnosis  is  not  dif- 
ficult if  the  case  be  observed  from  the  beginning.  The  diphtheritic  pseudo- 
membrane  is  in  the  commencement  white  or  grayish-white.  It  presents  the 
dark-gray  color  of  gangrene  only  at  an  advanced  stage  by  imbibition  of 
blood  and  commencing  disintegration.  Gangrenous  sore  throat  is  from  the 
first  of  a  dark -gray,  brownish,  or  even  dark  color.  Gangrene  produces  a  fetid 
breath ;  malignant  diphtheria  does  not  produce  fetor  to  such  an  extent  until 
decomposition  begins  or  gangrene  supervenes.  Gangrene  not  infrequently 
complicates  the  later  stages  of  severe  diphtheria. 

Herpetic  Pharyngitis — No  one  can  mistake  herpes  of  the  fauces  in  its 
commencement  for  diphtheria,  the  minute  vesicles  of  the  former  disease  are 
so  unlike  the  diphtheritic  exudate.  But  when  the  vesicles  have  disappeared 
and  are  replaced  by  minute  ulcerations,  covered  by  a  white  and  adherent 
exudate,  the  differentiation  of  herpes  from  benign  diphtheria  is  not  easy. 
The  presence  of  herpes  labialis  affords  presumptive  evidence  that  the  pharyn- 
gitis is  herpetic,  but  not  conclusive,  for  it  is  sometimes  also  present  in  diph- 
theria. Immediately  after  the  disappearance  of  the  vesicles  small  rounded 
concretions  distinct  from  one  another  occupy  their  place,  presenting  an 
appearance  entirely  unlike  that  of  diphtheria,  which  exhibits  at  first  a  film, 
soon  becoming  a  thick  and  firm  patch.  It  is  when  the  concretions  unite, 
forming  a  patch,  that  the  diagnosis  is  difficult.  I  need  not  state  that  herpetic 
pharyngitis,  like  follicular  tonsillitis,  is  often  mistaken  for  benign  diphtheria, 
and  vice  versa. 

Ulcero-memhranous  Pharyngitis. — This  is  an  extension  of  ulcero-mem- 
branous  stomatitis.  It  is  characterized  by  a  necrosis,  limited  in  extent  and 
superficial,  of  the  mucous  membrane.  The  presence  of  ulcero-membranous 
stomatitis  as  the  important  part  of  the  disease,  predominating  over  the 
pharyngeal  affection,  aids  to  a  correct  diagnosis.  Constitutional  symptoms 
are  slight  or  are  wanting  in  this  form  of  pharyngitis.  Fever,  albuminuria, 
and  glandular  swellings,  which  characterize  diphtheritic  pharyngitis,  are 
absent  or  insignificant.  The  sphacelus  over  the  tonsils,  unlike  that  in  diph- 
theria, is  in  patches  isolated  from  one  another.  The  microscope  reveals 
epithelial  cells  and  bands  of  elastic  fibres  pertaining  to  the  chorion  as  the 
elements  in  the  necrosed  tissue. 

Anatomical  Characters. — The  characteristic  and  diagnostic  feature  of 
diphtheria  is  the  formation  upon  one  of  the  mucous  surfaces,  usually  the 
fauces,  or  upon  the  skin  denuded  of  its  cuticle,  of  a  whitish  or  grayish-white 
pseudo-membrane.     This  membrane,  occurring  upon  mucous  surfaces  lined 


ANATOMICAL   CHARACTERS.  371> 

by  pavement  epithelium,  penetrates  and  is  incorporated  with  the  mucous 
membrane,  which  undergoes  necrosis.  The  mucous '  membrane  when  the 
pseudo-membrane  is  fully  formed  loses  its  vitality  and  becomes  a  part  of 
the  pseudo-membranous  mass.  It  cannot,  therefore,  be  detached  without 
tearing  the  fibres  of  connective  tissue  and  the  vessels  which  unite  the  mucous 
membrane  to  the  submucous  tissues,  until  such  time  as  it  becomes  detached 
by  the  sloughing  process.  Upon  such  mucous  surfaces  as  are  lined  by 
columnar  epithelium  the  pseudo-membrane  does  not  form  an  integral  con- 
nection with  the  mucous  membrane,  but  lies  over  it  or  lines  it,  so  that  it  can 
be  removed  without  injuring  it.  This  form  of  pseudo-membrane  occurs 
upon  the  respiratory  tract  below  the  superior  vocal  cord.  Above  this  cord 
squamous  epithelium  lines  the  larynx,  except  in  front,  where  columnar 
epithelium  occurs  as  high  as  the  middle  of  the  epiglottis.  If  croup  occur 
during  the  course  of  diphtheria,  and  a  pseudo-membrane  form  upon  the 
laryngo-tracheal  surface  in  addition  to  that  already  existing  upon  the  faucial 
surface,  the  patient  has  both  forms  of  pseudo-membrane  described  above. 
Moreover,  in  the  vicinity  of  these  pseudo-membranous  inflammations,  and 
extending  from  them,  we  ordinarily  find  a  catarrhal  inflammation  of  greater 
or  less  extent — an  inflammation  characterized  by  redness  and  swelling  of  the 
mucous  surfaces  and  a  muco-purulent  secretion,  but  without  the  false  mem- 
brane. Sometimes  also,  when  diphtheria  is  occurring  in  a  family,  one  of  the 
children  has  a  simple  catarrhal  inflammation  of  the  fauces  of  a  few  days' 
continuance.  If  he  have  a  pseudo-membrane  upon  any  of  the  surfaces,  it  is 
not  visible.  These  three  forms  of  inflammation — that  in  which  the  mucous 
membrane  undergoing  necrosis  becomes  incorporated  with,  and  forms  an 
integral  part  of,  the  pseudo-membrane ;  that  in  which  the  pseudo-membrane 
covers  the  mucous  membrane,  but  is  anatomically  distinct  from  it ;  and  that 
in  which  no  pseudo-membrane  occurs,  the  catarrhal — we  are  in  the  habit  of 
designating  by  the  term  diphtheritic,  inasmuch  as  they  occur  from  the  irri- 
tating action  of  the  diphtheritic  poison.  Unfortunately,  the  most  renowned 
living  pathologist,  Virchow,  restricts  the  use  of  the  term  diphtheritic  to  that 
form  of  inflammation  in  which  mucous  membrane  undergoing  necrosis  forms 
part  of  the  pseudo-membrane,  while  he  does  not  apply  the  term  diphtheritic, 
but  the  term  croupous,  to  that  form  of  inflammation,  although  occurring  in 
a  diphtheritic  patient,  in  which  the  pseudo-membrane  lies  upon  the  mucous 
surface.  This  explanation  seems  to  be  necessary  in  order  to  avoid  confusion 
in  the  use  of  the  terms  diphtheritic  and  croupous  as  employed  by  the  school 
of  Virchow. 

Soon  after  diphtheria  commences,  as  manifested  by  fever  and  the  concom- 
itant symptoms,  we  observe  redness  upon  one  of  the  surfaces  which  is  to  be 
the  chief  seat  of  the  local  manifestation  of  the  disease.  When  the  malady 
is  contracted  in  the  usual  manner,  this  local  manifestation  is  ordinarily  upon 
the  faucial  surface  and  primarily  upon  the  tonsillar  portion.  If  there  be  a 
pre-existing  inflammation  of  one  of  the  other  mucous  surfaces,  or  a  portion 
of  the  cuticle  denuded  of  its  epidermis  and  inflamed,  the  specific  inflamma- 
tion is  likely  to  appear  primarily  upon  this  part,  as  we  have  stated  above, 
with  or  without  its  simultaneous  appearance  upon  the  faucial  surface. 

The  inflammation  varies  greatly  in  severity  and  extent.  In  a  mild  attack 
it  is  often  limited  to  a  part  of  the  fauces,  and  there  are  few  exceptions  to  the 
rule  that  the  tonsillar  portion  is  afi'ected,  the  redness  gradually  fading  away 
in  the  healthy  membrane  beyond.  But  in  the  course  of  a  few  hours,  in  all 
except  the  mildest  cases,  the  entire  faucial  surface  presents  the  character- 
istic inflammatory  redness  and  swelling  and  its  follicles  are  tumefied  and 
actively  secreting.  In  severe  cases  the  uvula  is  elongated  and  enlarged  from 
infiltration,  and  the  inflammation  even  extends  to  the  submucous  connective 


380  DIPHTHERIA. 

tissue,  which  becomes  hyperaemic  and  swollen,  and  the  submucous  lymphatic 
glands,  especially  the  tonsils,  also  swell  and  are  painful.  The  color  of  the 
inflamed  surface  is  sometimes  a  deep  bright  red,  almost  like  arterial  blood ; 
in  other  cases  it  is  a  dusky  red,  which  indicates,  if  there  be  no  croupal  symp- 
toms, an  adynamic  and  dangerous  type  of  the  disease.  The  dusky-red  hue  is 
more  common  in  secondary  than  in  primary  diphtheria. 

Within  a  day,  and  usually  within  a  few  hours,  from  the  commencement 
of  the  inflammation  a  small,  slightly-raised,  whitish  or  grayish  spot  or  patch 
is  observed,  usually  upon  the  tonsillar  portion  of  the  inflamed  surface — very 
significant  as  a  diagnostic  sign  and  as  a  forerunner  of  what  is  to  happen. 
This  patch,  termed  the  pseudo-membrane,  gradually  becomes  firmer,  and  at 
the  same  time  thicker  and  broader  from  fresh  exudations  underneath.  It 
retains  for  a  time  its  grayish-white  color,  but  it  becomes  brownish  white  from 
age.  In  mild  cases  the  pseudo-membrane  is  usually  limited  to  the  tonsillar 
surface,  but  in  severe  cases  it  covers  the  uvula,  portions  of  the  velum,  the 
isthmus,  and  the  walls  of  the  pharynx,  both  lateral  and  posterior.  It  does 
not  ordinarily  attain  a  greater  thickness  than  one-eighth  to  one-sixth  of  an 
inch.     I  have  seen  it,  however,  not  far  from  one-third  of  an  inch  thick. 

Briefly  stated,  the  pseudo-membrane  of  diphtheria  is  found  to  consist  of 
fibrin,  forming  a  delicate  interlacing  network,  epithelial  cells  more  or  less 
altered  by  the  inflammatory  process,  leucocytes,  nuclei,  mucus,  and  amor- 
phous matter.  It  also  contains,  as  has  been  remarked  above,  different  species 
of  bacteria,  of  which  the  micrococci  are  most  abundant.  The  significance 
of  the  bacteria  is  fully  dwelt  upon  elsewhere  in  this  article.  The  same 
pseudo-membrane  is  often  firmer  in  one  part  than  in  another,  the  outer  and 
central  portions  being  more  compact  and  tough  for  a  time  than  that  under- 
neath, which  is  more  recent.  After  a  few  days,  however,  decomposition 
begins,  and  then  that  which  was  first  formed  becomes  softer  than  the  more 
recent  production.  When  this  occurs,  the  color  of  the  exudation  changes  to 
a  dirty  brown,  and  its  exposed  surface  is  uneven  and  jagged  from  the  partial 
separation  of  shreds  and  fibres.  Sometimes  the  diphtheritic  patch  has  a  red- 
dish tinge,  due  to  rupture  of  the  capillaries  and  escape  of  blood-corpuscles. 
Its  lower  or  attached  surface  may  be  blood-stained,  while  the  exposed  surface 
has  the  usual  grayish-white  hue. 

The  inflamed  mucous  membrane  is  not  only  hypersemic  and  infiltrated  with 
serum,  but  it  also  contains  numerous  round  white  corpuscles  (leucocytes), 
which  may  result  in  part  from  proliferation  of  connective-tissue  corpuscles,  but 
are  believed  by  most  pathologists,  since  Cohnheim's  well-known  discovery,  to 
be  in  great  pai't  wandering  white  corpuscles  of  the  blood  which  have  escaped 
through  the  walls  of  the  blood-vessels  along  with  the  fibrin.  In  the  com- 
mencement of  the  diphtheritic  inflammation,  before  the  pseudo-membrane 
forms,  we  often  observe  a  grayish  tinge  of  the  mucous  surface,  which  is  due 
to  the  crowding  of  the  cellular  elements  in  and  underneath  the  mucous  mem- 
brane ;  for  these  newly-formed  cells  not  only  infiltrate  the  mucous  membrane, 
but  can  also  be  traced  into  the  submucous  connective  tissue.  Even  where 
the  inflammation  remains  catarrhal,  as  it  does  over  certain  areas  in  all  cases 
of  diphtheria,  this  infiltration  of  the  mucous  and  submucous  tissues  with 
cells  is  common. 

During  the  active  period  of  diphtheria  it  is  often  astonishing  to  see  with 
what  rapidity  the  pseudo-membrane  returns  when  removed  by  force.  A  few 
hours  sufiice  to  restore  it  as  firm  and  extensive  as  before  the  interference. 
In  the  most  favorable  cases  the  membrane  is  detached  in  a  few  days,  and 
is  not  reproduced.  Its  separation  is  promoted  by  the  secretions  underneath, 
especially  by  pus,  which  is  secreted  in  abundance  between  it  and  the  tissues 
underneath,  which  have  preserved  their  integrity.     In  most  instances  it  does 


ANATOMICAL   CHARACTERS.  381 

not  separate  in  mass,  but  disappears  by  progressive  liquefaction.  Occasion- 
ally, even  in  cases  which  do  not  present  a  severe  type,  the  diphtheritic 
patch  does  not  disappear  until  the  lapse  of  four  or  five  or  even  six  vreeks, 
or  if  it  softens  and  is  detached  another  appears  in  its  place.  In  these 
instances  of  an  unusual  prolongation  diphtheria  has  been  designated 
chronic. 

8uch  are  the  appearances,  character,  and  history  of  the  pseudo-membrane 
in  this  malady.  Although  its  common  seat  is  upon  the  fauces,  and  in  mild 
cases  it  is  limited  to  them,  nevertheless  all  the  mucous  surfaces  are  liable  to 
be  attacked  by  the  inflammation  in  consequence  of  infection  of  the  blood, 
and  therefore  in  severe  cases,  and  even  in  cases  of  moderate  severity,  we  often 
find  the  product  elsewhere  as  well  as  upon  the  fauces,  and  in  localities  where 
from  its  mechanical  effect  it  greatly  increases  the  danger  and  even  compro- 
mises life.  The  mucous  membrane  of  the  nostrils,  mouth,  larynx,  trachea, 
bronchial  tubes.  Eustachian  tube,  conjunctiva,  oesophagus,  stomach,  intestines, 
vagina,  prepuce,  and  even  the  delicate  lining  membrane  of  the  middle  ear,  are 
at  times  the  seat  of  diphtheritic  inflammation  with  the  characteristic  product. 
In  a  case  which  occurred  in  the  Nursery  and  Child's  Hospital  of  New  York 
the  surface  of  the  stomach  was  almost  completely  lined  by  the  diphtheritic 
formation,  so  as  apparently  to  abolish  the  function  of  this  important  organ. 
The  occurrence  of  the  pseudo-membrane  in  the  nares  is  common,  and  is 
attended  by  the  discharge  from  the  nose  of  thin  mucus  and  pus.  Nasal 
diphtheria  involves  great  danger,  from  the  fact  that  it  is  likely  to  give  rise 
to  systemic  infection  of  a  grave  type.  In  the  nursing  infant  it  is  also  dan- 
gerous, since  by  its  mechanical  effect  it  interferes  with  lactation.  The  thin, 
irritating  discharge  pi'oduces  excoriations  around  the  nostrils  and  upon  the 
upper  lip.  I  have  met  only  one  case  of  diphtheritic  inflammation  of  the 
intestines  in  which  the  diagnosis  was  certain.  A  physician  in  whose  family 
diphtheria  was  occurring  became  seriously  sick  with  symptoms  which  closely 
resembled  those  of  typhoid  fever.  After  a  long  sickness  he  expelled  per 
rectum  about  one  foot  of  pseudo-membrane  of  a  cylindrical  form,  evidently 
derived  from  the  surface  of  the  intestines.  In  the  subsequent  months  the 
patient  suflTered  from  constipation  and  severe  abdominal  pains,  apparently  due 
to  contraction  in  healing  of  the  large  intestinal  ulcer.  Death  finally  occurred 
from  this  state  of  the  intestines.  The  formation  of  the  diphtheritic  pellicle 
upon  the  vulva  and  vaginal  walls  is  not  infrequent,  and  in  parturient  women 
exposed  to  diphtheria  it  sometimes  occurs  upon  the  uterine  walls,  usually 
with  a  fatal  result.  A  considerable  number  of  cases  are  on  record  in  which 
diphtheritic  inflammation  occurred  upon  the  prepuce  after  circumcision,  pro- 
ducing the  usual  pseudo-membrane,  and  in  one  instance  in  my  practice, 
referred  to  above,  it  attacked  the  prepuce  the  day  after  I  had  dilated  it  with 
an  instrument  clean  and  free  from  infection. 

In  mild  cases  of  diphtheria,  in  which  the  pellicle  is  small,  superficial,  and 
limited  to  the  fauces,  systemic  infection  is  usually  slight ;  and  it  is  the 
belief  of  many  that  the  disease  when  of  this  mild  type  not  infrequently 
remains  local.  But  in  grave  cases,  in  which  the  diphtheritic  pellicle  is 
extensive  and  deeply  imbedded,  systemic  infection  commonly  results,  not- 
withstanding the  efficient  local  antiseptic  treatment.  The  lymphatics  and 
blood-vessels  which  are  in  immediate  relation  with  the  under  surface  of  the 
pseudo-membrane  take  up  poisonous  ptomaines.  Septic  blood-poisoning  is 
likely  to  occur  in  those  cases  in  which  the  pseudo-membrane  has  become  dark- 
gray  and  friable  from  decomposition,  producing  an  ichorous  discharge  and 
offensive  breath. 

The  Blood. — The  blood  in  cases  of  a  severe  type  is  usually  darker  than 
in  health  and  the  clots  soft.     x\fter  death  from  diphtheritic  croup  it  is  also 


382  DIPHTHERIA. 

dark  from  the  excess  of  carbonic  acid  in  it.  The  chemical  changes  which  the 
blood  undergoes  in  diphtheria  are  partially  known.  MM.  Andral  and  Gavarret 
found  a  notable  diminution  of  fibrin  in  grave  infectious  diseases,  as  typhoid 
fever,  puerperal  fever,  etc.,  and  it  is  not  improbable  that  the  same  is  true  of 
diphtheritic  blood,  although  the  exudation  of  fibrin  is  so  abundant.  M. 
Bouchut  and  others  have  noted  an  excess  of  the  white  corpuscles  in  the 
blood  in  diphtheritic  patients,  so  that,  instead  of  three  or  four  in  the  field  of 
the  microscope,  as  many  as  sixty  have  been  counted.  M.  Sanne  writes  of 
diphtheria  :  "  It  is  necessary  to  recognize  in  the  dark-brown  blood  an  abnor- 
mal accumulation  of  the  debris  of  the  red  corpuscles,  debris  of  little  abun- 
dance in  the  normal  state,  augmented  considerably  under  the  noxious 
influence  of  the  diphtheritic  poison,  which  has  rapidly  produced  destruction 
of  a  great  number  of  globules."'  Small  extravasations  of  blood  in  the 
various  organs  are  among  the  most  constant  lesions.  They  have  been  most 
frequently  observed  in  the  brain  and  its  meninges,  the  lungs,  spleen,  and 
kidneys.  In  one  case  which  I  examined  after  death  in  the  New  York  Found- 
ling Asylum  the  extravasations  in  and  under  the  gastric  mucous  membrane 
produced  mottling  as  great  as  that  of  the  skin  in  measles. 

The  most  minute  examinations  of  the  organs  in  diphtheria  yet  published 
are  those  recently  made  by  Oertel,  and  we  will  present  a  summary  of  them  in 
the  following  pages. 

Brain  and  Spinal  Cord. — The  anatomical  changes  occurring  in  these  organs 
are  in  a  measure  described  in  our  remarks  on  diphtheritic  paralysis.  Oertel 
discovered,  as  the  earliest  anatomical  change  in  the  brain  and  spinal  cord  as 
well  as  in  the  membranes,  a  venous  hyperaemia,  with  small  extravasations  of 
blood,  "  not  larger  than  a  pea,"  in  the  white  medullary  matter  of  the  brain, 
while  in  the  cortical  layer  and  in  the  central  parts  no  extravasation  was 
found.  In  the  most  severe  forms  of  the  disease  small  hemorrhages  not 
larger  than  a  pea  were  found  not  only  in  the  cerebral  meninges,  but  also 
in  various  parts  of  the  brain.  These  produced  some  softening  in  their  imme- 
diate neighborhood.  These  small  hemorrhages  have  been  found  also  in  or 
upon  the  medulla  oblongata  and  spinal  cord,  but  with  less  softening.  Buhl,, 
in  addition  to  the  extravasations  in  and  upon  the  brain  and  spinal  cord,  dis- 
covered in  one  case  great  enlargement  of  the  anterior  and  posterior  roots  and 
the  ganglionary  swellings  of  the  spinal  nerves.  The  swelling  was  found  ta 
be  due  to  the  accumulation  of  cells  and  nuclei  in  the  sheaths  of  the  nerves 
and  to  extravasations  of  blood.  These  anatomical  changes  were  most  marked 
at  the  roots  of  the  lumbar  nerves.  (For  further  particulars  relating  to  the 
pathology  of  the  nervous  system  in  diphtheria  the  reader  is  referred  to  our 
remarks  on  Paralysis.) 

Tonsils. — Covering  these  organs  is  the  pseudo-membrane,  consisting  of 
the  usual  fibrillar  meshwork,  enclosing  leucocytes,  changed  epithelial  cells,. 
and  amorphous  matter :  the  older  the  exudation  the  coarser  is  the  network. 
The  adenoid  tissue  and  the  septa  have  undergone  hyperplasia.  The  follicles, 
are  crowded  with  cells  which  have  undergone  necrobiosis.  As  a  result  of  the 
necrobiosis  masses  are  formed  of  various  shapes  and  sizes,  staining  deeply. 
In  consequence  of  the  necrobiosis  and  degenerative  changes  the  follicles; 
become  a  hyaline  network  infiltrated  with  leucocytes  and  granules.  In 
advanced  cases  the  adenoid  and  connective  tissues  undergo  a  similar  necro- 
biotic  change,  and  are  so  blended  with  the  pseudo-membrane  that  it  is  difii- 
cult  to  determine  where  the  latter  ends  and  the  tonsillar  tissue  begins.  The 
vessels  of  the  tonsils  undergo  a  hyaline  thickening  of  their  walls,  and  if  this 
occur  chiefiy  in  the  intima  total  occlusion  may  result.  In  the  tissues  imme- 
diately surrounding  the  tonsils  hyaline  degeneration  of  the  muscular  fibres 

1  Traite  de  la  Diphtherie,  p.  107,  Paris,  1877. 


ANAT03IICAL  CHARACTERS.  383 

occurs  (Zenker's  degeneration),  and  the  connective  tissue  between  the  mus- 
cular fibres  is  infiltrated  with  leucocytes. 

Faucial  Surface  and    Uvula. — These  parts  are  often   also  covered  with 
pseudo-membrane,  and  are  more  or  less  changed  by  the  application  of  reme- 
dies.    The  line  of  separation  of  the  exudate  and  underlying  tissues  cannot 
be  readily  distinguished.   .  The  upper  portion  of  the  diphtheritic  pellicle  i? 
filled  with   bacteria  and  with  leucocytes  and  other  cells  which  have  under 
gone   necrobiosis.       In   the   mucosa   next   to   the   pseudo-membrane   hyalin( 
degeneration  of  the  connective  tissue  occurs,  and  the  mucosa  is  infiltrate( 
with  cells  which  have  undergone  marked  changes.     The  nuclei  of  the  con 
nective-tissue  cells  exhibit  various  stages  of  degeneration  and  decay,  though 
the  cells  may  retain  their  form.     The  deeper  layers  of  the  mucosa,  like  the 
upper,  are  infiltrated   with  leucocytes. 

The  iwula  in  severe  cases  is  usually  swollen  and  oedematous,  and  some- 
times entirely  covered  by  the  diphtheritic  pellicle.  When  the  uvula  is 
involved  in  the  general  faucial  inflammation,  necrobiosis  of  the  cells  and 
nuclei  occurs  in  every  part  of  it.  The  cells  in  the  arterial  adventitia  and 
in  the  perivascular  tissue  exhibit  necrobiotic  change,  their  nuclei  being  dis- 
integrated. In  the  uvula,  also,  hyaline  degeneration  occurs  in  the  walls  of 
the  vessels. 

Epiglottis. — The  epithelial  cells  covering  the  epiglottis  undergo  marked 
proliferation  early  in  the  disease,  and  are  infiltrated  with  leucocytes.  They 
soon  begin  to  undergo  degeneration,  forming  granular  masses.  Areas  of 
necrobiosis  occur,  and  finally  hyaline  degeneration  of  the  network  takes  place. 
The  leucocytes  extend  deeply  into  the  mucous  membrane,  followed  by  degen- 
erative and  necrobiotic  changes.  In  places  the  epithelium  is  thrown  oif,  and 
a  pseudo-membrane  forms  of  exuded  fibrin  and  necrobiotic  leucocytes  and 
epithelium.  Bacteria,  along  with  leucocytes  and  degenerated  epithelial  cells, 
occupy  the  meshes  of  the  pseudo-membrane. 

Lungs. — The  anatomical  characters  of  the  air-passages  are  fully  treated  of 
in  the  article  on  Diphtheritic  Croup.  Catarrhal  bronchitis  is  common  in  diph- 
theria. It  is  not  often  absent  in  croup,  and  one  of  the  chief  sources  of  danger 
in  this  disease  is  the  extension  of  pseudo-membrane  from  the  laryngo-tracheal 
surface  to  the  bronchial,  and  the  transformation  of  the  catarrhal  into  a  ci'oup- 
ous  inflammation.  When  bronchitis  occurs  the  inflammation  creeps  down- 
ward gradually  from  the  laryngo-tracheal  surface,  and  its  severity  is  propor- 
tionate to  the  degree  of  extension.  When  there  is  a  general  bronchitis  and 
it  is  very  liable  to  become  croupous,  the  muco-purulent  exudation  is  abun- 
dant. When  pseudo-membranous  bronchitis  occurs,  there  are  usually  portions 
of  the  bronchial  tree  in  which  the  inflammation  remains  catarrhal.  One  of 
the  chief  sources  of  danger  in  diphtheritic  croup  is  the  extension  of  the 
inflammation  to  the  bronchial  tubes  and  the  abundant  secretion  of  muco-pus, 
which  clogs  the  tubes  and  prevents  proper  decarbonization  of  the  blood. 
When  the  bronchitis  becomes  croupous,  a  thin,  easily-detached  film  appears 
upon  the  intensely-red,  hypersemic,  and  swollen  bronchial  surface.  It  increases 
in  thickness  and  firmness  and  assumes  a  dull  white  color.  Still  later  it  becomes 
thicker,  firmer,  and  of  a  brownish-gray  color.  Whatever  the  stage  of  the 
inflammation,  the  pseudo-membrane  can  always  be  readily  detached  from  the 
bronchial  surface,  since  its  relation  to  it  is  one  of  apposition,  and  not  of  inte- 
gral connection,  as  upon  the  pharyngeal  surface.  In  the  large  tubes  and 
those  of  medium  size  hollow  cylinders,  more  or  less  complete,  form  ;  but  in 
the  smaller  tubes,  if  the  pseudo-membrane  extend  to  them,  solid  cylinders 
are  produced.  Frequently,  in  the  bronchial  croup  of  diphtheria,  while  the 
entire  bronchial  surface  is  intensely  red  and  swollen,  the  pseudo-membrane  is 
absent  in  certain  parts ;  in  other  parts  it  forms  cylinders,  in  other  parts  still 


384  DIPHTHERIA. 

longitudinal  bands  of  a  ribbon  shape  are  produced,  and  in  more  or  fewer  of 
the  minuter  tubes  plugs  which  entirely  fill  the  lumina  and  prevent  the  entrance 
of  air.  The  alveoli  beyond  these  plugs  gradually  collapse,  and  more  or  fewer 
of  them  return  to  the  unexpanded  foetal  state.  From  the  tubes  which  are 
still  pervious  the  muco-pus  is  with  difficulty  expectorated  on  account  of  its 
viscidity,  and  this  thick  secretion  contains  floating  particles  of  pseudo-mem- 
brane. Pseudo-membranous  bronchitis  in  diphtheria  is  in  nearly  all  instances 
an  extension  of  a  laryngo-tracheal  croup.  It  occurs,  according  to  Sanne,  most 
frequently  between  the  second  and  sixth  days. 

Various  forms  of  pulmonary  disease  occur  in  diphtheria,  usually  as  a 
complication  and  often  as  a  final  result  of  the  downward  extension  of  inflam- 
mation from  the  larynx,  trachea,  and  bronchial  tubes.  Splenization,  atelec- 
tasis, and  broncho-pneumonia  are  common  complications  of  diphtheritic  croup. 
Broncho-pneumonia,  like  pseudo-membranous  laryngo-tracheitis  and  pseudo- 
membranous bronchitis,  upon  which  it  largely  depends,  occurs  usually  in  the 
first  week  of  diphtheria.  In  121  cases  of  broncho-pneumonia  complicating 
diphtheria,  observed  by  Sanne,  the  pneumonia  commenced  in  2  on  the  first 
day  of  diphtheria  and  in  71  between  the  second  and  sixth  days  inclusive. 

Pulmonary  congestion,  occupying  by  preference  the  depending  portions 
of  the  lungs,  especially  the  posterior  and  inferior  portions  of  the  lower  lobes, 
is  also  not  infrequent.  It  occurs  when  respiration  is  obstructed  in  croup  and 
when  the  circulation  is  feeble  in  consequence  of  heart-failure.  In  the  dyspncea 
which  accompanies  paralysis  of  the  pneumogastrics  venous  congestion  of  the 
lungs  commonly  occurs. 

Peter  found  the  lesions  of  pleurisy  9  times  in  121  autopsies  in  diphtheria, 
and  Sanne  observed  them  in  20  cases.  The  latter  writer  says  :  "  All  forms 
of  diphtheria,  but  particularly  croup  and  pseudo-membranous  bronchitis, 
are  to  be  found  with  pleurisy.  Pleurisy  always  accompanies  some  other 
phlegmasia." 

Vesicular  emphysema,  commonly  occurs  during  the  progress  of  croup. 
Whenever,  in  consequence  of  occlusion  of  the  tubes,  a  considerable  part  of 
a  lung  fails  to  receive  air,  its  alveoli  begin  to  retract  and  collapse,  and  the 
alveoli  which  receive  air,  which  are  principally  those  in  the  superior  and 
anterior  portions  of  the  lung,  are  over-distended,  since  their  function  is  com- 
pensatory. Vesicular  emphysema  consequently  results,  and  in  exceptional 
instances  the  vesicles  rupture  and  the  escaped  air  passes  into  the  connective 
tissue,  producing  interstitial  emphysema. 

Pulmonary  apoplexy  occasionally  occurs,  the  extravasations  usually  being 
of  small  size  and  disseminated  through  the  lungs.  It  is  most  frequent  in 
malignant  cases — in  cases  attended  by  profound  blood-poisoning.  It  has  been 
attributed  in  some  instances  to  pulmonary  emboli  resulting  from  cardiac 
thrombosis,  or  microbic  masses  intercepted  in  the  capillaries.  Pulmonary 
(edema  also  occasionally  occurs,  especially  in  cases  of  bronchial  croup,  pul- 
monary congestion,  and  broncho-pneumonia.  Oertel  in  his  recent  microscopic 
examinations  of  the  lungs  noted  subpleural  hemorrhages  and  hemorrhages 
extending  to  the  alveoli,  which  were  compressed.  "  Leucocytes  infiltrated 
the  alveolar  septa,  and  in  later  stages  invaded  the  alveoli,  the  epithelium  of 
which  became  detached,  and  the  characters  of  catarrhal  pneumonia  were  thus 
produced.  Some  alveoli  contained  fibrinous  exudation,  and  in  one  severe  case 
the  alveolar  contents  consisted  of  nuclei  which  exhibited  disintegrating 
changes  somewhat  like  those  in  necrobiosis." 

Lymphatic  Glands. — Enlargement  of  the  cervical  and  submaxillary  glands 
is  of  common  occurrence  in  diphtheria,  and  it  is  a  diagnostic  symptom  of  some 
value.  Hyperplasia  of  the  cells  of  these  glands  occurs,  with  numerous 
hemorrhagic  points  in  their  capsules  and  in  the  periglandular  tissue.     Points 


ANATOMICAL  CHARACTERS.  385 

of  necrobiosis,  staining  faintly,  occur  in  the  glands,  more  in  the  cortical  than 
in  the  central  portions.  The  cells  exhibit  evidences  of  disintegration,  and 
when  this  process  is  advanced  granular  masses  form  in  the  affected  foci. 
Hyaline  degeneration  is  also  observed  in  portions  of  the  glandular  tissue,  a 
degeneration  common  in  other  organs  in  diplitheria.  Where  disintegration 
is  not  too  far  advanced  cells  with  j)olymorphous  nuclei  are  observed — evidence 
of  an  active  hyperplasia.  Hyperplasia  with  points  of  hemorrhagic  extrava- 
sation takes  place  also  in  the  bronchial  glands,  but  fewer  points  of  necrobiosis 
occur  than  in  the  cervical  and  submaxillary  glands,  and  these  chiefly  in  the 
follicles.  The  lymph-ducts  may  contain  no  normal  cells,  and  only  those  which 
have  disintegrated  nuclei  along  with  other  products  of  disintegration. 

Heart. — The  state  of  the  heart  will  be  in  part  described  in  our  remarks 
relating  to  cardiac  paralysis.  Small  extravasations  of  blood  under  the  peri- 
cardial, and  less  frequently  the  endocardial,  surface  have  been  observed. 
Oertel  attributes  these  hemorrhages  to  changes  in  the  walls  of  the  vessels 
caused  by  the  diphtheritic  virus,  and  Buhl,  to  nuclear  proliferation  in  the 
walls  and  mechanical  obstruction.  Leucocytes  in  masses  often  occur  under 
the  pericardium  and  endocardium  and  between  the  muscular  fibres.  Some- 
times the  muscle-nuclei  have  undergone  segmentation  and  degenerative 
changes.  These  nuclear  changes  occur  mostly  in  fibres  under  the  endo- 
cardium and  around  the  coronary  arteries.  The  nuclei  in  the  muscular  coat 
of  the  arteries  are  increased  in  size,  and  slight  proliferation  and  desquamation 
of  the  endothelia  and  infiltration  of  the  adventitia  also  take  place. 

3Ioi(th,  Stomachy  Intestines. — The  diphtheritic  pellicle  sometimes  forms  in 
the  cavity  of  the  mouth,  generally  in  small  patches ;  but  the  buccal  surface 
is  usually  only  superficially  involved,  except  upon  the  tongue,  where  the 
pellicle  extends  more  deeply.  I  have  elsewhere  stated  that  the  diphtheritic 
exudate  sometimes  occurs  upon  the  surface  of  the  stomach  and  portions  of 
the  intestines,  producing  more  or  less  destruction  of  the  mucous  membrane. 
Necrobiotic  foci  have  been  observed  by  Bizzozero  and  Oertel  in  the  intestinal 
follicles  and  agminate  glands,  but  to  a  less  extent  than  upon  the  respiratory 
surfaces.  Active  cell-proliferation  and  disintegration  and  cleavage  of  nuclei 
occur,  but  these  altered  cells  are  mixed  with  others  which  are  normal.  The 
epithelium  is  for  the  most  part  retained  and  normal,  and  hyaline  changes 
have  not  been  observed  in  the  gastro-intestinal  vessels.  The  mesenteric 
glands  sometimes  undergo  enlargement  from  hyperplasia,  especially  when 
the  intestines  are  affected  and  points  of  necrobiosis  occur  in  them.  For  the 
most  part,  however,  the  gastro-intestinal  sui'face  is  less  frequently  affected 
than  other  mucous  surfaces. 

Spleen. — The  diphtheritic  virus  reaches  this  organ  through  the  blood- 
current.  The  spleen  is  swollen,  so  as  to  render  its  capsule  tense.  The  pulp 
is  soft,  rising  up  through  the  cut  surface  of  the  capsule  ;  the  follicles  are 
large  and  prominent ;  in  the  pulp  are  extravasations  of  blood  and  hjematoidin 
masses,  and  the  vessels  are  distended.  Hyperplasia  of  the  splenic  corpuscles 
occurs,  which  is  most  marked  around  the  bifurcations  of  the  arteries,  so  that 
the  reticulum  is  less  prominent.  The  follicles  are  surrounded  by  a  wide  zone 
of  the  reticulated  cells,  among  which  we  find  lymphatic  corpuscles,  leucocytes, 
and  large  round  cells.  The  nuclei  in  the  cells  undergo  two  changes :  first, 
direct  segmentation  as  in  ordinary  cell-division,  and  fragmentation,  in  which 
the  chromatin  is  broken  up  in  small,  irregularly-disposed  masses  and  the 
nuclear  juice  is  susceptible  of  staining.  In  the  Malpighian  follicles  either 
numerous  epithelioid  cells  form,  as  mentioned  by  Stilling,'  or  large  cells  occur. 
The  latter  stain  better  by  coloring  reagents  than  the  epithelioid  cells,  but  less 
than  the  leucocytes.     The  epithelioid  cells  occur  mostly  in  young  patients. 

'  Virchoiv's  Arehiv,  Bd.  ciii. 
25 


386  DIPHTHERIA. 

A  wide  zone  of  leucocytes  surrounds  and  invades  the  follicles.  The  necro- 
biotic  process  also  occurs  as  in  other  organs,  beginning  with  nuclear  disinte- 
gration, and  when  at  its  maximum  the  follicles  are  surrounded  and  loaded  with 
the  altered  nuclei  furnished  by  the  round  or  epithelioid  cells.  Hemorrhages 
also  occur  in  the  follicles.  In  some  protracted  cases  the  vessels  of  the  pulp 
exhibit  the  hyaline  degeneration. 

Liver. — Capillary  hemorrhages  take  place  within  the  capsule,  and  occa- 
sionally within  the  parenchyma.  Leucocytes  occur  at  certain  points  within 
the  liver,  infiltrating  the  tissue  of  the  organ.  They  occupy  the  interlobular 
spaces  and  do  not  exhibit  nuclear  changes.  The  hepatic  cells  are  unchanged 
or  they  become  fatty. 

Kidneys. — Albuminuria  occurs  from  different  causes,  as  we  have  stated 
elsewhere.  Feeble  heart-action,  obstructed  respiration,  fever,  and  the  direct 
irritating  action  of  the  diphtheritic  virus  upon  the  blood  and  the  kidneys, 
are  sufficient  causes.  The  kidneys  may  be  normal  in  cases  of  albuminuria, 
or  exhibit  different  degrees  of  parenchymatous  inflammation.  Hemorrhages, 
glomerulitis,  and  disseminated  nephritis  are  common  lesions  observed  in  the 
kidneys  in  those  who  have  died  having  diphtheritic  albuminuria.  Hemor- 
rhagic points  occur  not  only  under  the  capsule,  but  also  in  the  glomeruli  and 
in  and  between  the  tubules.  Cell-infiltration  takes  place  around  the  vessels 
and  the  cells  exhibit  nuclear  disintegration.  On  examining  the  glomeruli, 
thickening  of  Bowman's  capsule  is  sometimes  observed,  with  some  albuminous 
exudation  underneath  it,  and  epithelial  proliferation  and  desquamation.  The 
nuclei  and  endothelia  of  the  glomerular  capillaries  are  increased,  and  the 
chromatin  and  nuclear  juice  have  undergone  disintegrating  and  degenerative 
changes — results  of  inflammation.  The  capillaries  are  therefore  in  a  degree 
diseased  through  the  action  of  the  blood-poison.  The  epithelium  of  the 
convoluted  and  straight  tubes  is  also  diseased.  The  epithelial  cells,  under- 
going cloudy  swelling,  become  detached  from  the  basement  membrane,  fill 
the  lumina  with  the  necrosed  product,  and  some  of  them  escape,  forming 
casts  in  the  urme.  Occasionally  only  the  outer  portion  of  the  cell  is  necrosed 
and  detached,  the  part  adjacent  to  the  basement  membrane  containing  the 
nucleus  remaining  in  situ.  Oertel  says  that  when  the  entire  cells  are  thrown 
off  granular  casts  are  formed,  but  if  only  the  outer  portions  are  lost  hyaline 
casts  are  produced.  The  collecting  tubes,  filled  with  granular  masses  con- 
taining broken  nuclei,  cells,  and  epithelia,  may  be  dilated. 

The  above  description  of  the  anatomical  changes  which  occur  in  the 
various  organs  is  for  the  most  part  a  resume  of  the  recent  investigations  by 
Oertel.  Whether  his  published  statement  will  be  fully  sustained  by  subse- 
quent microscopic  examinations  remains  to  be  seen. 

Symptoms. — Diphtheria,  like  scarlet  fever,  varies  greatly  in  severity, 
from  a  form  so  mild  that  medical  advice  is  not  sought  and  the  child  is  not 
even  confined  to  his  home,  to  a  form  so  severe  that  the  system  is  at  once 
overpowered  and  the  patient  is  in  a  critical  state  from  the  first.  In  general 
in  the  commencement  of  an  epidemic  the  symptoms  are  more  severe  than 
when  the  epidemic  influence  is  abating.  During  the  continuance  of  the 
attack  the  prominent  symptoms,  such  as  arrest  attention,  are  often  dispro- 
portionate to  the  gravity  of  the  attack.  Striking  cases  illustrative  of  this 
fact  have  occurred  in  my  practice,  the  friends  not  supposing  that  there  was 
any  serious  ailment,  and  not  seeking  medical  advice  until  the  fatal  termina- 
tion was  near. 

In  benign  diphtheria  the  initial  symptoms  are  often  slight,  such  as 
languor  or  lassitude,  slight  chilliness  succeeded  by  fever  of  a  light  form, 
mild  headache,  pain  or  aching  in  the  body  or  limbs,  thirst,  and  impaired 
appetite.     Usually  some  soreness  of  the  throat  is  noticed  in  swallowing  soon 


SYMPTOMS.  387 

after  the  attack  begins,  and  this  continues.  But  the  patient  with  mild  diph- 
theria often  continues  to  walk  about,  in  the  belief  that  he  is  affected  with  a 
slight  and  temporary  ailment.  Children  with  mild  diphtheria  in  the  poorer 
families  are  usually  allowed  to  go  abroad,  and  do  great  harm  by  propagating 
the  disease.  The  symptoms  in  these  mild  cases  so  closely  resemble  those 
from  a  severe  cold  that  the  disease  is  liable  to  be  mistaken  for  it.  The  slight 
tenderness  or  .sensation  of  fulness  in  the  fauces  usually  experienced  by  those 
old  enough  to  express  their  sensations  should  always  lead  to  an  examination 
of  the  fauces,  when  the  character  of  the  attack  will  frequently  be  apparent. 
A  distinguished  clergyman  of  the  Pacific  coast  who  fell  a  victim  to  this  dis- 
ease dreamed  a  few  nights  before  he  complained  of  his  illness  that  his  throat 
was  cut.  Doubtless  the  diphtheritic  inflammation  had  already  commenced, 
so  that  what  seemed  a  forewarning  had  a  natural  explanation.  So  insidious 
was  the  commencement  in  this  case  that  the  disease  had  advanced  beyond  all 
hope  of  relief  when  medical  advice  was  first  sought. 

Soon  after  the  attack  commences  inspection  of  the  fauces  reveals  redness 
of  the  tonsillar  surface,  and  this  extends  until  the  entire  fauces  present  an 
injected  appearance.  After  the  lapse  of  twelve  to  thirty-six  hours,  or  even 
as  late  as  forty-eight  hours,  from  the  commencement  of  the  disease,  the 
diphtherrtic  exudate  begins  to  form  over  the  tonsils,  producing  the  character- 
istic pellicle.  Before  it  forms  we  often  observe  a  grayish  color  of  the  prom- 
inent part  of  the  tonsils,  produced  by  the  infiltration  of  the  mucous  mem- 
brane, and  even  of  the  surface  of  the  tonsils,  with  newly-formed  cells.  The 
exudate  may  appear  as  points,  which  coalesce,  forming  a  patch,  eras  a  pellicle, 
which  soon  becomes  thicker  and  at  the  same  time  firm.  Its  anatomical  cha- 
racters are  described  elsewhere. 

But  in  most  cases,  in  all  except  of  the  mildest  type,  the  initial  symptoms 
are  more  severe  than  we  have  delineated  above.  The  attack  in  the  ordinary 
as  well  as  severe  form  of  diphtheria  commences  abruptly,  like  scarlet  fever, 
without  a  premonitory  stage  and  with  pronounced  symptoms  from  the  first. 
The  temperature  rises  to  102°,  103°,  or  even  104°  F.,  with  corresponding  heat 
of  surface,  thirst,  languor,  loss  or  impairment  of  appetite,  tenderness  of 
throat,  etc.  Delirium  as  well  as  eclampsia  may  occur ;  but  both  are  rare. 
The  temperature  ordinarily  begins  to  fall  after  the  second'  or  third  day  in 
favorable  cases,  and  often  in  those  of  a  grave  and  fatal  type.  Subsequently 
to  the  third  or  fourth  day  the  temperature  is  frequently  but  little  elevated. 
The  diphtheritic  poison,  when  the  system  is  fully  under  its  influence,  does 
not  exhibit  any  marked  tendency,  like  that  of  scarlet  fever,  to  increase  the 
animal  heat.  Even  in  profound  and  fatal  diphtheritic  blood-poisoning  rap- 
idly approaching  an  unfavorable  termination  the  thermometer  often  indicates 
nearly  the  normal  temperature,  so  that  the  inexperienced  practitioner  may  be 
deceived  by  this  fact  in  his  prognosis.  A  continued  elevation  of  temperature 
considerably  above  the  normal  should  lead  the  physician  to  examine  for  some 
complication,  perhaps  nephritis. 

The  tongue  is  moist  and  slightly  furred.  Many  patients  vomit  in  the 
commencement;  and  if  this  symptom  cease  or  be  not  repeated  it  is  not  of 
grave  import  ;  but  vomiting  occurring  often,  so  that  a  considerable  part  of 
the  food  is  rejected,  is  common  in  grave  cases  and  is  an  unfavorable  prog- 
nostic symptom.  It  frequently  is  due  to  uraemia.  The  appetite  in  severe 
cases  is  usually  poor.  Repugnance  to  food  from  loss  of  appetite  and  pain 
in  swallowing  characterize  severe  forms  of  the  disease.  There  are  no  notable 
symptoms  referable  to  the  state  of  the  intestines.  The  stools  appear  normal, 
except  as  they  are  changed  by  the  medicines  prescribed.  In  all  cases  except 
the  mildest  a  rapid  destruction  of  red  corpuscles  occurs  and  a  relative  increase 
of  white  corpuscles.     Hence  the  anaemia,  which  is  soon  manifested  by  pallor 


388  DIPHTHERIA. 

of  the  surface,  and  which  rapidly  increases  as  the  disease  advances.  The 
early  loss  of  the  tendon  reflex  has  recently  been  brought  to  the  notice  of  the 
profession.  It  often  occurs  as  early  as  the  first,  second,  or  third  day.  It  is 
fully  treated  of  in  our  remarks  relating  to  diphtheritic  paralysis  in  subsequent 
pages.  It  is  a  symptom  of  diagnostic  value.  Diphtheritic  inflammations 
have  a  marked  tendency  to  produce  hyperplasia,  and  consequent  notable 
enlargement  of  the  lymphatic  glands  in  their  immediate  neighborhood.  The 
poisonous  and  irritating  products  of  the  inflammation  upon  the  surface  taken 
up  by  the  lymphatics  and  deposited  in  the  adjacent  glands  produce  in  them 
tenderness,  swelling,  an  increased  afflux  of  arterial  blood,  and  a  rapid  increase 
of  the  cellular  elements.  An  inflammation  both  of  the  lymphatic  ducts  and 
glands  arises,  with  more  or  less  oedema  and  sometimes  inflammation  of  the 
adjacent  connective  tissue.  Suppuration  of  the  glands  and  connective  tissue, 
though  it  may  occur,  is  much  less  frequent  than  in  scarlet  fever. 

Temperature. — There  is  probably  no  other  disease  in  which  the  thermom- 
eter furnishes  so  little  aid  to  an  understanding  of  the  case  as  in  this,  since 
the  degree  of  fever  does  not  sustain  any  fixed  relation  to  the  amount  of 
blood-poisoning.  Malignant  diphtheria  with  profound  blood-poisoning  and 
approaching  a  fatal  termination  may  be  almost  apyretic,  while  a  benign  form 
of  the  disease  with  but  little  blood-poisoning  may  commence  with  consider- 
able fever  (102°,  103°,  or  104°  F.).  Fever  in  diphtheria  is  rather  a  symp- 
tom of  the  inflammation  than  of  the  blood-poisoning.  Considerable  elevation 
of  temperature  in  diphtheria  usually  indicates  an  active  pharyngitis,  ton- 
sillitis, laryngo-tracheitis,  bronchitis,  pneumonia,  or  nephritis.  Therefore, 
although  the  thermometer  does  not  aid  in  determining  the  amount  of  blood- 
poisoning,  it  enables  us  to  form  an  opinion  in  regard  to  the  extent  and 
severity  of  the  inflammation  which  may  be  present.  The  thermometer  is 
also  useful  when  diphtheria  occurs  as  a  complication  of  another  constitutional 
disease,  as  scarlet  fever,  measles,  typhoid  fever,  since  it  indicates  the  severity 
of  this  disease. 

Such  is  the  clinical  history  of  diphtheria  as  it  usually  occurs,  its  local 
manifestation  being  primarily  upon  the  tonsillar  portion  of  the  fauces,  and 
extending  from  the  tonsils,  when  the  case  is  severe,  to  the  posterior  surface 
of  the  fauces,  over  the  anterior  and  posterior  pillars,  and  to  the  uvula.  The 
uvula,  when  it  is  involved,  becomes  greatly  swollen,  even  two  or  three  times 
its  normal  size,  so  as  to  lie  upon  the  tongue,  and,  especially  if  it  be  covered 
by  a  pseudo-membrane,  to  fill  up  the  space  between  the  swollen  tonsils  and 
intercept  the  view  of  the  posterior  fauces.  When  the  inflammation  is  intense 
and  the  pseudo-membrane  has  not  yet  formed  or  has  been  removed  by  solv- 
ent applications,  the  tonsillar  portion  of  the  fauces  often  presents  a  grayish 
appearance  from  infiltration  of  leucocytes.  This  infiltration,  if  so  great  as 
to  obstruct  the  circulation,  leads  to  necrosis ;  but,  as  we  have  stated  else- 
where, the  necrosis  of  the  mucous  membrane  is  more  likely  to  occur  when 
it  is  still  covered  by  the  pseudo-membrane,  the  pseudo-membrane  and  mucous 
surface  being  incorporated  with  each  other  and  being  detached  together.  The 
color  of  the  pseudo-membrane,  at  first  whitish  or  a  grayish  white,  becomes 
in  a  few  days,  in  severe  cases,  a  yellowish  brown  by  the  action  of  the  atmo- 
sphere and  sometimes  by  extravasation  of  blood.  If  the  membrane  be  abun- 
dant, it  is  likelj'  to  have  in  a  few  days  a  musty  and  offensive  odor,  due  to  com- 
mencing decomposition.  The  constant  inhalation  of  the  highly  poisonous  gases 
which  result  is  detrimental  to  the  patient,  and  they  increase  the  danger  of 
infection  in  others.  However,  with  the  use  of  disinfectants,  now  so  com- 
monly employed,  the  poisonous  gaseous  products  of  decomposition  are  not  so 
common  as  in  former  times.  Since  the  pseudo-membrane  is  incorporated 
with  the  mucous  membrane  and  capillaries  penetrate  its  under  surface,  forci- 


SYMPTOMS.  389 

ble  detiiclnuent  of  the  pellicle  is  likely  to  give  rise  to  hemorrhage.  Hemor- 
rhage is  always  a  bad  prognostic  sign.  The  duration  of  the  pseudo-membrane 
is  very  variable.  On  the  average  in  favorable  cases  it  is  from  one  to  two 
weeks.  There  are  cases,  however,  in  which  the  ulcerated  surface  is  long  in 
healing,  and  the  ulcers  are  covered  many  days  with  the  grayish-white  diph- 
theritic exudate.  In  exceptional  cases,  at  the  clo.se  of  the  third  or  even 
fourth  week  we  occasionally  observe  on  the  faucial  surface  diphtheritic 
patches  two  or  three  lines  in  diameter,  without  surrounding  inflammation, 
in  those  who  consider  themselves  nearly  well  and  who  would  appear  in  the 
streets  if  they  were  allowed  to  do  so.  We  will  consider  elsewhere  how  long 
enforced  seclusion  of  the  patient  should  be  enjoined  in  order  to  prevent  the 
propagation  of  the  disease  to  others. 

N^circs. — Usually  inflammation  of  the  nostrils  occurring  in  diphtheria  is 
secondary  to  that  of  the  pharynx.  The  pharyngitis  has  continued  one  or 
more  days  when  a  discharge  of  a  thin  serous  appearance  occurs  from  the 
nostrils.  This  is  attended  by  swelling  of  the  Schneiderian  membrane  ;  and  in 
proportion  to  the  amount  of  swelling  the  respiration  through  the  nostrils  is 
embarrassed.  As  the  inflammation  continues  the  swelling  increases  and  res- 
piration is  accompanied  by  a  nasal  snufile,  or  the  occlusion  of  the  nostrils  is 
so  great  that  it  is  performed  entirely  through  the  mouth.  The  impediment 
to  respiration  in  infants  at  the  breast,  so  as  to  necessitate  spoon-feeding,  we 
have  alluded  to  above.  The  discharge  is  very  acrid  and  irritating,  causing 
excoriation  around  the  entrance  of  the  nostrils  and  even  upon  the  cheeks.  It 
soon  becomes  more  viscid  or  less  fluid  than  at  first,  and  it  presents  a  creamy 
appearance  from  the  large  proportion  of  pus-corpuscles.  When  the  inflam- 
mation of  the  nares  is  severe,  the  glands  around  the  articulation  of  the  lower 
jaw  usually  undergo  hyperplasia,  becoming  nodular  and  prominent,  so  as  to 
be  apparent  not  only  to  the  touch,  but  also  to  the  sight. 

Although,  commonly,  diphtheritic  inflammation  of  the  nasal  surface  is 
secondary  to  that  of  the  fauces,  it  is  sometinfes  the  primary  inflammation. 
It  may  exist  for  some  days  before  the  fauces  become  affected,  and  under 
such  circumstances  the  diagnosis  is  frequently  not  made  until  the  disease  is 
in  an  advanced  stage  and  profound  blood-poisoning  has  occurred.  In  nasal 
diphtheria  the  pseudo-membrane  probably  occurs  as  early  as  in  other  forms 
of  diphtheritic  inflammation,  but  being  usually  out  of  sight  it  is  not  observed 
in  the  first  days  or  until  it  has  extended  so  that  its  anterior  edge  can  be  seen 
on  inspecting  the  nasal  fossa.  From  its  concealed  position  it  is  easy  to  per- 
ceive why  the  disease  is  so  frequently  overlooked,  and  a  simple  nasal  catarrh 
is  supposed  to  be  present  when  there  is  no  inflammation  of  the  fauces  to  aid 
the  diagnosis  or  it  is  late  in  appearing. 

Nasal  diphtheria  always  involves  great  danger,  since  it  is  very  liable  to 
give  rise  to  systemic  infection  from  the  large  number  of  lymphatics  lodged 
in  the  connective  tissue  of  the  nares.  In  certain  severe  cases  accompanied 
by  swelling  of  the  face  there  is  reason  to  think  that  the  inflammation  has 
entered  the  antrum  of  Higbmore — a  very  serious  extension.  It  sometimes 
extends  up  the  tear-duct,  producing  its  occlusion,  and  also  along  the  Eusta- 
chian tube.  Hemorrhage  sometimes  occurs  in  nasal  diphtheria.  In  those 
who  recover  the  Schneiderian  membrane  returns  slowly  to  its  normal  state. 
The  Eye. — We  have  stated  above  that  the  inflammation  sometimes  pas.ses 
.along  the  tear-duct  to  the  conjunctiva,  but  in  other  instances  the  inflamma- 
tion occurs  independently  of  this  mode  of  propagation.  Thus,  if  a  child 
with  simple  conjunctivitis  contract  diphtheria,  the  pre-existing  inflammation 
is  very  liable  to  assume  a  diphtheritic  character,  in  accordance  with  the 
law  already  stated,  that  diphtheria  attacks  by  preference  surfaces  that  are 
already  inflamed.     I  have  elsewhere  stated  that  diphtheria  at  one  time  entered 


390  DIPHTHERIA. 

the  ophtlialmic  wards  of  the  New  York  Foundling  Asylum,  and  three  chil- 
dren, under  treatment  for  granular  lids,  who  contracted  the  disease,  had 
diphtheritic  inflammation  of  the  lids,  with  the  usual  pseudo-membranous 
exudate.  The  result  of  diphtheritic  conjunctivitis,  even  with  prompt  and 
appropriate  treatment,  is  likely  to  be  disastrous  as  regards  the  eye.  The 
eyelids  become  red  and  greatly  swollen  from  oedema,  and  their  under  sur- 
face is  soon  lined  by  a  thick  and  firm  pseudo-membrane.  The  eye  itself  is 
the  seat  of  chemosis.  The  pseudo-membrane  upon  the  ocular  conjunctiva  is 
less  firm,  not  so  thick,  and  more  in  flakes  than  that  upon  the  palpebral  con- 
junctiva. The  eye  afi"ected  by  this  disease  should  be  closely  watched  and 
promptly  and  efiiciently  treated ;  but,  unfortunately,  under  the  most  judi- 
cious treatment  the  cornea  is  likely  to  become  hazy  and  sloughing  or  ulce- 
ration follow,  with  total  destruction  of  sight  and  perhaps  prolapse  of  the  iris. 

The  Ear. — The  ear  may  become  inflamed  by  extension  of  the  inflamma- 
tion along  the  Eustachian  tube  from  the  fauces.  The  opening  of  this  tube 
upon  the  faucial  surface  is  small  and  slit-like  in  the  child,  and  moderate  inflam- 
mation and  exudation  are  sufficient  to  close  it.  When  this  occurs  the  patient 
complains  of  pain  in  the  site  of  the  tube  and  in  the  ear.  The  formation  of  a 
membrane  plugging  the  tube  and  the  extension  of  the  inflammation  to  the 
ear,  producing  an  otitis  media,  add  very  much  to  the  gravity  of  the  case. 
Perforation  of  the  drum,  caries  of  the  bones  of  the  ear,  and  that  grave  dis- 
ease otitis  interna  may  occur,  increasing  very  much  the  gravity  of  the  ease. 
Fortunately,  this  extension  of  the  inflammation  is  not  frequent.  It  does  not 
often  occur  except  in  those  malignant  cases  which  are  likely  to  be  fatal  from 
other  causes.  Sometimes,  also,  a  diphtheritic  otitis  externa  occurs.  It  is 
usually  preceded  by  a  catarrhal  inflammation  which  has  arisen  from  other 
causes  and  was  present  when  the  diphtheria  commenced.  Bezold  described 
three  cases  of  otitis  externa  with  a  diphtheritic  pellicle  upon  the  drum.' 
Moos   and  Callan   have   also   narrated   cases. 

The  3fouth. — During  th#  progress  of  diphtheria  any  sore  or  abrasion  of 
the  mouth  is  likely  to  become  the  seat  of  the  diphtheritic  exudate.  Usually 
the  fauces,  and  sometimes  the  nares,  are  at  the  same  time  afiected.  The 
diphtheritic  pellicle,  commonly  of  small  extent,  may  appear  upon  the  inside 
of  the  cheek,  the  tongue,  gums,  and  lips.  Usually  the  inflammation  of  these 
parts  is  of  secondary  importance,  but  in  malignant  or  highly  septic  cases  it 
may  be  attended  by  considerable  infiltration  and  thickening.  Buccal  diph- 
theria, if  severe,  is  painful,  and  it  may  interfere  with  the  proper  nutrition. 
The  clinical  history  of  diphtheritic  inflammation  of  the  fauces  and  respira- 
tory tract  below  the  epiglottis  is  sufficiently  presented  elsewhere. 

(Esophagus,  Stomach,  Intestines. — The  upper  part  of  the  oesophagus  not 
infrequently  participates  in  the  inflammation  of  the  pharynx.  Its  walls  are 
thickened,  and  the  pseudo-membrane  presents  the  same  characters  as  upon 
the  fauces.  Occasionally,  nearly  the  entire  oesophagus  is  the  seat  of  diph- 
theritic inflammation,  the  oesophageal  walls  being  greatly  thickened  from 
infiltration  of  cells  and  very  vascular.  In  one  of  the  cases,  related  in  a 
foregoing  page,  of  diphtheria  of  the  newly-born,  the  oesophagus  was  in 
nearly  its  entire  length  covered  by  the  diphtheritic  pseudo-membrane.  In 
only  one  instance  have  I  observed  a  severe  diphtheritic  gastritis.  In  this 
case  nearly  the  entire  surface  of  the  stomach  was  covered  by  a  thick  pellicle. 
Probably  the  inflamed  follicles  did  not  secrete  normal  pepsin.  A  few  cases 
are  on  record  of  diphtheritic  inflammation  of  the  intestines.  Dr.  A.  Jacob! 
relates  the  case  of  a  child  of  three  years  who  had  diphtheritic  enteritis. 
Fever,  moderate  tenderness  of  the  abdomen  with  but  little  tympanitis,  con- 
stipation, and  great  prostration,  were  the  prominent  symptoms.     The  autopsy 

'  Virchoiv's  Arcliiv,  Ixx.  329. 


SYMPTOMS.  391 

revealed  the  presence  of  a  diphtheritic  inflammation  in  the  jejunum  and  ileum, 
the  membrane  consisting  of  "  a  dense  network  with  granular  contents."  The 
most  marked  case  of  diphtheritic  intestinal  inflammation  which  has  come 
under  my  notice  was  that  of  a  physician  to  whose  case  I  have  elsewhere 
referred.  He  lost  his  appetite,  had  fever,  lost  flesh  and  strength,  had  distress 
in  the  abdomen  which  raised  the  suspicion  of  a  typhoid  fever ;  but  at  the 
usual  time  for  the  termination  of  a  self-limited  fever  no  abatement  of  symp- 
toms occurred.  Finally,  after  weeks  of  suffering,  he  expelled  a  cast  of  the 
intestine  several  inches  in  length,  probably  from  the  colon.  Obstinate  con- 
.stipation  was  the  most  prominent  symptom  during  this  time  and  subsequently, 
due  probably  to  cicatrization  and  contraction  of  the  intestine.  The  patient 
died  from  the  effects  of  the  disease  several  months  subsequently,  having  suf- 
fered constantly  from  faulty  digestion,  abdominal  pain,  and  constipation,  which 
no  treatment  could  relieve  or  benefit. 

Gen'do-Urinary  Organs. — Diphtheria  of  the  prepuce  commonly  occurs  after 
some  injury.  It  either  arises  by  direct  inoculation  upon  an  abi'asion  or  wound, 
or  is  contracted  by  exposure  to  an  infected  atmosphere.  Many  cases  are  on 
record.  I  have  elsewhere  stated  that  the  eminent  surgeon  M.  Germain  See, 
whose  practice  is  in  a  locality  where  diphtheria  is  endemic  and  very  prevalent, 
now  recommends  stretching  of  the  prepuce  in  nearly  all  cases  of  narrow  and 
adherent  prepuce,  rather  than  circumcision,  for  the  reason,  among  others,  that 
diphtheria  is  more  liable  to  follow  the  latter  operation.  Diphtheria  of  the 
prepuce  is  contracted  by  the  use  of  infected  instruments,  sponges,  or  fingers 
in  the  operation  of  circumcision,  or  by  the  performance  of  the  operation  with 
clean  instruments  and  hands,  but  in  an  infected  atmosphere.  Thus,  Dr.  F. 
Lange  saw  a  case  of  preputial  and  scrotal  diphtheria  in  a  child  of  three  weeks 
who  had  been  circumcised  when  diphtheria  was  occurring  in  the  family .■*  Dr. 
Greves  states  that  a  boy  who  had  been  circumcised  for  phimosis  was  admitted 
into  the  Liverpool  Infirmary  with  an  unhealthy  prepuce  which  had  never 
healed  after  the  operation.  Weak  and  anaemic  when  admitted,  he  continued 
to  sink,  and  died  of  heart-failure.  The  wound  and  subjacent  tissues  were 
infiltrated  with  micrococci  presenting  the  same  characters  as  those  in  pharyn- 
geal pseudo-membranes.  In  a  preceding  page  I  have  alluded  to  a  case, 
related  by  Mr.  Phillips,  of  preputial  diphtheria  occurring  after  circumcision 
by  infected  instruments,  and  have  related  a  case  in  my  own  practice  of  a 
severe  diphtheria  of  the  prepuce,  and  simultaneously  of  the  fauces,  occurring 
after  instrumental  dilatation  of  the  foreskin.  Dr.  A.  Jacobi  states  that  he 
incised  the  upper  part  of  the  prepuce  in  a  healthy  boy  of  three  years, 
employed  stitches,  and  applied  carbolized  dressing.  On  the  following  day 
diphtheria  attacked  the  wound,  with  the  usual  swelling  and  erysipelatous 
appearance.  The  stitches  were  removed,  but  death  occurred  four  days  after 
the  operation.  Dr.  A.  Jacobi  also  relates  the  case  of  a  boy  of  four  years 
whom  he  circumcised,  and  dressed  the  wound  with  antiseptic  solutions. 
Diphtheria  supervened,  and  in  a  few  days  the  entire  prepuce  and  a  small 
portion  of  the  penis  became  gangrenous.  The  boy  eventually  recovered, 
with   deformity   of   the   organ. 

Billroth  has  called  attention  to  the  fact  that  diphtheria  in  localities 
where  it  is  prevailing  is  likely  to  attack  wounds  produced  by  operations  on 
the  urinary  apparatus,  as  after  lithotomy  or  urethrotomy,  and  in  cases  of 
ectopia  vesicae  and  vesico-vaginal  fistula.  The  inflammation  under  such  cir- 
cumstances is  usually  localized,  but  it  may  extend  to  the  retro-peritoneal 
connective  tissue  and  produce  a  fatal  peritonitis.  The  marked  liability  of 
the  uterus,  vagina,  and  vulva  when  wounded  in  any  way,  as  in  parturition, 
to  become  the  seat  of  diphtheritic  inflammation  in  case  of  exposure  to  the 
1  Medical  Record,  July  10,  1880. 


392  DIPHTHERIA. 

Infection,  is  well  known  to  the  profession,  and  no  prudent  obstetrician  will 
attend  an  obstetrical  case  after  visiting  a  diphtheritic  patient  without  change 
of  apparel  and  personal  disinfection.  Some  years  ago  I  was  summoned  to  a 
young  lady  who  during  the  week  following  her  confinement  insisted  on 
seeing  her  child,  then  in  the  commencement  of  diphtheria.  The  child  was 
brought  to  her  bedside  for  a  moment.  Within  a  day  or  two  she  was 
attacked  with  a  violent  form  of  metro-peritonitis,  which  was  speedily  fatal. 
In  children  diphtheritic  vulvitis  and  vaginitis  occasionally  occur,  associated 
or  not  with  pharyngitis.  I.  Zit  has  records  of  thirteen  cases  of  diphtheritic 
vulvitis,  in  some  of  which  inflammation  was  the  first  manifestation  of  diph- 
theria. Diphtheritic  inflammation  of  the  vulva  and  vagina  is  believed  to  be 
rare  without  a  pre-existing  catarrhal  inflammation. 

Skin — An  efflorescence  is  sometimes  observed  upon  the  skin  during  the 
time  in  which  the  temperature  is  exalted.  It  is  the  erythema  fugax  of  der- 
matologists suddenly  appearing  and  disappearing.  This  eruption,  which  is 
common  in  febrile  and  inflammatory  aff"ections  of  childhood,  does  not  seem 
to  present  any  peculiar  characters  in  diphtheria.  But  there  is  another  erup- 
tion which  I  have  not  infrequently  observed,  and  which  is  attributable  to 
diphtheritic  toxaemia  or  septicaemia.  It  appears  after  the  sixth  or  seventh 
day  in  the  form  of  red  points  or  spots  not  more  than  a  line  in  diameter,  and 
interspersed  with  patches  of  efflorescence  with  irregular  margins,  one  to  two 
inches  in  diameter.  This  roseolar  eruption  is  slightly  raised,  like  that  of 
measles.  Sometimes  it  is  punctate.  It  disappears  on  pressure,  and  in  my 
practice  it  has  usually  appeared  in  grave  cases  in  which  there  were  other 
evidences  of  blood-poisoning.  Occasionally  extravasations  of  blood  occur 
in  and  under  the  skin,  like  those  in  internal  organs.  The  pallor  of  the  skin 
which  diphtheritic  anaemia  and  toxsemia  produce  in  and  after  the  second 
week  is  known  to  all  who  have  had  experience  with  this  disease. 

The  anatomical  characters  and  symptoms  pertaining  to  the  nervous  sys- 
tem and  kidneys  will  be  treated  of  at  length  in  our  remarks  on  Albuminuria 
and  Paralysis.  Albuminuria  and  paralysis,  whether  we  regard  them  as 
symptoms,  complications,  or  sequelae,  occur  so  frequently  and  are  of  such 
grave  import  that  it  is  proper  to  treat  of  them  at  length.  They  are  the 
most  important  of  the  phenomena  pertaining  to  the  symptomatology  of 
diphtheria. 

Albuminuria. 

It  is  perhaps  remai'kable  that  numerous  epidemics  of  diphtheria  had  been 
observed  before  it  became  known  that  albuminuria  is  a  common  accompani- 
ment of  it.  The  fact  that  the  kidneys  are  aff"ected  so  as  to  give  rise  to  albu- 
minous urine  was  discovered  by  Mr.  Wade  of  Birmingham,  England,  in  1857. 
The  interesting  paper  communicating  his  discovery  was  published  in  the 
Midland  Quarterly  Journal  of  Medicine,  1857.  Immediately  after  its 
appearance  the  subject  to  which  he  drew  attention  was  fully  investigated  in 
different  countries,  and  in  the  same  year  Mr.  James  published  his  observa- 
tions in  the  Medical  Times  and  Gazette.  In  the  following  year  (1858)  two 
noteworthy  papers  appeared  on  the  same  subject,  one  by  MM.  Bouchut  and 
Empis,  read  before  the  Parisian  Academy  of  Sciences  and  published  in  the 
Gazette  den  Hopitaux.,  and  another  by  Grei'main  See,  and  read  before  the  Soci- 
ete  des  Hopitaux.  Since  1858  monographs  and  reports  of  cases  too  nume- 
rous to  mention  have  been  published,  so  that  the  literature  of  diphtheritic 
albuminuria  is  quite  full. 

As  to  the  frequency  of  albuminuria  in  diphtheria,  Bouchut  and  Empis 
found  it  in  two-thirds  of  their  cases,  Germain   See  in   one-half  of  his,  and 


ALBUMINURIA.  393 

Sanne  in  224  cases  out  of  410.  Tn  New  York  City,  where  diphtheria  has 
been  many  years  naturalized  or  endemic,  1  made  in  the  years  1875  and  1876 
daily  examinations  of  the  urine  in  02  consecutive  cases,  and  found  it  present 
in  24,  while  38  were  recorded  exempt.  But  the  proportion  of  cases  as 
stated  in  my  statistics  is  probably  below  the  truth,  for  the  albuminuria  is 
sometimes  transient,  and  it  often  occurs  as  a  mere  trace  and  is  liable  to  be 
overlooked.  Its  duration  is  fref|uently  not  more  than  from  one  to  three 
days,  and  in  the  majority  of  instances  it  does  not  continue  longer  than  ten 
days ;  but  we  are  all  familiar  with  cases  in  which  it  continues  fifteen  or 
twenty  days,  or  even  for  months. 

The  date  of  the  commencement  of  albuminuria  varies  greatly  in  different 
cases.  Perhaps  the  largest  number  of  observations  bearing  on  this  point  are 
those  of  Sanne.  In  224  cases  albuminuria  was  detected  on  the  first  day  of 
diphtheria  in  3,  on  the  second  day  in  10,  on  the  third  day  in  30,  on  the  fourth 
day  in  30,  on  the  fifth  day  in  22.  From  the  sixth  day  to  the  eleventh  the 
number  on  each  day  in  whom  albuminuria  was  present  for  the  first  time 
varied  from  10  to  83.  After  the  eleventh  day  there  were  only  9  new  cases^ 
and  after  the  fifteenth  day  only  1  new  case.  Hence  from  these  statistics  we 
infer  that  there  is  little  danger  that  albuminuria  will  occur  after  the  second 
week  if  the  patient  have  exhibited  no  symptoms  of  it  previously. 

The  amount  of  albumen  in  the  urine  varies  greatly  in  different  patients, 
from  a  slight  cloudiness,  scarcely  visible  after  boiling,  to  so  large  a  quantity 
that  it  becomes  semi-solid  by  the  application  of  heat  or  nitric  acid.  When 
the  proportion  of  albumen  is  very  large,  there  is  also  usually  a  notable  dimi- 
nution in  the  quantity  of  urine  passed.  In  ordinary  cases  the  percentage 
of  albumen  varies  at  different  times.  It  sometimes  disappears  during  one 
or  two  days,  and  we  are  led  to  think  that  the  patient  is  rapidly  recovering,, 
but  its  reappearance  in  full  quantity  shows  that  the  apparent  improvement 
was  due  to  some  transient  cause.  "  Nothing,"  says  Sanne,  "  is  more  irregu- 
lar than  the  course  of  diphtheritic  albuminuria.  At  one  time  the  precipitate 
is  sudden,  abundant,  and  flocculent;  at  another  it  commences  with  an  opaque 
cloud,  and  continues  with  this  characteristic  till  the  time  at  which  it  disap- 
pears." Diphtheritic  albuminuria  differs  in  many  respects  from  that  in  scar- 
let fever.  The  urine  at  first,  when  the  renal  disease  is  active,  sometimes 
presents  a  pinkish  tinge,  and  the  microscope  reveals  the  presence  of  red  blood- 
corpuscles,  but  afterward,  and  in  mild  cases  from  the  first,  the  urine  exhib- 
its nearly  the  normal  appearance,  even  when  very  albuminous,  in  contradis- 
tinction to  its  cloudy  appearance  in  scarlet  fever.  The  specific  gravity  is 
low,  falling  to  1010  or  less,  and  casts,  both  granular  and  hyaline,  are  present. 
When  the  kidneys  are  seriously  implicated  the  quantity  of  urine  is  usually 
notably  diminished.  Great  diminution  is  a  serious  symptom,  and  it  often 
precedes  the  fatal  issue. 

In  favorable  cases  the  albuminuria  does  not  in  the  average  continue  as 
long  as  in  scarlet  fever.  The  albumen  may  disappear  from  the  urine  in  two 
or  three  days  if  its  quantity  has  been  small,  and  in  a  large  proportion  of 
cases  it  disappears  within  ten  days  ;  but  cases  occur  in  which  albuminuria 
continues  many  months,  with  its  final  disappearance  and  the  complete  restora- 
tion of  the  health.  Thus,  a  boy  of  six  years  treated  by  me  had  nephritis 
following  a  very  mild  attack  of  diphtheria.  His  urine  in  the  first  weeks  was 
deeply  tinged  by  the  presence  of  red  blood-corpuscles,  but  its  quantity  was 
normal,  as  determined  by  daily  examinations,  and  it  contained  nearly  or  quite 
the  normal  amount  of  urea.  Its  specific  gravity  was  at  or  under  1010. 
After  a  time  the  blood-corpuscles  disappeared,  the  urine  when  not  heated  had 
its  normal  appearance,  its  specific  gravity  became  normal,  and  the  granular 
casts  at  first  present  disappeared.     The   patient  was  uniformly  cheerful,  was 


394  DIPHTHERIA. 

free  from  fever,  his  appetite  was  good,  and  no  subjective  symptoms  occurred 
to  indicate  renal  disease.  Nevertheless,  after  the  lapse  of  ten  months  a  little 
albumen  vras  still  present  in  the  urine. 

But  the  presence  of  albumen  in  the  urine,  if  considerable,  is  an  unfavor- 
able prognostic  sign.  Sanne  states  that  in  233  cases  of  diphtheria  accompanied 
by  albuminuria  142  died  and  91  recovered.  In  160  cases  in  which  albumi- 
nuria was  absent,  63  died  and  97  recovered.  The  statistics  of  others  corre- 
spond with  those  of  Sanne,  so  that  the  fact  may  be  considered  established 
that  a  larger  proportion  of  cases  of  diphtheria  with  albuminuria  perish  than 
of  those  without  albuminuria.  It  does  not  follow  necessarily  from  this  that 
the  affection  of  the  kidneys  which  produces  the  albuminuria  contributes  to 
the  fatal  result,  for  albuminuria  is  more  frequent  in  grave  cases  than  in  those 
of  a  mild  type.  The  termination  in  death  may  be  due,  and  often  is  largely 
due,  to  other  causes  than  the  renal  disease. 

Although  severe  and  so-called  malignant  forms  of  diphtheria  are  more 
likely  to  be  complicated  by  albuminuria  than  are  mild  forms  of  the  disease, 
yet,  as  in  scarlet  fever,  severe  and  fatal  renal  disease  giving  rise  to  albumi- 
nuria sometimes  occurs  in  very  mild  cases  of  diphtheria.  Several  years  ago  I 
attended  a  child  of  six  years  with  the  following  history :  He  had  mild 
pharyngitis,  with  scarcely  appreciable  exudation  and  almost  no  constitutional 
disturbance.  On  the  second  day  the  patient  seemed  so  nearly  well  that  both 
the  doctor  and  the  intelligent  grandmother  who  had  charge  of  him  did  not 
think  further  medical  attendance  necessary.  One  week  subsequently  I  was 
summoned  to  the  child  in  haste  on  account  of  nearly  complete  suppression 
of  urine.  About  one  drachm  was  passed  each  time  and  at  long  intervals. 
This  when  heated  became  semi-solid.  The  late  Prof.  Austin  Flint,  who  saw 
the  case  in  consultation,  and  myself  notified  the  family  of  the  extreme  grav- 
ity of  the  case  and  its  approaching  fatal  termination — a  prediction,  which  was 
verified  in  forty-eight  hours.  In  such  rare  cases,  while  the  diphtheritic 
poison  acts  with  great  power  upon  the  kidneys,  producing  a  fatal  nephritis,  its 
influence  is  feebly  felt  in  those  tissues  which  are  the  usual  seat  of  diphthe- 
ritic inflammation.  Diphtheritic  albuminuria  is  rarely  attended  by  anasarca  or 
by  symptoms  of  uraemic  poisoning.  In  224  cases  of  diphtheritic  albumi- 
nuria embraced  in  Sanne's  statistics,  dropsy  occurred  in  only  7.  Trousseau 
did  not  meet  it  oftener  than  in  1  case  in  20.  Its  infrequency  has  been 
attributed  to  the  fact  that  only  one  kidney  or  only  portions  of  the  kidneys 
have  been  affected,  the  sound  portions  performing  sufiiciently  the  excretory 
function. 

Oertel  says  :  "  The  albuminuria  of  diphtheria  is  referable  to  many  causes, 
of  which  the  virus  circulating  in  the  blood  is  only  one.  Cardiac  failure, 
respiratory  difficulty,  the  febrile  process,  are  adequate  for  the  production  of 
this  symptom.  The  kidneys  in  cases  where  albuminuria  has  been  present 
may  be  quite  normal,  or,  on  the  other  hand,  they  may  exhibit  varying 
degrees  of  parenchymatous  inflammation."  '  The  two  common  causes  appear 
to  be  passive  congestion  of  the  kidneys,  as  of  other  organs,  occurring  during 
the  dyspnoea  of  croup  or  from  heart-failure,  the  albumen  escaping  from  the 
over-distended  renal  veins,  and  parenchymatous  nephritis,  in  which  the  tubules 
contain  detached  and  disintegrating  epithelial  cells.  In  parenchymatous 
nephritis  granular  casts  are  commonly  present. 

As  regards  prognosis,  writers  agree  that  diphtheritic  albuminuria  in  itself 
does  not  tend  to  a  fatal  result  in  most  cases,  the  unaffected  portions  of  the 
kidneys,  as  stated  above,  being  sufficient  for  the  excretion  of  the  deleterious 
products,  especially  the  urea,  whose  retention  in  the  system  would  involve 
danger.     Therefore  Sanne   says  "  that   diphtheritic   albuminuria    is   an   epi- 

^  Synopsis  of  Oertel's  monograph,  London  Lancet. 


PARALYSIS.  395 

phenomenon  which  in  the  vast  majority  of  cases  remains  without  influence 
upon  the  course  of  the  disease."  But  cases  do  occur,  as  we  have  seen  by 
the  history  related  above,  in  which  fatal  albuminuria,  or  fatal  nephritis  pro- 
ducing albuminuria,  does  take  place  as  a  complication  or  sequel  of  diphtheria. 
Unruh  in  1881 '  expressed  the  opinion  that  the  albuminuria  of  diphtheria 
results  from  a  simple  transudation.  But  more  exact  microscopic  examina- 
tions show  that  it  is  only  in  cases  of  croupal  asphyxia  or  heart-failure  that 
that  degree  of  passive  renal  congestion  occurs  which  leads  to  a  transudation 
of  serum.  When  there  is  no  obstructed  respiration,  and  no  marked  weakness 
of  the  pulse,  the  albuminuria  is  a  result  and  symptom  of  infectious  nephritis. 
Prof.  Bouchard'^  states  that  infectious  nephritis,  whatever  the  cause  or  source 
of  the  infection,  is  a  parenchymatous  nephritis.  Says  he  :  "  The  kidneys  are 
sometimes  augmented  in  volume  and  weight.  Their  capsule  has  the  ordinary 
appearance  and  adherence.  The  cortical  substance  appears  sometimes  gray- 
ish, sometimes  congested  and  sprinkled  with  whitish  tracts.  The  medullary 
substance  preserves  its  normal  aspect.  In  kidneys  thus  changed  microscopic 
pathological  anatomy  reveals  integrity  of  the  tubes  of  Henle,  catarrhal  change 
of  the  straight  tubes,  and  to  a  considerable  extent  of  the  convoluted  tubes. 
In   the  convoluted  tubes  the  epithelial  cells  remaining  in  place  are  swollen 

and  sodden  together.     The  cellular  mass  is  entirely  granular Not  only 

are  the  convoluted  tubes  obstructed  by  granular  cells,  but  they  are  filled  in 
some  points  by  colloid  matter  or  by  blood.  The  glomeruli  appear  healthy, 
but  we  have  seen  the  glomerular  capsule  distended  with  blood.  In  another 
case  Kenaut  has  seen  it  distended  by  colloid  matter."  Brault^  has  observed 
in  diphtheritic  albuminuria  intense  congestion  of  the  capillaries  of  the  tubules 
and  glomeruli,  altered  epithelial  cells,  and  transuded  blood-elements  indicative 
of  parenchymatous  inflammation. 

Paralysis. 

Another  very  important  symptom  and  sequel  of  diphtheria  is  paralysis. 
It  has  diagnostic  and  prognostic  value.  Writers  in  medicine  prior  to  the 
sixteenth  century  were  either  ignorant  of  diphtheritic  paralysis,  or  they 
vaguely  alluded  to  it  when  they  described  the  extreme  debility  which  some- 
times accompanies  or  follows  diphtheria.  No  clear  and  certain  allusion  to  it 
has  been  discovered  in  medical  literature  until  near  the  close  of  the  sixteenth 
century.  According  to  Sanne,  Nicholas  Lepois  referred  to  it  in  1580,  and 
Miguel  Heredia  in  1690.  Ghisi,  in  a  letter  describing  the  epidemic  which 
occurred  in  Cremona  on  the  north  bank  of  the  river  Po  in  1747-48,  writes 
of  his  own  son,  who  had  paralysis  in  a  severe  form  following  diphtheria,  "  I 
left  to  nature  the  cure  of  the  strange  consequences,  ....  which  had  been 
remarked  in  many  who  had  already  recovered,  and  which  had  continued  for 
about  a  month  after  recovery  from  the  sore  throat  and  abscess.  During  this 
period  this  child  spoke  through  the  nose,  and  food,  particularly  that  which 
was  least  solid,  returned  through  the  nares  in  place  of  passing  down  the 
gullet."  In  France  also  diphtheritic  paralysis  began  to  attract  attention 
at  or  about  the  time  when  Ghisi  in  Italy  wrote  the  above.  Chomel  in  1748 
described  two  cases,  following  what  he  designated  gangrenous  sore  throat. 
The  first  patient,  he  says,  had  not  quite  commenced  convalescence  at  the 
forty-fifth  day  of  the  disease,  having  still  difficulty  in  articulating,  speaking 
through  the  nose,  and  having  the  uvula  pendulous.  In  the  second  case  the 
patient  became  squint-eyed  and  deformed,  but  day  by  day  as  his  strengih 
returned  he  regained  his  natural  appearance. 

'  Jahrb.  fur  Kinderheilk.  ^  Revue  de  Medecine,  1881. 

^Jour.  d'Anat.  et  de  Phys.,  Nov.,  1880. 


396  DIPHTHERIA. 

In  America,  in  1771,  Dr.  Samuel  Bard  of  New  York  also  related  a  case 
of  this  form  of  paralysis :  A  girl  of  two  and  a  half  years  had  recovered  from 
a  diphtheritic  sore  throat,  and  a  diphtheritic  pseudo-membrane  upon  the  skin 
following  the  application  of  a  blister  had  disappeared,  when  her  convalescence 
was  retarded  by  paralytic  symptoms.  "  Whenever,"  says  Bard,  "  she  attempted 
to  drink  she  was  seized  with  a  fit  of  coughing,  yet  she  was  able  to  swallow 
solid  food  without  any  difficulty.  She  improved,  but  in  the  second  month 
she  could  scarcely  walk  or  raise  her  voice  above  a  whisper." 

From  the  time  of  Chomel,  Ghisi,  and  Bard  more  than  half  a  century 
elapsed  during  which  diphtheritic  paralysis  attracted  little  attention,  though 
Jurine  and  Albers  alluded  to  it  in  1809.  It  cannot  be  doubted  that  cases 
occurred  in  this  long  period  wherever  diphtheria  prevailed,  but  it  might  have 
been  of  such  a  type  that  the  paralysis  was  infrequent,  for  Bretonneau, 
although  he  was  familiar  with  Ghisi's  and  Bard's  writings,  did  not  recollect 
that  he  had  seen  a  case  of  diphtheritic  paralysis  prior  to  1843.  Although  a 
close  observer  of  diphtheria,  the  paralysis  had  not  been  observed  by  him,  or 
at  least  had  not  attracted  his  attention,  until  it  occurred  in  the  person  of  his 
townsman,  Dr.  Turpin,  in  1843.  Twelve  years  subsequently,  in  1855,  Bre- 
tonneau  had  made  a  sufficient  number  of  observations  to  convince  him  that 
diphtheria  frequently  gave  rise  to  a  peculiar  form  of  paralysis,  and  in  his 
writings  of  this  year  he  called  the  attention  of  physicians  to  this  fact.  But 
the  opinions  expressed  by  the  eminent  physician  of  Tours  did  not  gain  gen- 
eral acceptance  until  his  friend  and  admirer  Trousseau,  at  first  distrustful  of 
the  existence  of  such  a  paralysis,  had  made  a  series  of  observations  which 
fully  established  in  his  mind  the  theory  of  Bretonneau.  His  remarks  on  this 
subject,  published  in  his  Treatise  on  Clinical  Medicine^  are  interesting,  as 
showing  how  gradually  important  truths  are  revealed  in  medicine.  He  had 
seen  as  far  back  as  1833  a  marked  case  in  the  service  of  Recamier  in  the 
Hotel-Dieu,  and  another  equally  severe  and  typical  case  in  1846,  but  it  was 
a  long  time  before  he  recognized  this  ailment  as  one  of  the  eff"ects  of  the 
diphtheritic  poison.  Says  he,  speaking  of  the  cases  seen  in  1833  and  1846  : 
"  They  were  a  dead  letter  to  me,  yet  I  was  acquainted  with  the  case  described 
by  Dr.  Turpin  of  Tours.  Bretonneau  related  it  to  me,  and  said  that  it  was 
a  case  of  diphtheritic  paralysis.     The  statement  seemed  to  me  incredible.     I 

refused  to  see  anything  more  in  the  case  than  a  coincidence It  was 

not  till  about  the  year  1852  that,  enlightened  by  new  cases  better  studied 
and  better  interpreted,  I  understood  diphtheritic  paralysis  ae  Bretonneau  under- 
stood it.  From  this  time,  whenever  an  opportunity  occurred,  I  in  my  turn 
called  the  attention  of  my  colleagues  to  this  important  subject."  The  clinical 
teachings  and  observations  of  Bretonneau  and  Trousseau  were  widely  read, 
and  the  profession  throughout  the  world  soon  recognized  the  fact  that  diph- 
theria often  gives  rise  to  a  form  of  paralysis  which,  if  not  peculiar  to  it,  is  yet 
rare  in  other  infectious  diseases.  Since  these  observations  of  Trousseau  were 
published  many  observations  have  been  made  and  many  monographs  on 
diphtheritic  paralysis  have  been  written  by  such  men  as  Roger,  Germain  See, 
Herman  Weber,  Charcot  and  Vulpian,  Gubler,  Landouzy,  Suss,  H.  von 
Ziemssen,  A.  Jacobi,  and  W.  H.  Thomson.  But  the  nature  of  the  paralysis 
and  the  manner  in  which  it  occurs  are  still  undetermined.  The  fact  that 
there  is  such  a  paralysis  was  slow  in  gaining  acceptance  in  the  minds  of 
physicians,  and  so  the  cause  and  pathology  of  the  paralysis  are  still  not  fully 
ascertained. 

Clinical  History. — The  statistics  of  different  writers  vary  in  regard  to 
the  frequency  of  diphtheritic  paralysis.  Probably  it  is  difi'erent  in  difi'erent 
epidemics,  and  some  observers  may  overlook  the  milder  cases,  which  soon 
recover,  and  which  are  indicated  by  a  slight  impediment  in  swallowing  and  a 


PARALYSIS.  397 

slight  nasal  intonation  of  the  voice.  We  may  accept,  as  approximating  the 
truth  as  regards  its  frequency,  the  following  statistics  of  well-known  and 
painstaking  clinical  instructors,  who  would  be  likely  to  detect  the  mildest 
forms  of  paralysis.  In  987  diphtheritic  cases  observed  by  Cadet  de  Gassi- 
court,  paralysis  occurred  in  128;  Kj.G  per  cent,  of  Roger's  cases  of  diphthe- 
ria had  paralysis,  and  11  per  cent,  of  Sanne's  cases. 

But  it  must  be  borne  in  mind  that,  since  paralysis  is  in  most  instances 
post-diphtheritic,  those  severe  cases  which  are  speedily  fatal  from  blood-poi- 
soning or  croup  do  not  live  long  enough  to  suffer  from  it,  and  such  cases 
would  be  more  likely  to  have  the  paralysis,  if  they  lived,  than  the  milder 
cases  which  recover.  Hence  it  has  been  estimated  that,  if  all  diphtheritic 
patients  lived  sufficiently  long,  one  in  every  four,  or  even  one  in  every  three, 
would  exhibit  paralytic  symptoms. 

Time  op  Commencement. — In  most  instances  the  paralysis  does  not  begin 
until  the  period  of  apparent  convalescence  from  diphtheria  and  the  pseudo- 
membrane  has  nearly  or  quite  disappeared.  Sanne  says  it  most  frequently 
appears  from  eight  to  fifteen  days  after  recovery,  the  limit  perhaps  extending 
to  thirty  days,  but  he  adds  that  it  may  appear  from  the  fifth  to  the  eleventh, 
and  even  as  early  as  the  second  or  third,  day  of  diphtheria.  Cadet  de  Gassi- 
court  states  that  in  twenty  of  his  cases  the  paralysis  began  before  the  disap- 
pearance of  the  pseudo-membrane,  most  frequently  about  the  seventh  or  eighth 
day  of  diphtheria.  In  two  it  commenced  on  the  third  day,  and  once  in  a 
prolonged  diphtheria  it  began  as  late  as  the  thirty-fifth  day,  the  pseudo-mem- 
brane still  being  present.  Usually,  according  to  my  observations,  when  paraly- 
sis follows  diphtheria  the  nasal  voice  and  some  impediment  in  swallowing  are 
observed  early  in  the  stage  of  convalescence,  and  at  a  later  period  muscles 
remote  from  the  fauces  may  or  may  not  be  affected.  Dr.  L.  E.  Holt  exhib- 
ited to  the  New  York  Clinical  Society  in  December,  1887,^  a  child  of  two 
years  who  had  diphtheria  in  August  and  a  second  attack  in  the  middle  of 
October.  She  convalesced  slowly,  and  in  her  convalescence  had  no  paralytic 
symptoms,  except  a  nasal  voice,  until  December  1,  when  multiple  paralysis 
suddenly  developed.  A  brother  of  this  patient  also  had  diphtheria  in  Octo- 
ber, moderately  severe,  and  early  in  convalescence  paralysis  of  the  muscles 
of  the  palate  began,  followed  by  that  of  other  muscles,  but  it  was  not  until 
the  middle  of  December  that  the  lower  extremities  were  paralyzed.  These 
cases  are  examples  of  the  usual  mode  of  commencement  and  extension  of 
the  paralysis. 

Diphtheritic  paralysis  is,  therefore,  with  few  exceptions,  a  late  symptom 
of  diphtheria  or  a  sequel ;  but  Dr.  Boissarie  ^  has  related  cases  in  which  the 
paralysis  was  not  preceded  by  the  ordinary  symptoms  of  diphtheria,  and 
which,  so  far  as  I  am  aware,  are  unique.  An  officer  in  the  police  had  been 
ailing  two  or  three  days :  he  had  a  nasal  voice  and  drinks  returned  through 
the  nose.  On  inspection  the  velum  palati  was  found  insensible  and  motionless, 
but  the  fauces  were  otherwise  in  their  normal  state.  In  the  hospital  along- 
side the  barracks  in  which  the  above  case  occurred  a  young  man  without 
fever,  redness,  or  swelling  of  the  fauces  had  also  a  nasal  voice  and  return  of 
liquid  food  through  the  nose.  The  porter  of  the  hospital  was  similarly 
aft'ected,  and  the  doctor  stated  that  certain  other  patients  in  like  manner  pre- 
sented symptoms  of  paralysis  without  the  history  of  an  antecedent  diphtheria. 
Dr.  Reynaud,  called  in  consultation,  expressed  the  opinion  that  the  paralysis 
had  a  diphtheritic  origin  ;  and  this  opinion  was  strengthened  by  the  occur- 
rence immediately  afterward  of  an  epidemic  of  diphtheria  in  the  place  where 
these  cases  occurred.  It  appeared  as  if  the  diphtheritic  poison  had  attacked 
the  kidneys  without  manifesting  its  action  in  any  other  part  of  the  system. 

^  New  York  Medical  Journal,  Dec,  1887.  ^  Gazette  hebdomadaire,  1881. 


398  DIPHTHERIA. 

Certainly,  such  remarkable  cases  should  have  been  more  minutely  examined. 
It  is  remarkable,  inasmuch  as  diphtheria  is  so  widely  spread  and  so  closely 
studied,  that  if  paralysis  is  sometimes  the  only  manifestation  of  the  operation 
of  the  diphtheritic  poison,  other  similar  cases  have  not  been  observed  and 
reported.  It  is,  in  my  opinion,  more  probable  that  in  the  above  cases  diph- 
theria had  occurred  of  so  mild  a  form  that  it  escaped  notice.  I  have  related 
elsewhere  a  case  in  which  diphtheritic  albuminuria  was  preceded  by  diphtheria 
of  so  mild  a  form  as  regarded  the  usual  manifestations  that  it  nearly  escaped 
detection,  and  yet  the  renal  complication  or  sequel  was  so  severe  that  death 
resulted.  In  another  instance  a  little  girl,  not  complaining  of  herself,  left  a 
call  for  a  visit  to  her  brother,  whom  I  found  with  diphtheria  of  rather  a 
severe  type.  At  the  time  of  my  visit  she  was  playing  with  other  children  in 
the  street,  and  it  occurred  to  me  to  call  her  in  and  examine  her  throat.  To 
the  surprise  of  the  family,  the  characteristic  diphtheritic  patch  was  observed 
over  one  tonsil.  Such  mild  walking  cases  are  not  infrequent  in  New  York 
City,  where  diphtheria,  established  for  many  years,  is  constantly  present, 
sometimes  pernicious  and  speedily  fatal,  but  in  other  instances  having  a  type 
at  the  extreme  of  mildness  and  with  no  evidence  of  blood-poisoning.  All 
physicians  who  have  had  much  experience  with  diphtheria,  as  in  localities 
where  it  is  naturalized  or  endemic,  can  recall  cases  in  which  a  sequel  of  diph- 
theria, such  as  paralysis  or  albuminuria,  has  led  to  an  accurate  diagnosis  of 
a  pre-existing  throat  affection  which  was  so  mild  that  its  true  nature  was  not 
suspected.  In  this  respect  diphtheria  resembles  scarlet  fever,  which  also 
presents  an  equally  variable  type  from  extreme  mildness  to  a  fatal  severity. 
Hence  it  seems  probable  that  in  Boissarie's  cases  diphtheria  of  so  mild  a 
form  that  it  escaped  notice  had  preceded  the  paralytic  manifestation. 

The  paralysis,  as  a  rule,  affects  both  motor  and  sensory  nerves.  Thus  in 
paralysis  of  the  velum  and  pharynx  anaesthesia  more  or  less  marked  occurs 
of  the  velum,  the  isthmus  of  the  fauces,  and  the  walls  of  the  pharynx,  in 
addition  to  the  motor  paralysis.  In  the  more  severe  cases  anaesthesia  with 
absence  of  reflex  action  occurs  not  only  over  the  entire  pharynx,  but  also 
over  the  epiglottis.  The  combination  of  motor  and  sensory  paralysis  should 
be  borne  in  mind  in  studying  the  cause  and  nature  of  the  ailment.  The 
muscles  affected  by  diphtheritic  paralysis  atrophy  as  in  other  forms  of 
paralysis.  Dr.  H.  von  Ziemssen^  says  that  such  marked  atrophy  does  not 
occur  in  any  other  disease,  except  in  acute  poliomyelitis  and  saturnine 
paralysis. 

The  symptoms  and  course  of  diphtheritic  paralysis  vary  according  to  its 
location  and  the  muscles  affected.  Therefore  we  will  sketch  the  clinical  his- 
tory of  its  various  forms  separately,  beginning  with  that  which  is  first  in 
time,   most  frequent,   and  least   dangerous : 

1.  Loss  of  the  Tendon  Reflexes. — In  1882,  Dr.  Buzzard  made  the 
observation  that  the  knee-jerk  is  absent  in  cases  of  diphtheritic  paralysis. 
Bernhard'^  stated  that  loss  of  knee-jerk  may  precede  other  nervous  symptoms,. 
or  may  occur  without  other  symptoms  indicating  impairment  of  the  nervous 
system.  He  also  stated  a  fact,  now  generally  admitted,  that  the  loss  of  knee- 
jerk  may  have  diagnostic  value  in  indicating  the  diphtheritic  nature  of  a  pre- 
existing obscure  disease.  But  the  profession  in  this  country  had  little  know- 
ledge of  the  loss  of  the  tendon  reflexes  in  diphtheria  until  Prof.  R.  L.McDon- 
nell  of  the  Montreal  General  Hospital  read  a  paper  on  this  subject  before  the 
Canada  Medical  Association,  August  31, 1887,  and  published  it  in  the  Medical 
JVeivs  of  Philadelphia  in  the  following  October.  Dr.  McDonnell's  observations 
relate  to  18  cases  of  diphtheria  admitted  into  the  General  Hospital.  Of 
these  18  patients,  10  had  loss  of  knee-jerk  at  the  time  of  admission,  while 
1  Klinische  Vortrdge,  1887,  No.  iv.  ^  Virchoufs  Archiv,  Bd.  xcix. 


PARALYSIS.  399 

in  the  remaining  8  it  was  present.  The  cases  observed  by  the  doctor  were 
sufficient,  he  believed,  to  enable  him  to  make  the  following  statement :  Knee- 
jerk  in  many  cases  of  diplitheria  is  absent  from  the  very  first  day  of  llie  illness. 
It  is  a  noteworthy  fact  that  in  most  of  the  cases  detailed  by  McDonnell  in 
which  there  was  loss  of  the  tendon  reflex  other  forms  of  paralysis  subse- 
quently appeared. 

Since  the  publication  of  Dr.  McDonnell's  paper  many  observations  have 
been  made  confirmatory  of  his  statement.  At  a  meeting  of  the  New  York 
Clinical  Society,  held  December  23,  1887,  Dr.  L.  E.  Holt  exhibited  a  brother 
and  sister  of  five  and  two  years  with  multiple  paralysis  who  had  lost  the 
knee-jerk,  and  the  examination  of  one  of  them  showed  complete  loss  of  the 
plantar  reflex.  Since  the  attention  of  the  profession  has  been  directed  to  the 
loss  of  the  tendon  reflexes,  all  observers  admit  that  it  is  not  only  the  earliest, 
but  also  the  most  frequent,  of  the  paralytic  symptoms,  probably  occurring  in 
one-third  to  one-half  of  all  cases  under  treatment.  Dr.  Angel  Money,  in  a 
discussion  before  the  London  Clinical  Society,  September,  1887,  stated  that 
he  had  observed  an  initial  increase  of  the  knee-jerk  preceding  its  abolition. 
Dr.  H.  von  Ziemssen  remarks  that,  while  the  tendon  reflexes  are  so  often  lost, 
the  cutaneous  reflexes  are  frequently  exaggerated. 

The  loss  of  the  tendon  reflexes,  while,  as  we  have  stated,  it  is  the  first  in 
time  of  the  paralytic  symptoms,  appears  also  to  have  the  longest  duration. 
In  cases  of  multiple  paralysis  it  seems  to  be  the  last  to  disappear.  Thus, 
Dr.  McDonnell  states  that  the  loss  of  knee-jerk  in  a  boy  of  fourteen  years 
continued  four  months,  and  in  his  two  sisters  it  was  still  present  when  all 
other  symptoms  of  the  disease  had  disappeared. 

2.  Palatal  Paralysis. — With  the  exception  of  the  loss  of  the  tendon 
reflexes  the  most  common  form  of  diphtheritic  paralysis  is  that  in  which 
the  velum  palati  and  muscles  of  the  pharynx  are  afiected.  This  form  of 
paralysis  is  revealed  by  a  nasal  intonation  of  the  voice,  slow  speech,  snoring 
during  sleep,  difficult  deglutition,  and  return  of  liquids  through  the  nares. 
As  the  paralysis  increases  in  severity  and  extent,  and  the  palato-glossus  and 
constrictor  muscles  of  the  pharynx  become  paralyzed,  the  diificulty  in  swal- 
lowing increases.  The  patient  finds  it  necessary  to  throw  his  head  backward 
in  swallowing  and  to  swallow  slowly  and  in  small  amount.  The  food  descends 
in  the  a?sophagus  by  its  weight,  and  with  but  little  aid  from  the  pharyngeal 
muscles.  On  examining  the  fauces  we  discover  the  velum  relaxed  and 
motionless,  and  the  uvula,  deprived  of  its  tonicity,  drops  on  the  base  of  the 
tongue.  On  touching  the  uvula  with  the  point  of  a  pen  or  pencil  it  is  found 
to  be  insensible,  no  reflex  action  occurring.  Sensory  paralysis  occurs,  as  a 
rule,  in  typical  eases,  the  patient  experiencing  no  pain  when  the  parts  are 
pricked  with  a  pin  or  other  instrument.  The  fauces  should  be  inspected  and 
tested  from  day  to  day  in  order  to  determine  the  progress  of  the  paralysis. 
In  mild  cases  it  may  be  limited  to  the  velum  and  palate,  but  it  frequently 
extends  to  the  epiglottis  and  upper  part  of  the  larynx,  so  that  in  attempts  to 
swallow  portions  of  the  food  enter  the  larynx,  exciting  a  cough.  The  affected 
muscles  may  regain  their  use  in  less  than  a  week,  but  frequently  from  one  to 
two  months  elapse  before  their  function  is  restored. 

Palatal  paralysis  terminates  favorably  with  few  exceptions,  if  the  patients 
are  otherwise  in  good  condition,  but  if  there  be  much  prostration  from  the  ante- 
cedent diphtheria  and  from  the  dysphagia,  death  may  occur  from  inanition. 
Cadet  de  Gassicourt  has  cited  two  cases  of  death  from  this  cause,  although 
life  was  probably  prolonged  by  feeding  by  means  of  an  oesophageal  tube  intro- 
duced through  the  nostrils.  Rarely,  also,  death  has  occurred  from  the  descent 
of  food  into  the  air-passages  and  the  plugging  of  a  bronchus.  Tardieu  and 
Peter  have  each  related  a  case  of  this  mode  of  death.     As  a  chief  function 


400  DIPHTHERIA. 

of  the  velum  palati  is  to  close  the  posterior  nasal  fossae  during  deglutition, 
food,  especially  if  liquid,  is  liable  to  be  returned  through  the  nostrils  until 
the  function  of  the  velum  is  restored. 

3.  Multiple  Paralysis. — This  form  of  paralysis  is  commonly  preceded  by 
loss  of  the  tendon  reflexes.  In  most  instances  it  begins  with  loss  of  power  in 
the  muscles  of  the  palate,  but  exceptions  occur.  Cases  are  reported  in  which 
the  muscles  of  the  eye,  those  of  motion  and  of  accommodation,  are  first  para- 
lyzed, the  palatal  muscles  being  unaffected  or  subsequently  attacked.  Trous- 
seau has  stated  that  in  cutaneous  diphtheria  the  first  loss  of  muscular  power 
is  sometimes  in  the  lower  extremities  instead  of  in  the  palate ;  and  other 
observers  have  recorded  cases  in  which  multiple  paralysis  commenced  in  one 
or  more  of  the  extremities.  Therefore  the  order  of  the  paralytic  seizures 
differs  in  different  cases,  and  muscles  are  affected  in  one  patient  that  escape 
in  another.  The  degree  of  paralysis  varies  in  different  muscles.  In  some 
the  loss  of  power  is  complete,  while  in  others  it  is  partial.  When  the  lower 
extremities  are  entirely  motionless  the  patient  frequently  has  considerable 
use  of  the  upper  extremities. 

Even  in  the  severest  cases  many  groups  of  muscles  entirely  escape. 
Therefore  I  prefer  the  term  multiple  paralysis  to  the  term  general  paralysis 
employed  by  some  writers  to  designate  this  form  of  the  disease. 

Trousssau  speaks  of  what  he  designates  the  mutability  of  diphtheritic 
paralysis.  He  says  the  paralysis  which  occupies  one  limb  disappears  in  this 
limb  to  manifest  itself  in  another.  "  The  numbness,  for  example,  which  the 
patient  has  been  experiencing  in  one  leg  will  suddenly  cease,  and  become 
greater  in  the  other  leg.  To-day  the  right  hand  will  not  give  a  dynamomet- 
ric  pressure  of  more  than  ten  to  twelve  kilogrammes,  and  to-morrow  its  power 
will  have  augmented,  while  that  of  the  left  will  have  diminished ;  then  the 
parts  which  were  first  affected  are  a  second  time  attacked  and  become  more 
affected."  Even  the  dysphagia  may  vary  on  different  days,  as  Cadet  de  Gas- 
sicourt  has  stated.  He  relates  the  case  of  a  child  of  three  and  a  half  years 
in  whom  the  velum  palati  suddenly  resumed  its  function  :  the  head,  which 
had  dropped  from  paralysis  of  the  muscles  of  the  neck,  became  erect,  the 
patient  was  able  to  sit,  and  the  upper  extremities  recovered  their  power,  but 
the  improvement  was  of  short  duration,  the  paralysis  returning  as  at  first. 
These  sudden  and  unexplained  variations  in  the  degree  of  paralysis  resemble, 
says  Trousseau,  the  mutability  of  paralysis  in  hysteria.  Among  the  most 
noteworthy  of  the  paralyses  resulting  from  diphtheria  are  those  pertaining  to 
the  eye.  The  media  and  retina  are  unaffected,  but  the  levator  palpebrae,  the 
muscles  of  accommodation,  and  the  motor  muscles  of  the  eye  are  paralyzed 
in  certain  patients,  so  as  to  cause  dropping  of  the  eyelids,  strabismus,  and 
indistinct  vision.  In  addition  to  the  muscles  already  mentioned,  various 
muscles  of  the  trunk,  of  the  neck,  the  sphincter  ani,  and  the  sphincter 
vesicae  are  sometimes  paralyzed,  producing  deformity  and  incontinence  of 
urine  and  feces.  The  paralysis  of  the  muscles  of  accommodation  is  usually 
such  that  patients  become  presbyopic,  seeing  distinctly  distant,  but  not  near, 
objects. 

The  muscles  of  the  face  are  also  occasionally  paralyzed.  Many  observers 
have  related  cases  of  facial  hemiplegia.  When  general  paralysis  of  the  facial 
muscles  occurs — fortunately,  a  rare  event — whatever  the  mental  state,  how- 
ever great  the  excitement,  the  features  are  entirely  devoid  of  expression  ;  the 
aspect  is  dull  and  idiotic  ;  the  face  is  flabby  and  motionless ;  the  lids  and  lips 
droop ;  saliva  flows  from  the  mouth  ;  and  speech  is  slow  and  difficult.  At 
the  same  time,  the  mental  faculties,  though  deprived  of  the  usual  mode  of 
expression,  are  sound  and  active. 

But  the  most  accurate  idea  of  the  symptoms  of  multiple  paralysis  can  be 


PARALYSIS.  401 

imparted  by  the  narration  of  a  case,  and  I  select  for  this  purpose  the  graphic 
description  of  this  form  of  paralysis  published  by  T)r.  C.  W.  Fallis  in  the  Med- 
ical Sunirnarjj  for  January,  1888.  He  describes  the  ailment  as  it  occurred  in 
his  own  person,  as  follows:  "About  three  weeks  after  the  subsidence  of  the 
disease  [diphtheria]  the  paralytic  symptoms  began  to  show  themselves.  Im- 
paired vision  was  the  first'  trouble  noticed,  inability  to  accommodate  the  eyes 
to  near  objects,  and  in  taking  up  the  paper  to  read  one  morning  I  found  I 
could  scarcely  see  a  word,  and  soon  after,  although  distant  objects  could  be 
seen  as  well  as  ever,  high-power  glasses  were  refjuired  to  read  any  kind  of 
print.  Double  vision  was  noticed  afterward.  At  about  the  same  time  numb- 
ness of  the  tongue  was  felt;  the  muscles  of  deglutition  became  paralyzed,  so 
that  swallowing  was  attended  with  strangling  and  regurgitation  of  food 
through  the  nose.  There  was  a  rapid  pulse,  120  to  the  minute,  showing  that 
the  pneumogastric  was  involved.  Weakness  of  the  limbs,  causing  a  stagger- 
ing gait,  appeared  ;  fingers  became  weak  and  numb,  so  that  small  objects 
could  not  be  picked  up,  the  symptoms  becoming  worse  and  worse  as  the  dis- 
ease progressed.  The  muscles  of  the  left  side  of  the  face  became  affected 
with  all  the  symptoms  of  facial  paralysis  from  organic  disease.  Motion 
became  more  and  more  impaired,  till  I  could  neither  stand  nor  walk,  and 
when  at  the  worst  I  was  perfectly  helpless,  could  not  feed  myself,  had  to  be 
lifted  from  chair  to  chair,  turned  in  bed,  and  could  not  even  lift  ray  hand  to 
my  head  or  throw  one  limb  over  the  other.  Sensation  was  so  impaired  that 
hands  and  feet  felt  like  lifeless  weights,  and  in  the  dark  I  could  not  tell 
whether  my  feet  were  on  the  floor  or  not.  The  muscles  of  respiration  were 
at  no  time  affected  to  such  an  extent  as  to  render  breathing  difficult,  and  the 
power  of  perfect  speech  was  retained.  Paralysis  of  the  bowels  necessitated 
the  use  of  warm-water  injections  to  promote  their  action.  Some  of  the  symp- 
toms abated,  while  others  became  more  aggravated,  those  first  to  appear  being 
generally  the  first  to  subside :  however,  the  smaller-sized  muscles  recovered 
rapidly,  while  the  large  fleshy  ones  were  more  tardy  in  reaching  their  normal 
state,  the  facial  paralysis  lasting  but  a  few  days,  while  locomotion  was  either 
labored  or  impossible  for  many  weeks.  The  course  of  the  disease  from  the 
beginning  to  the  worst  stage  was  about  nine  weeks,  when  it  remained  station- 
ary for  two  weeks.  Improvement  was  at  first  very  slow  and  tedious,  but 
after  I  could  walk  a  little  it  was  much  more  rapid,  and  by  the  fifteenth  week, 
with  the  exception  of  some  weakness,  I  was  well." 

Multiple  paralysis  not  infrequently  continues  from  two  to  six  months. 
As  might  be  expected,  the  prognosis  is  less  favorable  when  the  paralysis  is 
multiple  than  when  it  is  restricted  to  the  velum  and  pharynx.  In  13  cases 
observed  by  Cadet  de  Gassicourt,   6  died. 

4.  Cardiac  Paralysis  fthe  cardio-puhnonari/  poralysis  of  certain  French 
writers). — In  cases  of  the  first,  second,  and  third  forms  of  paralysis  which 
have  been  considered  above  the  vital  organs  are  not  directly  involved. 
These  paralyses,  however  inconvenient  they  may  be,  are  not  directly  fatal. 
The  paralysis  which  we  are  about  to  consider  presents  a  very  different  clin- 
ical aspect,  inasmuch  as  the  organs  affected  are  among  the  most  important 
in  the  system,  a  serious  impairment  of  their  functions  rendering  death  inevi- 
table. 

Physicians  who  have  had  experience  in  the  treatment  of  diphtheria  have 
met  cases  in  which  symptoms,  usually  of  sudden  development,  indicated 
dangerous  heart-failure.  Perhaps  the  patient  has  been  gradually  improving, 
the  pseudo-membrane  has  nearly  or  quite  disappeared,  the  temperature  is 
not  far  from  normal,  the  swallowing  is  better  and  more  nutriment  is  taken, 
the  family  are  cheerful  in  the  prospect  of  a  speedy  recovery,  and  the  phy- 
sician expects  soon  to  discharge  the  patient  cured.  Suddenly  the  scene 
26 


402  DIPHTHERIA. 

changes.  The  pulse  becomes  feeble  and  abnormally  slow  or  rapid — it  is 
usually  at  first  slow  and  subsequently  rapid — the  respiration  is  superficial, 
and  the  surface  becomes  pallid,  often  slightly  cyanotic.  In  the  more  favor- 
able of  these  cases  the  patient  may  rally  by  active  stimulation,  and  perhaps 
he  eventually  recovers,  or  after  some  hours  or  a  day  or  two  of  comparative 
comfort  he  succumbs  to  a  return  of  heart-failure.  There  is  no  other  disease 
in  which  these  sudden,  unforeseen,  and  fatal  attacks  of  heart-failure  occur  so 
frequently  as  in  diphtheria.  There  is  no  other  disease  in  which  physicians 
are  so  frequently  deceived  in  their  prognosis  for  various  reasons,  but  largely 
on  account  of  the  occurrence  of  these  unexpected  attacks  of  heart-weakness. 

But  a  clear  and  accurate  idea  of  the  clinical  history  of  these  eases  of 
sudden  heart-failure  can  be  best  imparted  by  the  relation  of  typical  cases. 
For  this  purpose  I  will  briefly  narrate  cases  occurring  in  the  hospital  service 
of  one  of  the  most  trustworthy  clinical  teachers  of  the  present  time,  M. 
Cadet  de  G-assicourt,  though  I  believe  that  all  physicians  who  have  been  sev- 
eral years  in  practice  where  diphtheria  is  prevailing  can  recall  to  mind  cases 
equally  striking  and  typical.  I  select  his  cases  on  account  of  the  complete- 
ness of  his  records : 

A  child  of  two  years  entered  Cadet  de  Gassicourt's  service  on  January 
3d  with  diphtheritic  pharyngitis  of  ten  days'  continuance.  The  tonsils  were 
large,  still  covered  with  pseudo-membrane,  and  the  submaxillary  glands  were 
also  enlarged.  He  had  no  laryngeal  symptoms  and  his  urine  was  without 
albumen.  On  the  following  day  the  velum  and  pharyngeal  muscles  were 
slightly  paralyzed,  the  speech  nasal,  and  deglutition  moderately  embarrassed. 
He  was  quiet  during  the  night  of  January  4th  and  in  the  morning  of  the  5th, 
but  at  ten  A.  M.  he  became  chilly,  his  face  and  extremities  feebly  cyanotic, 
and  slight  dyspnoea  and  dilatation  of  the  alse  nasi  were  observed.  His  pulse, 
at  first  abnormally  slow,  became  rapid ;  he  was  agitated,  uttered  loud  screams 
of  distress,  and  fell  back  cyanotic  and  dead.  The  death-struggle  did  not 
occupy  more  than  one  minute.  Another  infant,  also  two  years  of  age, 
entered  the  same  service,  having  diphtheritic  pharyngitis  of  two  days'  con- 
tinuance. The  fauces  presented  the  usual  red  appearance,  the  tonsils  were 
swollen  and  covered  with  a  thick  exudate,  but  there  was  no  albuminuria  nor 
croupiness.  Two  days  later  the  pseudo-membrane  had  diminished,  but  the 
velum  palati  was  paralyzed.  On  the  following  day  the  general  appearance 
was  satisfactory  and  the  pseudo-membrane  had  still  further  diminished.  At 
eight  P.  M.  the  infant  was  suddenly  seized  with  vomiting,  accompanied  with 
great  dyspncea,  rapid  pulse  (160),  and  a  cyanotic  hue  of  the  face  and 
extremities.  He  was  restless  and  uttered  cries  of  distress.  Two  hours  later 
he  screamed  loudly,  raised  himself  in  bed,  and  fell  back  dead.  A  child  of 
five  years  was  admitted  with  diphtheritic  pharyngitis  of  two  days'  continu- 
ance, having  enlarged  tonsils  covered  with  pseudo-membrane,  and  enlarged 
cervical  glands,  but  without  cough  or  albuminuria.  Seven  days  later,  the 
ninth  of  the  disease,  the  pseudo-membrane  had  disappeared,  but  the  velum 
palati  was  paralyzed.  On  the  following  day  there  was  little  change,  except 
occasional  vomiting,  but  the  general  state  was  good  and  sleep  tranquil.  At 
seven  A.  M.  on  the  following  day,  the  eleventh  of  the  disease,  after  a  calm 
night,  the  child  uttered  two  or  three  cries,  the  pulse  became  rapid,  the  respi- 
ration embarrassed,  the  features,  extremities,  and  finally  the  entire  surface, 
cyanotic,  and  at  eight  A.  M.  death  occurred  quietly. 

The  similarity  of  these  three  cases  is  apparent.  Paralysis  of  the  velum 
and  palate  had  continued  in  the  first  case  eighteen  hours,  in  the  second  case 
thirty-six  hours,  and  in  the  third  case  forty-eight  hours,  when  suddenly  the 
heart  and  lungs  were  greatly  embarrassed  in  their  functions,  and  death  occur- 
red within  one  hour  from  the  commencement  of  the  severe  symptoms.     The 


PARALYSIS.  403 

agitation,  repeated   cries   of  distress,  and  the  shrill   crj'  that  preceded  death 
indicated  extreme  suffering. 

Severe  pain,  praecordial,  epigastric,  or  ahd(jniiiial,  is  present  in  some  if 
not  in  most  of  these  cases  of  sudden  heart-failure,  as  we  shall  see  from  others 
presently  to  be  related.  It  was  probably  experienced  by  tliese  three  patients, 
who  were  too  young  to  express  clearly  their  subjective  symptoms. 

Gombault  made  a  minute  microscopic  examination  of  the  affected  organs 
in  these  three  cases  after  the  tissues  had  been  properly  hardened  by  chemical 
agents.  In  one  of  the  cases  he  examined  the  pneumogastrics  and  myo- 
cardium, and  both  were  found  in  their  normal  state.  As  regards  the  nervous 
centres,  the  anatomical  changes  were  alike  in  all  three.  In  the  spinal  cord 
lesions  were  found  at  the  origin  of  the  anterior  roots  of  the  spinal  nerves, 
characterized  by  fragmentation  of  the  medullary  substance  in  the  nerve- 
fibres,  numerous  granules  and  minute  globules  appearing  in  this  substance 
and  occupying  its  place. 

In  addition  to  this,  undue  swelling  of  the  axis-cylinders  was  observed. 
In  the  three  cases  the  gray  substance  in  the  anterior  cornua  had  undergone 
a  sort  of  rarefaction,  the  microscopic  sections  being  more  transparent  and  the 
elements  in  the  section  being  wider  apart  than  in  the  normal  state.  No 
meningitis  or  injury  of  the  blood-vessels  was  observed  in  the  spinal  columns, 
but  numerous  nerve-cells  were  deprived  of  their  prolongations.  The  medulla 
oblongata,  the  centre  and  source  of  the  nervous  supply  to  the  heart,  lungs, 
and  stomach  through  the  pneumogastrics,  was  also  carefully  examined  in  the 
three  cases.  Nothing  abnormal  was  observed  in  this  organ,  except  small 
masses  of  leucocytes  in  the  vessels.  The  substance  of  the  medulla  oblongata 
and  the  nerve-fibres  constituting  the  roots  of  the  pneumogastrics  seemed 
healthy.  The  small  masses  of  leucocytes  in  the  blood-vessels  were  not 
sufficient  to  obstruct  the  circulation,  and  the  appearance  of  the  blood-cor- 
puscles was  normal.  Hence,  in  the  opinion  of  Gombault,  the  small  aggrega- 
tions of  leucocytes  in  the  vessels  had  no  effect  on  the  innervation  of  the 
thoracic  organs  derived  from  the  medulla.  The  points  of  special  interest  in 
the  microscopic  examination  of  the  three  cases  were  the  apparently  healthy 
and  normal  state  of  the  pneumogastrics  and  myocardium  in  the  one  case  in 
which  they  were  examined,  and  of  the  medulla  oblongata  in  the  three  cases, 
while  the  gray  matter  of  the  spinal  cord,  which  has  no  immediate  nerve-con- 
nection with  the  heart,  showed  marked  degenerative  changes. 

The  above  are  striking  examples  of  sudden  and  fatal  heart-failure  occur- 
ring during  apparent  convalescence,  when  the  symptoms  of  diphtheria 
appeared  to  be  abating,  with  the  exception  of  the  paralysis  of  the  velum 
and  palate.  The  following  cases  presented  a  clinical  history  in  some  respects 
different :  A  child  of  eight  years  had  been  under  treatment  for  diphtheria 
since  February  9,  1883.  On  February  20th  the  membrane  had  disappeared, 
but  slight  paralysis  of  the  velum  and  left  upper,  extremity  was  observed  and 
the  urine  contained  a  little  albumen.  At  three  P.  M.  she  was  seized  with 
severe  abdominal  pains,  followed  by  vomiting,  slow  respiration,  slow  and 
feeble  but  regular  heart-beat,  imperceptible  pulse,  coolness  of  surface,  and 
cyanosis.  These  symptoms  increased,  and  at  half-past  six  p.  M.  death  occurred. 
The  clinical  history  differed  from  that  in  the  three  cases  related  above  in  the 
fact  that  there  was  no  agitation  or  moaning  at  the  close  of  life,  and  that  the 
heart-beat  remained  abnormally  slow  unless  during  the  last  moments.  In 
another  case  paralysis  of  the  velum  and  palate  began  on  the  third  day  of 
diphtheria,  while  the  pharyngeal  and  nasal  inflammations  were  in  full  activity. 
The  urine  was  slightly  albuminous.  Three  days  subsequently,  in  the  morn- 
ing, the  muscles  of  the  nucha  and  right  shoulder  were  paralyzed.  At  two 
P.  M.  the  child  complained  of  violent  abdominal  pains,  followed  by  nausea 


404  DIPHTHERIA. 

and  vomiting.  The  vomiting  was  partially  relieved,  but  dyspnoea  and  a  rapid 
heart-beat  followed.  The  cyanosis  increased  until  it  extended  over  the  entire 
surface,  and  death  occurred  three  hours  after  the  commencement  of  symp- 
toms referable  to  heart-failure.  A  boy  of  five  years  had  diphtheritic  croup, 
for  which  tracheotomy  was  performed  and  the  canula  inserted.  He  subse- 
quently did  well  for  a  time,  but  afterward  lost  his  appetite.  On  the  eleventh 
day  of  the  disease  he  had  paralysis  of  the  velum  and  palate.  On  the  twelfth 
and  thirteenth  days  the  disease  seemed  to  be  stationary  and  the  child  was 
quiet.  Suddenly,  at  seven  p.  M.  on  the  thirteenth  day,  multiple  paralysis 
occurred.  Liquid  food  taken  by  the  mouth  was  returned  in  part  through 
the  nostrils,  and  a  part  entered  the  larynx  and  escaped  from  the  tracheal 
opening.  An  hour  later  the  muscles  of  the  nucha,  the  arms,  and  both  sides 
of  the  trunk  were  paralyzed  and  the  head  dropped.  At  seven  A.  M.  on  the 
following  day  vomiting,  dyspnoea,  cyanosis  of  the  face  and  extremities,  and  a 
very  rapid  pulse  occurred.  The  asphyxia  increased,  the  pulse  grew  more 
feeble,  the  surface  cool,  and  death  took  place  three  hours  later. 

Cases  like  the  above  are  not  infrequent  in  severe  epidemics  of  diphtheria, 
but  in  some  instances  the  loss  of  power  in  the  heart  occurs  more  gradually, 
A  boy  of  twelve  years  had  diphtheritic  pharyngitis  from  which  he  was 
apparently  convalescing.  Some  days  after  the  disappearance  of  the  inflam- 
mation the  velum  palati  and  muscles  of  the  pharynx  were  paralyzed.  Then 
succeeded  paralysis  of  the  muscles  of  the  nucha,  of  the  muscles  of  accom- 
modation, and  of  those  of  the  upper  and  lower  extremities.  The  march  of 
the  paralysis  was  for  a  time  progressive.  Then  it  seemed  to  recede,  but  the 
improvement  did  not  continue.  One  month  from  the  commencement  of  diph- 
theria the  child  uttered  plaintive  cries,  became  motionless  as  if  from  general 
paralysis,  and  a  state  of  asphyxia  slowly  occuiTed,  accompanied  by  cyanosis. 
During  the  following  night  the  patient  lay  in  a  stupor,  and  on  the  ensuing 
morning  the  features  presented  a  cadaverous  and  slightly  cyanotic  hue,  the 
extremities  were  cool  and  blue,  the  tongue  pallid,  moist,  and  of  a  normal 
warmth,  the  respiration  hurried  and  without  auscultatory  signs  of  disease, 
the  pulse  feeble  and  rapid  (148).  Finally,  the  sphincters  were  paralyzed,  the 
urine  and  feces  escaping  involuntarily.  Within  ten  minutes  after  the  above 
notes  were  written  the  patient  died  of  heart-failure.  The  feature  of  special 
interest  in  this  case  was  the  long  continuance  of  multiple  paralysis  when  the 
cardiac  and  pulmonary  symptoms  occurred. 

Sudden  heart-failure  in  diphtheria  is  usually  fatal,  but  recovery  is  possi- 
ble. Cadet  de  Gassicourt  in  his  large  clinical  experience  met  1  recovery  to 
14  deaths.  This  case  is  interesting,  since  the  heart-failure  preceded  the  palatal 
and  other  forms  of  paralysis,  instead  of  being  preceded  by  them,  as  is  ordi- 
narily the  case.  Twenty  days  after  the  commencement  of  diphtheria,  and 
when  in  apparent  convalescence,  the  patient  was  seized  with  extreme  pain  in 
the  prgecordial  region,  attended  by  a  fall  of  pulse  to  42.  He  had  cold  sweats, 
rigors,  and  vomiting.  In  one  and  a  half  hours  these  symptoms  abated. 
Three  days  subsequently  another  similar  attack  occurred,  and  subsequently 
two  others,  but  less  severe  than  the  first.  On  the  twenty-eighth  day  from 
the  beginning  of  diphtheria  and  eight  days  after  the  syncopal  attacks  par- 
alysis of  the  velum  and  pharynx  began,  soon  followed  by  paralysis  of  the 
vocal  cords,  of  the  muscles  of  accommodation,  and  of  those  of  the  extremities, 
which  continued  three  months,  when  recovery  was  complete.  Cases  of  recov- 
ery from  sudden  and  alarming  symptoms  of  heart-failure  have  also  been 
related  by  Sanne,  Billard,  and  others. 

What  is  the  cause  of  this  sudden  loss  of  power  in  the  heart  in  diphtheria, 
occurring  usually  during  apparent  convalescence?  Does  it  result  from  dis- 
ease in  the  muscular  structure  of  the  heart,  from  thrombosis  or  ante-mortem 


PARALYSIS.  405 

clots  in  the  cavities  of  the  heart,  or  does  it  result  from  disease  of  the  central 
organ  of  innervation,  the  medulla  oblongata,  or  from  disease  and  deficient 
conducting  power  in  the  important  nerve  which  controls  the  heart's  action, 
the  pneumogastric,  or  in  the  branches  which  this  nerve  supplies  to  the  heart 
as  well  as  the  lungs  and  the  stomach  ? — for  these  three  organs  appear  in  most 
instances  to  be  affected  simultaneously. 

Bouchut  and  Lagrave  attribute  sudden  heart-failure  in  diphtheria  to 
endocarditis ;  and  yet  it  is  very  seldom  that  a  bruit  or  heart-isigns  indicative 
of  endocarditis  have  been  observed  during  life.  The  belief  in  the  ocurrence 
of  this  inflammation  is  based  on  the  appearance  of  the  free  edge  of  the  mitral 
valve,  and  sometimes  of  the  aortic  valves  in  addition.  They  have  appeared 
roughened  as  if  from  the  presence  of  minute  vegetations.  At  the  same  time, 
the  surface  of  the  valves  and  the  endocardial  surface  have  undergone  no 
appreciable  change,  such  as  an  endocarditis  would  be  likely  to  cause.  Since 
the  announcement  of  the  theory  of  Bouchut  and  Lagrave  and  attention  has 
been  drawn  to  the  subject,  the  roughened  edge  of  the  mitral  and  aortic 
valves,  upon  which  their  theory  of  an  endocarditis  as  the  causal  agent 
of  sudden  heart-failure  is  based,  has  been  found  with  equal  frequency  in 
children  who  have  perished  with  other  diseases.  The  late  Prof.  Parrot  says 
Cadet  de  Gassicourt  expressed  the  decided  conviction  that  the  roughening 
of  the  tips  of  these  valves  does  not  have  an  inflammatory  origin,  but  is 
an  anatomical  peculiarity  which  originates  in  the  fcetal  development.  Sanne 
says  in  reference  to  Bouchut  and  Lagrave's  theory.  -  My  personal  investi- 
gations are  absolutely  negative.     Observations  of  diphtheria  to  the  number 

of  149,  taken  in  these  later  years have  not  furnished  a  single  case  of 

endocarditis.  I  should  fear  to  express  myself  in  such  a  positive  manner 
if  I  should  trust  to  the  simple  testimony  of  my  senses;  but  a  large  number 
of  these  patients  were  auscultated  by  Barthez  and  by  D'Espine  and  Gom- 
bault The  conclusion  ....  therefore  is  that  diphtheritic  endocar- 
ditis is  extremely  rare,  as  pathological  anatomy  and  clinical  observation  alike 
demonstrate.'"  Therefore  the  theory  whicb  attributed  sudden  heart-failure 
to  endocarditis  has  not  been  sustained  by  recent  observations,  and  does  not 
appear  to  be  tenable. 

Weakening  of  the  heart's  action  in  diphtheria,  witb  sudden  death  as  a 
consequence,  has  with  more  probability  been  attributed  to  granulo-fatty 
degeneration  in  the  muscular  fibres  of  the  heart  consequent  upon  a  prolonged 
and  severe  diphtheritic  attack.  Oertel  says :  ""Wlien  the  general  disease  lasts 
long  and  is  very  intense,  and  especially  in  cases  in  which  death  is  caused  sud- 
denly by  paralysis  of  the  heart,  the  muscle  appears  pale,  soft,  friable,  broken 
by  extravasations  of  blood,  and  on  microscopical  examination  most  of  its  fibres 
are  seen  to  be  already  in  an  advanced  stage  of  fatty  degeneration.''  Such 
degenerative  changes,  if  occurring  in  a  considerable  proportion  of  the  muscu- 
lar fibres  of  the  heart,  would  inevitably  render  the  contractile  power  of  this 
organ  feeble  and  perhaps  inadequate.  Still,  if  we  regard  it  as  a  cause  of 
sudden  heart-failure,  it  can  be  regarded  as  .such  in  only  a  relatively  small 
number  of  instances,  for  in  most  cases  the  weakening  of  the  power  of  the 
heart  is  sudden  and  during  convalescence — at  a  period,  therefore,  when  degen- 
erative changes  are  not  likely  to  occur.  In  most  of  the  recorded  cases  the 
contractile  power  of  the  heart  does  not  appear  to  have  been  notably  weakened 
previous  to  the  attack  of  heart-failure,  as  it  would  probably  have  been  were 
degenerative  changes  in  the  myocardium  the  sole  or  chief  cause.  The  clini- 
cal history  is  as  if  the  heart  were  suddenly  overpowered  by  an  agent  of  rapid 
— never  slow — development.  Moreover,  in  typical  cases  of  sudden  heart- 
failure  the  microscope   sometimes  reveals  a  healthy  myocardium,  as  in  one 

'  Ziernnien' s  Cyclopadia,  vol.  i. 


406  DIPHTHERIA. 

of  the  cases  related  above.  We  must  look,  therefore,  for  some  other  cause, 
although  admitting  that  degenerative  changes  in  the  muscular  fibres  of  the 
heart,  when  present,  contribute  to  a  weakened  action  of  this  organ. 

Sudden  heart-failure  in  diphtheria  has  also  been  attributed  to  cardiac 
thrombosis ;  but,  as  several  writers  have  pointed  out,  the  heart-clots  are 
identical  in  appearance  and  kind  with  those  found  in  the  heart  after  death 
from  other  diseases  than  diphtheria.  There  is  every  reason  for  the  belief 
that  they  occur  during  the  death-struggle,  and  therefore  are  not  the  primary 
cause  of  the  heart-failure,  but  are  secondary  or  consecutive. 

Among  the  most  strenuous  advocates  of  the  theory  that  cardiac  throm- 
bosis is  the  common  cause  of  sudden  heart-failure  and  sudden  death  in  diph- 
theria is  Dr.  Beverly  Robinson,  now  a  distinguished  physician  of  New 
York,  whose  able  thesis  on  this  subject,  published  in  1871  when  he  was  a 
resident  of  Paris,  attracted  much  attention  and  is  alluded  to  by  nearly  all 
recent  French  writers  on  this  subject.  But  the  opinion  of  most  pathologists 
in  reference  to  this  theory  is,  I  think,  expressed  by  Cadet  de  Gassicourt  in 
the  following  passages,  published  in  his  clinical  treatise :  "  I  have  often 
shown  you  these  clots,  and  I  have  enabled  you  to  see  that  they  occur  equally 
in  children  who  have  died  of  diphtheria  as  well  as  in  those  who  have  suc- 
cumbed to  other  maladies,  in  subjects  struck  with  sudden  death,  and  in  those 
who  have  not  been  attacked  by  any  sudden  casualty.  This  objection  is  in 
itself  conclusive.  You  have  been  able  to  see  also  that  the  constitution  of 
these  clots  does  not  have  any  of  the  characters  which  authors  the  most  com- 
petent have  assigned  to  clots  formed  during  life :  they  are  the  clots  of  the 
agony."     Sanne  also  writes  in  almost  identical  language. 

In  searching  for  the  cause  of  sudden  heart-failure  in  diphtheria  we  must 
note  the  fact  that,  as  a  rule,  in  typical  cases  it  is  preceded  by  palatal  and 
often  multiple  paralysis.  The  paralysis  has  continued  for  a  time,  extending 
perhaps  from  one  group  of  muscles  to  another,  when  suddenly  the  heart 
passes  under  some  powerful  influence  which  restricts  and  overpowers  its 
action.  The  theory  of  deficient  innervation  or  a  true  cardiac  paralysis 
appears  most  tenable  under  the  circumstances.  It  affords  the  most  satisfac- 
tory explanation  of  those  unfortunately  not  infrequent  cases,  in  which  death 
suddenly  occurs  during  apparent  convalescence  from  diphtheria,  when  the 
symptoms  are  fast  disappearing,  with  the  exception  of  the  palatal  or  other 
paralysis.  It  affords  best  of  all  the  theories  an  explanation  of  the  occur- 
rence of  sudden  death  from  heart-weakness  in  those  obscure  cases  which 
have  puzzled  physicians — cases  in  which  the  post-mortem  examination  has 
revealed  an  apparently  healthy  state  of  the  heart.  The  theory  of  an  arrested 
or  deficient  innervation  of  the  heart  also  furnishes  an  explanation  of  the 
occurrence  of  concomitant  symptoms  in  these  cases  of  sudden  heart-failure 
— such  symptoms  as  vomiting,  epigastric  pain,  and  dyspnoea  or  irregular 
respiration  ;  for  the  heart  derives  its  innervation  from  the  same  source  as 
the  lungs  and  the  stomach — that  is,  through  the  pneumogastric.  For  the 
reasons  now  given  we  feel  justified,  in  our  classification  of  the  forms  of 
diphtheritic  paralysis,  to  make  a  distinct  class  having  the  designation  cardiac 
paralysis,  or,  to  adopt  in  our  language  the  French  expression,  cardio-pulmo- 
nary  paralysis. 

Etiology. — The  four  forms  of  diphtheritic  paralysis — first,  the  abolition 
of  the  tendon  reflexes,  the  most  common,  the  earliest,  and  the  least  danger- 
ous of  all ;  secondly,  palatal  paralysis,  which  may  occur  as  early  as  the 
third  day  of  diphtheria,  but  is  most  common  during  its  later  stages,  or  in 
the  period  of  convalescence ;  thirdly,  multiple  paralysis,  in  which  various 
muscles  throughout  the  system  are  paralyzed  ;  and,  fourthly,  cardiac  paraly- 
sis, the  most  dangerous   of  all — probably  are   produced  by  the   same  cause 


PARALYSIS.  407 

and  have  the  same  pathology  in  most  instances.  We  may,  therefore,  in  the 
following  pages,  in  studying  the  cause  and  nature  of  diphtheritic  paralysis, 
regard  the  various  forms  which  it  exhibits  as  manifestations  of  one  disease. 
What  is  true  of  cardiac  paralysis  as  regards  its  cause  and  nature  we  may 
assume  to  be  true  in  reference  to  palatal  and  multiple  paralysis,  and  even  the 
abolition  of  the  tendon  reflexes.  The  must  dangerous  and  fatal  paralysis, 
the  cardiac,  is,  as  we  have  stated  above,  in  nearly  all  patients  associated  with 
the  milder  forms,  showing  that  the  same  cause  or  causes  are  operative  at  the 
same  time  in  the  individual. 

Gubler,  in  his  memoir  published  in  1860-61,  attributed  paralysis  of  the 
velum  and  palate  to  disease  of  the  terminal  nerves  produced  by  contiguity 
or  propagation  from  the  inflamed  fauces:  and  he  held  that  the  same  injury 
of  the  nerves  and  paralysis  might  result  from  any  anginose  inflammation  if 
severe  enough.  But  this  theory  was  short-lived,  for  physicians  soon  per- 
ceived that  it  was  inadequate  to  explain  the  occurrence  of  paralysis  at  a  dis- 
tance from  the  inflamed  surfaces ;  and  palatal  paralysis  sometimes  occurs 
after  cutaneous  and  other  forms  of  diphtheritic  inflammation  in  which  both 
the  fauces  and  the  nares  have  entirely  escaped  and  remained  healthy. 

Trousseau,  impressed  with  the  inadequacy  of  Gubler's  theory,  directed  his 
attention  to  the  nervous  centres.  He  was  led  to  believe,  from  the  fact  that 
the  paralysis  usually  terminates  favorably,  and  because  in  certain  fatal  cases 
he  was  unable  to  discover  any  lesion  sufiicient  to  produce  the  paralysis  in 
the  brain,  spinal  cord,  or  meninges,  that  it  did  not  occur  from  any  structural 
change  in  the  nervous  system.  Trousseau,  an  unsurpassed  clinical  observer, 
was  not  a  microscopist,  and  being  unable  to  discover  any  anatomical  cause  of 
the  paralysis,  he  relates  the  case  of  the  crew  of  a  vessel  who  were  paralyzed 
by  eating  an  eel  which  contained  some  poisonous  ingredient,  and,  after  allud- 
ing to  instances  of  paralysis  resulting  from  smallpox,  typhoid  and  typhus 
fevers,  and  cholera,  continues  :  "  Well,  then,  diphtheritic  paralysis  belongs 
to  the  same  category  :  its  real  cause  is  the  poisoning  of  the  system  by  the 
morbific  principle  which  generates  the  malady  on  which  the  paralysis  depends, 
and  in  regard  to  the  mode  of  action  of  which  in  producing  the  paralysis  we 
shall  always  perhaps  remain  in  ignorance." 

Since  the  time  of  Trousseau  many  eminent  pathologists  have  endeavored 
to  discover  the  anatomical  characters  and  elucidate  the  nature  of  diphtheritic 
paralysis  by  patient  and  thorough  microscopic  examinations.  We  have 
already  detailed  the  microscopic  appearance  in  Cadet  de  Gassicourt's  three 
memorable  cases.  In  1862,  Charcot  and  Vulpian  stated  that  they  had  exam- 
ined the  nervous  filaments  in  the  velum  palati  paralyzed  by  diphtheria,  and 
found  certain  of  them  entirely  free  from  medullary  matter,  granular  bodies 
occupying  its  place ;  but  partial  degeneration  was  more  common.  In  some 
of  the  fibres  the  medullary  matter  was  intact.  Lionville  in  1872  stated  that 
he  had  found  degenerative  changes  in  the  phrenic  nerve  of  a  patient  who 
had  died  of  asphyxia  following  an  attack  of  diphtheria.  The  contents  of 
certain  of  the  fibres  constituting  this  nerve  were  amorphous,  filled  with 
granular  bodies  instead  of  the  normal  nerve-substance.  Leyden  in  1872 
discovered  lesions  in  the  peripheral  nerves  and  in  the  central  organ  upon 
which  he  based  his  theory  of  an  ascending  neuritis.  Roger  and  Damaschino 
in  1875  examined  the  nervous  system  in  four  children  who  had  died  of 
diphtheritic  paralysis,  and  found  atrophy  of  the  nerve-fibres  in  the  periph- 
eral nerves.  The  medullary  matter  appeared  granular  in  certain  points, 
and  in  others  it  had  entirely  disappeared,  while  the  axis-cylinder  was  not 
notably  altered. 

Such  observations,  to  which  others  might  be  added,  have  fully  established 
the  fact  of  peripheral  nerve-lesions,  such  as  would  be  likely  to  result  from  a 


408  DIPHTHERIA. 

neuritis,  in  the  paralysis  of  diphtheria ;  but  it  must  be  borne  in  mind  that 
the  various  observers,  while  they  report  degenerative  changes  in  certain  of 
the  nerve-fibres  or  tubes  in  the  peripheral  nerves  of  the  paralyzed  part, 
also  state  that  others  in  the  same  nerves  were  to  appearance  normal  and 
capable  of  performing  their  function.  Such  are  the  facts  upon  which  the 
theory  that  diphtheritic  paralysis  is  caused  by  peripheral  nerve-lesions,  a 
peripheral  neuritis,  is  based. 

In  the  endeavor  to  elucidate  the  cause  of  diphtheritic  paralysis  attention 
has  also,  as  might  be  expected,  been  directed  to  the  state  of  the  brain  and 
spinal  cord,  and  anatomical  changes  have  been  discovered  in  them  quite  as 
marked  as  in  the  peripheral  nerves.  Buhl,  Roger  and  Damaschino,  Pierret, 
Vulpian,  Dejerine,  and  Oertel  discovered  in  different  cases  in  the  brain  and 
spinal  cord  in  those  who  died  of  paralysis  various  anatomical  changes,  among 
which  we  may  mention  small  extravasations  of  blood  and  slight  softening  in 
the  cerebral  substance,  extravasations  of  blood  and  thickening  of  the  neuri- 
lemma in  the  roots  of  paralyzed  nerves  (Buhl)  ;  endo-  and  perineuritis  at  the 
point  of  origin  of  the  affected  nerves,  thickening  of  the  walls  of  the  vessels 
and  accumulation  in  them  of  white  corpuscles  (Pierret)  ;  rarefaction  of  the 
connective  tissue  and  degenerative  change  in  the  nerve-cells  in  the  anterior 
cornua  of  the  cervical  and  upper  dorsal  region  of  the  spinal  cord  (Vulpian)  ; 
atrophy  and  granular  degeneration  and  fragmentation  of  the  myeline  in  the 
nerve-tubes  in  the  anterior  roots  of  the  spinal  nerve,  increase  of  nuclei  in  the 
white  substance  of  Schwann,  disappearance  of  the  axis-cylinder  and  slight, 
fatty  degeneration  of  the  walls  of  the  capillaries  (Dejerine). 

Dejerine  in  the  microscopic  examination  of  five  cases  of  paralysis  dis- 
covered anatomical  alterations  in  the  gray  substance  of  the  spinal  cord,  the 
white  substance  being  intact.  He  observed  in  the  gray  substance  cells 
atrophied  or  in  process  of  atrophy,  with  the  disappearance  of  their  prolonga- 
tions, so  that  healthy  cells  were  comparatively  infrequent.  The  cells  seemed 
to  have  undergone  the  change  which  occurs  in  acute  or  subacute  myelitis. 
The  vessels  in  the  gray  substance  were  dilated  and  flexuose.  They  were  in 
a  state  of  hyperaemia  or  congestion,  and  at  points  small  intestinal  hemor- 
rhages had  occurred.  Around  the  central  canal  and  in  the  commissures  the 
nuclei  were  increased.  The  white  substance  of  the  spinal  cord  presented  the 
normal  appearance.  These  anatomical  changes  in  the  cord  apparently  resulted 
from  a  myelitis.  The  spinal  nerves  whose  roots  originated  in  the  diseased 
gray  matter  of  the  cord  were  found  to  have  undergone  a  similar  change  in 
their  peripheral  distribution.  Therefore  in  the  five  cases  in  which  such 
minute  examinations  of  the  nervous  system  were  made  the  lesions  in  the 
cord  and  the  nerves  were  similar. 

In  1883,  Dr.  E.  Hyla  Greves  of  Liverpool,  pathologist  to  the  Royal 
Infirmary,  obtained  permission  to  examine  the  spinal  cord  in  a  child  of 
three  years  who  had  died  of  sudden  heart-failure  after  having  suffered  from 
an  aggravated  form  of  multiple  diphtheritic  paralysis.  She  had  had  anaes- 
thesia of  the  fauces  and  all  her  extremities,  liquid  food  regurgitated  through 
her  nostrils  and  entered  her  larynx,  she  passed  urine  and  feces  in  bed,  she 
could  not  stand  or  sit  without  support,  her  head  dropped  helpless,  her  speech 
was  indistinct,  her  tongue  could  not  be  protruded,  her  respiration  was  slow 
and  shallow,  her  pulse  50  per  minute  and  feeble,  and  she  was  nourished  by 
enemata  of  pancreatized  milk.  The  paralysis  increased  so  that  the  diaphragm 
alone  acted  in  respiration,  the  pulse  became  slower,  irregular,  and  more  feeble, 
and  death  occurred  suddenly.  At  the  autopsy,  which  was  limited  to  the 
spinal  cord,  the  veins  of  the  lower  part  of  the  cord  were  much  congested ; 
the  white  substance  of  the  cord  presented  the  normal  appearance  to  the 
naked  eye,  but  the  gray  matter  of  the  lumbar  and  lower  dorsal  regions  was 


PARALYSIS.  409 

extensively  softened,  and  in  the  left  half  of  the  cord  diffluent,  so  as  to  flow 
from  the  section,  leaving  a  cavity.  Higher  up  in  the  cord  the  gray  sub- 
stance was  hypcraeniic,  but  not  diffluent.  The  diffluent  gray  matter  was 
unsuitable  for  microscopic  examination,  but  other  portions  of  the  cord  were 
examined,  with  the  following  result :  Many  ganglion-cells  of  the  anterior 
cornua  were  destroyed  or  in  the  state  of  "  cloudy  swelling ;"  others  had  lost 
their  processes  and  were  reduced  in  size  ;  increase  in  the  number  of  nuclei  in 
the  neuroglia  throughout  the  cord  ;  gray  substance  in  the  right  half  of  the 
cord  in  an  early  stage  of  softening ;  in  the  dorsal  and  cervical  regions  every- 
where the  ganglion-cells  were  in  a  state  of  "  cloudy  swelling."  No  appre- 
ciable change  in  the  white  matter  of  the  cord.  It  is  evident  that  this  was 
an  extreme  and  rare  case  of  degenerative  change  in  the  cord,  and  one  in 
which  the  paraplegia,  had  the  patient  lived,  would  have  been  permanent,  for 
the  diffluent  gray  matter  in  the  cord  could  not  have  been  restored  to  its  nor- 
mal integrity.  It  was  not,  therefore,  an  ordinary  ease,  inasmuch  as  the 
paralyzed  muscles,  as  a  rule,  recover  their  function  in  those  who  survive. 

Such  is  a  summary  of  the  lesions,  peripheral  and  central,  in  the  nervous 
system  which  have  been  discovered  in  fatal  cases  of  diphtheritic  paraly.sis. 
We  have  presented  the  facts  upon  which  the  theory  of  the  cause  and  nature 
of  the  disease  must  be  based.  Are  we  able  to  present  a  theory  which  will 
hold  good  in  regard  to  cardiac  paralysis  characterized  by  sudden  heart-failure, 
to  pulmonary  paralysis  characterized  by  superficial  or  embarrassed  respiration, 
to  palatal  and  multiple  paralyses  with  their  many  inconveniences,  and  to  the 
loss  of  the  tendon  reflexes? 

Must  we,  with  Trousseau,  rest  satisfied  with  the  belief  that  the  manner 
in  which  diphtheria  produces  paralysis  is  beyond  our  comprehension  and  will 
probably  never  be  known  ?  Dr.  Abram  Jacobi,  seeing  the  inadequacy  of  the 
various  theories  to  explain  all  cases  or  forms  of  diphtheritic  paralysis,  wrote 
in  1880  as  follows  in  his  treatise  on  diphtheria  :  "  It  may  be  positively  asserted 
that  diphtheritic  paralysis  does  not  in  every  case  depend  on  one  and  the  same 
cause." 

The  theory  which  is  most  strongly  advocated  at  the  present  time,  and 
which  appears  to  be  accepted  by  a  large  proportion  of  the  specialists  in 
nervous  diseases  under  the  lead  of  Charcot,  is,  as  we  have  stated  above,  that 
diphtheritic  paralysis  results  from  a  peripheral  neuritis.  Others,  observing 
central  lesions  in  the  nervous  system,  have  naturally  inferred  that  they  have 
an  important  share  in  the  production  of  the  paralysis.  It  is  very  important 
that  the  practitioner  when  confronted  by  this  grave  malady  should  have  a 
clear  conception  of  its  cause  and  nature,  that  he  may  be  better  able  to  apply 
the  appropriate  remedies.  We  will,  therefore,  examine  with  the  light  obtained 
from  clinical  experience  the  prevailing  theory  that  diphtheritic  paralysis 
results  from  anatomical  changes,  peripheral  or  central,  or  both,  in  the  nervous 
system.  Is  this  theory  adequate  to  explain  the  paralysis  as  it  commonly 
occurs  ?  We  will  give  a  brief  summary  of  the  objections  to  it,  at  the  risk 
of  repeating  what  we  have  already  stated  : 

1.  Cases  occur  in  which  carefully-conducted  microscopic  examinations 
reveal  an  apparently  normal  state  of  the  nerve  supplying  the  paralyzed  part 
and  also  of  the  nervous  centre  from  which  this  nerve  originates. 

Thus,  in  the  three  cases  of  typical  cardiac  paralysis  described  above 
occurring  in  the  practice  of  Cadet  de  Gassicourt,  the  pneumogastric  and  its 
branches  examined  in  one  case  appeared  normal,  and  no  lesion  suflicient  to 
cause  paralysis  was  found  in  a  careful  examination  of  the  medulla  oblongata, 
the  central  organ  of  innervation  of  the  heart. 

2.  Palatal  paralysis  sometimes  occurs  as  early  as  the  second  or  third  day 
of  diphtheria,  and  loss  of  the  tendon  reflexes  as  early  as  the  first  day.     Can 


410  DIPHTHERIA. 

we  believe  that  a  peripheral  neuritis  or  anatomical  changes  in  the  cerebro- 
spinal axis  have  occurred  at  so  early  a  date,  so  as  to  cause  the  paralysis  ? 

3.  In  its  commencement  diphtheritic  paralysis  often  exhibits  what  Trous- 
seau designates  mutability.  It  suddenly  shifts  from  one  group  of  muscles 
to  another.  Muscles  paralyzed  on  one  day  have  their  normal  action  on  the 
following  day,  while  other  muscles  are  attacked,  and  on  the  third  day  the 
group  of  muscles  first  attacked  are  perhaps  again  paralyzed.  This  mutability 
of  the  paralysis,  this  sudden  shifting  from  one  group  of  muscles  to  another, 
militates  strongly  against  the  theory  that  the  cause  of  the  paralysis  is  a 
structural  change  in  the  nervous  system,  whether  cerebral  or  peripheral.  It 
would  seem  impossible  that  there  should  be  a  sudden  recovery  from  the  par- 
alysis, and  then  on  the  following  day  a  recurrence  of  it,  if  it  resulted  from 
degenerative  changes,  either  central  or  peripheral,  occurring  in  the  nervous 
system.  These  lesions  do  not  undergo  such  sudden  fluctuations,  such  muta- 
bility, as  we  observe  in  the  paralysis.  A  persistent  cause  should  produce  a 
persistent  and  continuous  eiFect. 

4.  Several,  if  not  all,  of  the  mieroscopists  who  discover  degenerative 
changes  in  the  peripheral  nerves  which  supply  paralyzed  muscles  state  that 
some  nerve-fibres  have  undergone  complete  or  nearly  complete  degeneration, 
others  partial  degeneration,  and  others  still  seem  to  be  intact.  Would  com- 
plete paralysis  result  from  such  a  state  of  the  peripheral  nerves  ?  Would, 
for  instance,  the  velum  palati,  as  we  observe  it,  be  motionless  like  a  curtain, 
not  exhibiting  the  least  sensitiveness  when  pricked  by  the  point  of  a  pin  or 
other  instrument,  if  the  sole  cause  of  the  paralysis  were  degenerative  changes 
in  the  nerves  ?  Would  not  the  nerve-fibres  which  are  still  intact  be  sufficient 
to  produce  some  motion  ?  May  we  not,  in  at  least  some  instances,  regard  the 
paralysis  as  the  cause  of  the  degeneration  in  the  nerves  ? — for  it  is  a  well- 
known  pathological  fact  that  if  a  muscle  be  paralyzed — as,  for  instance,  from 
a  central  cause — the  nerves  supplying  it  usually  undergo  more  or  less  degen- 
erative change. 

5.  A  clinical  fact  antagonistic  to  the  theory  that  lesions  in  the  cerebro- 
spinal axis  cause  the  paralysis  has  been  alluded  to  both  by  Dr.  A.  Suss  and 
Dr.  W.  H.  Thomson  in  their  interesting  and  instructive  papers.  It  is  that 
•diphtheritic  paralysis,  motor  and  sensory,  is  sometimes  limited  to  the  muscles 
supplied  by  a  single  branch  of  a  nerve,  while  the  other  branches  have  their 
normal  function.  This  fact  is,  of  course,  not  antagonistic  to  the  theory  that 
peripheral  nerve-lesions  cause  the  paralysis,  but  it  affords  a  strong,  if  not 
conclusive,  argument  against  the  theory  that  central  lesions  are  the  cause. 

Such  are  the  clinical  facts  which  militate  against  the  theory  that  inflam- 
matory or  degenerative  changes  in  the  nervous  system  are  the  primary  and 
sole  cause  of  diphtheritic  paralysis.  We  have  stated  above  that  the  theory 
relating  to  the  causation  of  diphtheria,  which  is  now  gaining  acceptance  in 
both  continents  with  pathologists  and  specialists  in  diseases  of  children,  is 
that  the  specific  microbe  of  diphtheria  acts  locally  upon  the  surface,  and 
systemic  infection  occurs  from  ptomaines  produced  by  microbic  action,  which, 
entering  the  lymphatics  and  blood-vessels,  are  carried  to  the  interior  of  the 
body  and  exert  their  action  upon  the  blood  and  the  tissues.  If  this  theory 
be  true,  the  symptoms  which  indicate  systemic  infection  are  referable  to  the 
ptomaines.  Dr.  Thomson  in  his  paper  already  alluded  to  writes  as  follows : 
*'  It  is  quite  conceivable  that  a  ptomaine  may  follow  upon  the  changes  which 
the  diphtheritic  process  sets  up  in  the  organism,  and  thus  produce  all  its 
characteristic  symptoms.  The  special  tendency  of  diphtheritic  inflammation 
to  cause  necrotic  and  gangrenous  lesions  lends  further  support  to  this  sur- 
mise." 

The  ptomaines  spring  into  existence  suddenly  and  unexpectedly  under 


PROGNOSIS.  411 

favoring  conditions,  as  we  see  in  the  case  of  the  cheese  or  the  milk  ptomaine, 
the  tyrotoxicon  ;  and  it  is  not  improbable  that  cheniiHtry  brought  to  the  aid 
of  microscopy  will  yet  reveal  the  fact  that  the  coiiniion  cause  of  diphtheritic 
paralysis  is  a  ptomaine  or  chemical  agent  produced  by  niicrobic  action.  If 
the  cause  be  a  ptomaine,  it  probably  acts  in  a  measure  like  the  poison  of  the 
eel  in  the  case  alluded  to  by  Trousseau,  or  like  curare.  Clinical  facts  appear 
to  harmonize  best  with  the  theory  that  this  is  the  common  cause  of  the  paral- 
ysis, especially  in  those  cases  in  which  it  occurs  early,  and  the  use  of  the 
paralyzed  muscles  is  soon  regained.  But  it  would  be  idle  to  argue  that  the 
marked  degenerative  central  and  peripheral  lesions  which  are  frequently  pres- 
ent in  the  nervous  system,  in  those  who  have  died  of  diphtheritic  paralysis, 
do  not  prolong  and  intensify  the  paralysis,  and  perhaps  are  sometimes  the 
primary  cause  of  it. 

Prognosis. — The  prognosis  of  diphtheria,  like  that  of  scarlet  fever,  varies 
greatly  in  different  cases  according  to  its  type.  In  some  epidemics  a  large 
proportion  of  the  cases  are  mild  and  recovery  occurs  with  simple  treatment. 
Between  the  mild  and  the  most  severe  cases,  attended  by  profound  blood- 
poisoning,  there  is  every  grade  of  severity.  Cases  that  are  apparently  mild 
in  the  beginning  and  seem  likely  to  recover  with  simple  measures  sometimes 
become  severe,  dangerous,  and  even  fatal.  On  the  other  hand,  cases  that  set 
in  with  severity  may  become  modified  and  end  favorably  with  simple  treat- 
ment. So  variable  is  the  type  of  diphtheria  that  in  certain  epidemics  or 
localities  a  large  proportion  recover,  as  many  even  as  90  or  95  per  cent., 
while  in  other  epidemics  or  localities  the  proportion  that  perish  is  much 
larger. 

The  prognosis  is  usually  favorable  when  the  inflamed  surface  and  pseudo- 
membrane  are  of  little  extent,  the  fever  and  swelling  moderate,  and  the  neigh- 
boring lymphatic  glands  and  underlying  connective  tissue  but  little  involved. 
In  many  such  cases,  as  we  have  seen  from  the  description  given  above,  the 
patient  remains  in  good  general  health  or  feels  but  slightly  indisposed.  On 
the  other  hand,  if  the  inflamed  surface  be  extensive,  the  pseudo-membrane 
deep-seated  and  exhaling  an  ofi"ensive  odor,  while  the  adjacent  lymphatic 
glands  are  markedly  swollen,  the  patient  will  probably  perish.  Nasal  diph- 
theria, which  is  commonly  present  in  severe  cases,  and  which  produces  an 
off"ensive,  irritating,  and  highly  infectious  discharge,  always  involves  great 
danger.  It  is  likely  to  give  rise  to  systemic  infection,  since  the  submucous 
connective  tissue  of  the  nostrils  contains  numerous  lymphatics,  which  take 
up  the  poisonous  products  and  convey  them  to  every  part  of  the  system.  If, 
while  the  local  disease  is  severe  and  extensive,  the  breath  and  exhalations 
become  off'ensive  and  the  countenance  and  surface  generally  begin  to  have  a 
dusky,  pallid  hue,  profound  blood-poisoning  has  occurred  and  the  patient  will 
probably  die. 

Physicians  of  experience  are  guarded  in  the  expression  of  a  favorable 
prognosis  in  diphtheria,  since  there  is  no  other  disease  in  which  the  prognostic 
signs  on  which  a  favorable  prediction  is  based  are  so  likely  to  be  fallacious. 
We  hear  much  in  medical  circles  of  the  deceptive  character  of  diphtheria. 
Error  in  expressing  a  favorable  prognosis,  of  which  even  physicians  of  ample 
experience  complain,  is  largely  due  to  the  fact  that  diphtheria  terminates 
fatally  in   several  different  ways.     Death  may  occur  from — 

1.  Diphtheritic  blood-poisoning — systemic  infection  by  the  specific  prin- 
ciple, whether  acting  directly  or  through  the  agency  of  ptomaines  which  it 
produces. 

2.  Septic  blood-poisoning,  pi'oduced  by  absorption  from  the  under  sur- 
face   of    the    decomposing    pseudo-membrane    or    from    gangrenous    tissues. 


412  DIPHTHERIA. 

But  our  knowledge  is  not  sufficiently  advanced  to  enable  us  to  discrim- 
inate between  the  constitutional  effects  of  ordinary  sepsis  and  those  pro- 
duced by  the  agency  of  the  diphtheritic  poison.  Septic  infection  is  obvi- 
ously most  likely  to  occur  in  those  cases  in  which  the  pseudo-membrane  is 
extensive,  deeply  imbedded,  and  its  decomposition  attended  by  an  offensive 
effluvium.  Cervical  cellulitis  and  adenitis,  which  cause  considerable  swelling 
of  the  neck,  often  occur  from  septic  absorption  from  the  faucial  surface,  the 
septic  matter  being  conveyed  by  the  lymphatic  vessels  to  the  adjacent  glands 
and  causing  inflammation  of  the  glands  and  surrounding  connective  tissue. 
Considerable  tumefaction  of  the  neck  therefore  seldom  occurs  in  diphtheria 
without  manifest  symptoms  of  toxaemia,  and  it  is  to  be  regarded  as  a  sign  of 
its  presence. 

3.  Diphtheritic  croup  or  pseudo-membranous  laryngo-tracheitis,  a  most 
important  disease,  and  fully  treated   of  in   the   proper  place. 

4.  Uraemia  or  diphtheritic  nephritis,  also  one  of  the  most  important  of 
the  local  maladies  pertaining  to  diphtheria,  and  produced  by  the  action  of 
the   diphtheritic  poison. 

5.  Sudden  heart-failure.  The  action  of  the  heart  may  be  feeble  from 
granulo-fatty  degeneration  of  the  muscular  fibres  or  from  anaemia  or  general 
weakness ;  but  sudden  and  unexpected  death  from  heart-failure  is  commonly, 
as  we  have  seen,  due  to  paralysis  of  this  organ. 

6.  Suddenly-developed  passive  congestion  and  oedema  of  the  lungs,  prob- 
ably due  to  feebleness  of  the  heart's  action  or  to  paralysis  of  the  respiratory 
muscles.  Death  sometimes  occurs,  apparently  from  this  cause,  during  the 
period  of  supposed  convalescence  and  when  the  visits  of  the  physician  have 
been  discontinued.  Thus,  in  a  case  in  my  practice  symptoms  of  oedema  pul- 
monum  (abundant  moist  rales  in  both  sides  of  the  chest  and  embarrassed 
respiration)  suddenly  occurred  nearly  one  month  after  the  disappearance  of 
the  faucial  pseudo-membrane  and  inflammation.  The  urine,  which  had  con- 
tained considerable  albumen  during  the  active  period  of  the  malady,  had  for 
some  time  shown  no  trace  or  but  slight  trace  of  this  principle  by  the  proper 
tests.  By  active  stimulation  these  symptoms  entirely  disappeared  in  a  few 
hours,  and  the  heart's  action  seemed  normal,  except  that  it  was  a  little  weak- 
ened. On  the  following  day  the  symptoms  reappeared,  and  death  occurred 
before  I  was  able  to  reach  the  house. 

That  physician  is  obviously  least  likely  to  err  in  prognosis  who  recognizes 
the  fact  that  patients  are  liable  to  perish  in  any  of  these  different  ways,  and 
carefully  examines  in  reference  to  all  the  conditions  which  involve  danger. 
Many  physicians,  as  I  have  had  the  opportunity  to  observe,  are  remiss  in  not 
examining  more  frequently  the  urine  of  diphtheritic  patients ;  for  there  is 
often  a  large  amount  of  albumen  with  granular  casts  in  the  urine  in  diph- 
theria, indicating  a  poisonous  quantity  of  urea  in  the  blood,  and  yet  the 
appearance  of  the  urine  to  the  naked  eye  is  normal. 

Among  the  symptoms  which  render  the  prognosis  unfavorable  are  repug- 
nance to  food,  vomiting,  pallor  of  countenance,  and  general  anaemia,  with 
progressive  weakness  and  emaciation,  indicating  blood-poisoning ;  a  large 
amount  of  albumen,  with  casts,  in  the  urine,  showing  urgemia,  to  which  the 
irritability  of  the  stomach  is  often  due ;  an  abundant  irrritating  discharge  of 
muco-pus  from  the  nostrils  or  occlusion  of  them  by  membranous  exudation 
or  inflammatory  thickening,  showing  that  the  Schneiderian  membrane  is 
seriously  involved ;  hemorrhage  from  the  nostrils,  buccal  cavity,  or  fauces, 
showing  an  altered  state  of  the  blood  or  of  the  walls  of  the  capillaries,  or 
plugging  of  the  capillaries  by  masses  of  microbes  or  leucocytes.  Diphtheritic 
laryngo-tracheitis,  or  pseudo-membranous  croup,  largely  increases  the  aggre- 
gate of  deaths  from  diphtheria,  whether  it  be  treated  by  improved  inhalations, 


PREVENTIVE  TREATMENT.  413 

intubation,  or  tracheotomy.  Some  of  the  above  symptoms  have  been  present 
in  most  of  the  fatal  cases  which  I  have  observed.  On  the  other  hand,  the 
prospect  of  recovery  improves  in  proportion   to  their  absence. 

Prevkntive  Tre.vtment. — Diplithcria  is  so  highly  contagious,  and  when 
epidemic  is  so  likely  to  spread  from  one  household  to  another,  and  its  severe 
forms  are  iatal  in  so  large  a  proportion  of  cases,  that  preventive  measures  are 
of  the  greatest  importance.  The  area  of  contagiousness  of  diphtheria  is  small. 
Dr.  Lancry  cites  cases  to  show  that  it  is  limited  to  a  few  feet.  Dumez  also 
relates  an  instance  showing  that  the  contagious  area  is  of  small  extent.  In 
a  school  the  boys  and  girls  in  the  same  hall  were  separated  by  an  open  space 
a  few  yards  wide.  Diphtheria  prevailed  among  the  girls,  but  did  not  affect 
the  boys.  In  this  respect,  as  in  so  many  others,  diphtheria  resembles  scarlet 
fever,  and  is  unlike  pertussis  and  measles. 

The  most  efficient  method  of  preventing  diphtheria  is  the  isolation  and 
disinfection  of  patients,  the  prompt  and  thorough  disinfection  of  the  apart- 
ments in  which  patients  have  been  treated  and  of  the  bedding  and  furniture 
in  these  apartments,  and  the  exclusion  or  prevention  of  all  noxious  gases, 
especially  those  ascending  from  the  sewers  and  from  filthy  accumulations  of 
all  kinds. 

Dr.  H.  B.  Baker  of  Michigan  has  published  statistics  showing  that  in  102 
outbreaks  of  diphtheria  the  average  number  of  cases  where  disinfection  and 
isolation,  one  or  both,  were  neglected  was  16,  and  the  average  deaths  3.26, 
while  in  116  outbreaks  in  which  isolation  and  disinfection  were  enforced  the 
average  number  of  cases  per  outbreak  was  2.86,  and  the  average  deaths  .66. 
Therefore  these  precautionary  measures  prevented  13  cases  and  2.57  deaths 
for  each  outbreak ;  in  the  total,  1515  cases  and  298  deaths.  These  statistics 
relate  to  only  one  year.^ 

It  is  obvious  that,  in  order  to  prevent  the  spread  of  diphtheria,  wherever 
a  case  has  occurred  prompt  and  efficient  personal  and  domiciliary  disinfection 
should  be  practised  so  far  as  the  condition  of  the  patient  will  allow.  But 
there  is  reason  to  think  that  disinfection  as  commonly  practised  is  inadequate. 
In  the  winter  of  1887-88  and  the  following  spring  an  epidemic  of  diphtheria 
occurred  in  the  New  York  Infant  Asylum,  and  it  extended  to  the  maternity 
ward.  In  this  ward  5  of  the  new-born  infants  contracted  diphtheria,  and  2 
of  these  5  had  at  the  same  time  umbilical  phlegmons  in  addition  to  the  usual 
diphtheritic  exudate  upon  the  fauces.  It  was  evident  from  the  occurrence 
of  these  cases  that  the  maternity  ward  was  infected  to  such  a  degree  that 
subsequent  patients  could  not  be  safely  admitted  without  its  thorough  disin- 
fection. The  ward  was  therefore  vacated,  the  windows,  doors,  and  crevices 
closed,  and  forty  pounds  of  sulphur,  or  two  pounds  to  the  hundred  cubic  feet 
of  air,  were  burnt  until  they  were  consumed.  After  some  hours  the  windows 
and  doors  were  opened,  and  Drs.  Prudden  and  Cheesemen  immediately  raised 
a  dust  from  the  floor  and  bedding  and  allowed  it  to  settle  in  culture-media. 
All  other  sources  of  infection  were  excluded  from  the  media.  The  cultures 
produced  so  large  a  number  of  microbes  that  they  overlay  each  other ;  but 
the  observers  were  able  to  distinguish  the  streptococcus  pyogenes  in  the 
media,  identical  in  form  and  appearance  with  the  streptococcus  which  they  had 
previously  discovered  in  the  umbilical  phlegmon.  Although  more  sulphur 
was  employed  than  is  recommended  by  the  New  York  Health  Board,  and 
employed  in  the  manner  recommended  by  this  board,  it  was  inadequate  to 
destroy  the  microbes.  It  was  evident  that  some  more  efficient  mode  of  domi- 
ciliary disinfection  was  required. 

Since  the  ordinary  mode  of  disinfection  was  apparently  futile  in  the 
maternity  ward,  it  seemed  to  me  advisable  to  obtain  the  views  of  so  eminent 

^  American  Lancet.     (See  Ann.  Univ.  Med.  Sci.,  1888.) 


414  DIPHTHERIA. 

an  authority  as  Dr.  E.  R.  Squibb  of  Brooklyn ;  and  lie  has  kindly  favored 
me  with  the  following  note : 

"  Within  the  past  ten  years  the  efficacy  of  sulphur-fumigation  against 
infectious  material  has  been  repeatedly  denied  and  reaffirmed  upon  very  good 
authority,  and  observations,  apparently  made  with  accuracy  and  care,  have 
been  reported  from  time  to  time  to  prove  both  sides  of  the  question  ;  so  that 
all  that  can  now  be  said  is  that  burning  sulphur  is  of  doubtful  efficacy,  with 
the  weight  of  the  highest  authorities  in  bacteriology  against  it.  But  to  this  it 
must  be  added  that  it  is  still  largely  used  by  very  intelligent  bodies  in  large 
institutions,  boards  of  health,  etc.,  where  it  would  not  be  likely  long  to  main- 
tain an  unearned  confidence. 

"  How  often  the  fumes  are  applied  dry  and  how  often  moist  no  one  can 
tell  from  the  current  record ;  and  how  many  of  the  failures  of  the  dry 
gas  would  be  successes  in  the  presence  of  moisture  there  is  no  means  of 
knowing. 

"  Formerly,  when  sulphur  was  burned  in  closed  chambers  as  a  disinfectant, 
the  surfaces  were  all  wetted,  and  the  pot  of  burning  sulphur  was  set  in  water 
or  wet  sand,  that  the  heat  might  evaporate  off  a  constant  supply  of  watery 
vapor. 

"  These  conditions  are  now  frequently,  if  not  generally,  neglected ;  and 
where  this  is  the  case  failure,  on  principle,  should  be  the  rule. 

"  Nearly  all,  if  not  all,  chemical  disinfectants  are  in  a  state  of  tension, 
ready  to  change  on  coming  in  contact  with  the  matter  to  which  they  are 
applicable ;  and  these  changes  are  either  by  oxidation  or  deoxidation,  and 
the  moment  of  greatest  power  or  activity  is  the  moment  of  change,  when 
they  by  reacting  on  infectious  matter  pass  from  a  state  of  tension  to  a  state 
of  rest  under  new  relations.  The  agency  through  which  these  changes 
almost  universally  become  operative  is  the  vapor  of  water. 

"  When  sulphur  is  burned  in  a  close  chamber  the  dioxide  is  formed  by 
condensing  two  molecules  of  oxygen  from  the  air  upon  each  molecule  of  the 
sulphur,  and  a  heavy  gas  is  the  result,  which  tends  to  settle  at  the  bottom  of 
the  chamber  and  to  run  out  through  the  lower  cracks.  Any  moisture  present 
is  at  once  seized  by  this  rather  inactive  anhydride,  first  forming  sulphurous 
acid,  and  then,  by  oxidation  from  the  air,  sulphuric  acid.  The  dry  gas,  or 
anhydride,  not  only  seizes  with  avidity  all  watery  vapor  in  the  air,  but  alsa 
the  water  held  in  the  surfaces  of  all  bodies  with  which  it  comes  in  contact, 
and  in  the  presence  of  this  moisture  only  is  it  ready  for  further  oxidation. 
Then  it  is  by  this  oxidation  that  it  deoxidizes  the  matters  with  which  it  is  in 
moist  contact,  filling  the  surfaces  of  these  matters  first  with  sulphurous  acid, 
then,  by  the  change,  with  sulphuric  acid ;  and  it  is  during  these  changes 
that  its  power  is  exerted. 

"  If  there  be  no  moisture  supplied  to  the  burning  sulphur,  that  which 
was  present  in  the  air  and  the  surfaces  of  the  chamber  is  soon  used  up,  and 
the  dry  gas  remains  indefinitely  in  a  comparatively  inactive,  ineffective  con- 
dition. The  dry  passive  anhydride  would  necessarily  destroy  all  organisms 
which  breathed  in  any  degree,  because  breathing-surfaces  are  moist.  But 
in  embryonic  life  protected  by  shell,  as  in  seed,  if  the  shell  be  dry  the  gas 
would  be  impotent.  Many  bacteriologists  have  admitted  that  burning  sul- 
phur would  kill  bacteria,  but  not  germs." 

It  seems  probable  that  the  apparently  negative  effect  of  burning  sulphur 
for  the  purpose  of  destroying  the  microbes  in  the  maternity  ward,  as  stated 
above,  was  due  to  the  absence  of  moisture,  for  it  was  burnt  dry.  The  above 
note  from  Dr.  Squibb  conveys  very  important  information.  If  the  facts  as 
stated  by  him  were  more  generally  known  and  acted  on  by  health  boards 
and  by  physicians  in  family  practice,  the  results  of  domiciliary  disinfectioa 


PREVENTIVE  TREATMENT.  415 

would  probably  be  better.  It  is  so  important  that  the  specific  principle  of 
diphtheria  should  be  destroyed  wherever  this  disease  appears,  in  order  to  pre- 
vent its  propagation,  that  any  safe  measures  which  will  aid  in  producing  this 
result  should  be  employed  with  or  without  the  sulphur  fumigation.  To 
accomplish  this  purpose,  Dr.  Llewellyn  Kliot  recommends  during  the  con- 
tinuance of  a  case  the  constant  evaporation  of  turpentine  over  a  water-bath, 
so  that  the  vapor  fills  the  room.  In  every  instance  in  which  he  has  used  the 
turpentine  no  second  case  of  the  disease  has  occurred.'  [  have  stated,  in  my 
remarks  on  the  prophylaxis  of  scarlet  fever,  that  I  have  employed  the  follow- 
ing prescription  for  the  purpose  of  disinfection  during  my  attendance  on  cases 
of  scarlet  fever  and  diphtheria,  with  apparently  so  good  a  result  that  I  am 
encouraged  to  continue  its  use  : 

R.  Acidi  carbolici,  5j  ; 

01.  eucalypti,  %]  ; 

Spts.  terebinth.,         Sviij.     Misce. 

Add  two  tablespoonfuls  to  one  quart  of  water  in  a  pan  with  broad  surface, 
and  maintain  a  constant  state  of  ebullition  or  simmering  in  the  room  occupied 
by  the  patient.  This  disinfecting  vapor  was  employed  in  the  quarantine  wards 
of  the  Infant  Asylum,  in  which  diphtheritic  patients  were  treated,  and  to  a 
certain  extent  in  the  other  wards,  and  no  subsequent  cases  have  occurred. 

In  Bellevue  Hospital,  where  pyaemia  had  been  prevalent.  Prof.  R.  Ogden 
Doremus  employed  chlorine  gas  mingled  with  steam  to  secure  disinfection,  in 
the  following  manner :  Strips  of  paper  having  been  pasted  over  the  crevices 
around  the  doors  and  windows,  equal  parts  of  common  salt  and  black  oxide 
of  manganese  (about  two  hundred  pounds)  were  placed  in  troughs  formed 
of  sheet  lead,  the  edges  being  turned  up  to  make  receptacles.  A  carboy  of 
sulphuric  acid  was  emptied  into  small  basins  and  other  vessels  and  placed 
beside  the  troughs.  The  floors  were  moistened  with  water,  and  abundant 
steam  was  allowed  to  escape  from  the  heaters  into  the  ward.  With  the  aid 
of  assistants  the  sulphuric  acid  was  quickly  poured  upon  the  mixture  in  the 
troughs  and  the  room  hastily  vacated,  the  door  being  nailed  up  to  prevent 
accidental  entrance,  for  the  large  quantities  of  chlorine  evolved  would  have 
been  fatal.  The  following  day  the  windows  were  opened  from  without,  and 
after  ventilation  the  contents  of  the  troughs  were  stirred  and  sulphuric  acid 
added  as  before.  In  the  ward  most  infected  this  process  was  repeated  once, 
fresh  salt  and  manganese  being  used.  No  further  cases  of  pyaemia  occurred 
in  these  wards.  Even  with  the  employment  of  a  disinfectant  vapor,  the 
infected  room  or  ward  should  not,  in  my  opinion,  be  reopened  until  it  has 
been  disinfected  in  the  manner  recommended  by  Prof.  Prudden.  It  is  to  rub 
the  ceiling  and  walls  with  slices  of  fresh  bread,  and  then  apply  to  ceiling, 
walls,  and  floor  a  strong  disinfectant  solution,  as  of  corrosive  sublimate. 

In  order  to  prevent  as  far  as  possible  the  spread  of  diphtheria,  stringent 
measures  should  be  taken  to  prevent  propagation  of  the  disease  by  walking 
cases,  by  children  mildly  aff"ected  who  are  allowed  to  attend  school  and  ride 
in  public  conveyances.  I  have  in  a  number  of  instances  seen  children  with 
diphtheria  sitting  with  other  children  in  the  clinics  at  Bellevue.  Recently  I 
saw  in  consultation  a  child  with  fatal  diphtheria,  which  apparently  was  con- 
tracted in  the  street  by  embracing  a  playmate  who  had  been  allowed  to  go 
out  for  the  first  time  after  an  attack  of  the  disease.  In  another  instance  a 
child  went  with  its  parent  to  a  Sunday  mission-school  in  one  of  the  tenement- 
house  sections  of  New  York.  Four  or  five  days  subsequently  it  had  diph- 
theria, which  was  communicated  to  other  children  of  the  family,  and  one  of 

^  Medical  Bulletin. 


416  DIPHTHERIA . 

them  died.  The  philanthropic  endeavor  to  benefit  the  poor  children  of  New 
York  by  conveying  them  to  rural  localities  in  midsummer  has,  it  is  said, 
resulted  in  the  occurrence  of  diphtheria  in  farming  sections  where  it  was 
previously  unknown.  I  have  now  under  treatment  a  family  with  diphthe- 
ria, and  the  child  first  attacked  states  that  a  schoolmate  sitting  near  her  in 
the  school  complained  of  sore  throat  a  few  days  previously.  Certainly  the 
safety  of  the  public  requires  that  all  children  with  sore  throats  should  be 
excluded  from  the  schools  whenever  diphtheria  is  prevalent,  and  it  should 
be  the  duty  of  teachers,  acting  under  the  direction  of  health  boards,  to  see 
that  this  is  done. 

In  a  paper  relating  to  the  therapeutics  of  diphtheria,  read  before  the 
Philadelphia  County  Medical  Society,  May  23,  1888,  and  printed  in  its 
Transactions^  Dr.  A.  Jacobi  remarks  that  the  well  children  in  a  family  where 
diphtheria  is  occurring  should  not  go  to  church  or  school,  and  that  schools 
should  be  closed  during  an  epidemic  of  diphtheria,  or,  if  not  closed,  that 
teachers  should  every  morning  inspect  the  throats  of  the  pupils  and  send 
home  those  with  sore  throats.  He  recommends  also  the  disinfection  of 
coaches  and  railroad-cars  at  regular  intervals  during  an  epidemic.  He  also 
states  that  a  patient  recovering  from  diphtheria  may  contract  it  anew  from 
the  curtains,  carpets,  and  furniture  which  he  has  infected  during  his  sickness, 
so  as  to  have  a  renewal  of  the  disease.  He  has  seen  patients  die  from  these 
renewals,  and  has  seen  other  patients  improve  immediately  when  removed  to 
other  apartments.  He  also  states  that  an  irritated  surface  is  more  likely  to 
contract  diphtheria  than  one  that  is  healthy,  and  therefore  buccal,  faucial, 
and  nasal  catarrhs  should  be  promptly  treated,  the  cure  of  these  diminishing 
the  liability  to  diphtheria.  Chronic  nasal  catarrh,  he  says,  should  be  treated 
with  two  or  three  daily  injections  of  a  solution  of  salt  (1  to  130),  to  which 
a  1  per  cent,  solution  of  alum  may  be  profitably  added,  and  the  same  may 
be  gargled  in  the  treatment  of  faucial  catarrh.  A  nasal  spray  of  nitrate  of 
silver  (1  to  500  or  1  to  1000)  also  hastens  the  cure.  The  inflamed  buccal 
surface  should  be  treated  by  the  potassium  chlorate  or  sodium  chlorate. 
Enlarged  tonsils,  which  may  harbor  the  diphtheritic  virus,  should  be  reduced 
by  the  galvano-cautery,  and  enlarged  cervical  glands  should  also  be  treated 
as  a  preventive  measure.  Very  similar  views  were  expressed  in  a  paper 
read  before  the  New  York  Academy  of  Medicine  in  January,  1888,  by  Dr. 
A.  Caille,  who  believes  that  he  has  prevented  the  recurrence  of  diphtheria  in 
those  who  have  suffered  repeated  attacks  of  it,  by  prolonged  daily  antiseptic 
treatment  of  their  exposed  surfaces,  which  harbored  the  poison  or  constituted 
a  nidus  favorable  for  its  lodgment  and  propagation.  Similar  views  were 
expressed  in  a  paper  read  before  the  American  Pediatric  Society  in  June, 
1890,  by  Dr.  Caille,  who  insists  on  the  daily  inspection  of  the  throats  of 
scholars  whenever  diphtheria  is  prevailing,  and  the  exclusion  from  the  schools 
of  those  who  have  sore  throats. 

Treatment. — Although  diphtheria  has  been  one  of  the  most  common  of 
the  severe  infectious  maladies  in  Europe  and  America  during  the  last  thirty 
years,  physicians  are  far  from  agreeing  in  reference  to  the  proper  mode  of 
treatment.  The  diversity  of  opinions  in  regard  to  the  use  of  therapeutic 
agents  is  due  in  part  to  a  variation  in  the  type  of  the  malady  in  different 
epidemics  and  localities,  in  part  probably  to  the  fact  that  other  forms  of 
inflammation  of  a  severe  type  have  been  mistaken  for  the  diphtheritic,  but 
more  to  the  fact  that  different  theories  have  been  held  respecting  the  cause 
and  nature  of  diphtheria.  Hence  one  physician  recommends  with  confidence, 
as  eminently  successful  in  his  hands,  a  medicine  or  mode  of  treatment  of 
which  another  speaks  disparagingly. 

The  germ  theory,  as  described  in  the  foregoing  pages,  according  to  which 


TREATMENT.  417 

diphtheria  is  produced  by  a  luicro-orgauisiu,  has  had  a  marked  influence  upon 
tlie  mode  of  treatment.  The  (juestion  has  been  much  discussed  whether 
diphtheria  is  prinnirily  a  constitutional  or  a  local  malady.  Acceptance  of 
the  germ  theory  does  not  require  us  to  believe  that  diphtheria  is  primarily 
local,  for  the  specific  microbe  might  enter  and  infect  the  blood  through  the 
lungs  before  any  symptom,  occurred,  and,  as  we  have  stated  elsewhere;  the 
long  incubative  period  of  six  or  seven  days  in  certain  cases  harmonizes  with 
the  theory  of  a  primary  blood-disease,  rather  than  with  the  theory  that  diph- 
theria is  in  the  beginning  strictly  local,  its  seat  being  upon  one  of  the  exposed 
surfaces  where  the  microbe  has  effected  a  lodgment.  But  the  latter  theory 
is,  as  we  have  seen,  moi'e  generally  accepted,  and  certain  facts  lend  strong 
support  to  it.  But  if  diphtheria  is  primarily  local,  there  can  be  no  doubt 
that,  as  in  the  vaccine  disease,  the  system  becomes  quickly  infected  in  cases 
of  ordinary  severity,  so  that  successful  treatment  requires  the  use  of  both 
constitutional  and  local  remedies.  Acceptance  of  the  germ  theory  evidently 
leads  to  the  employment  of  germicide  remedies,  the  so-called  antiseptics  or 
antiferments,  externally  and  internally,  in  order  to  destroy  the  specific  prin- 
ciple of  the  disease.  Hence,  in  proportion  as  this  doctrine  was  accepted, 
carbolic  acid,  the  chlorine  preparations,  bromine,  the  sulphites,  salicylic  acid, 
and  the  most  prompt  and  efiicient  agent  of  this  class,  corrosive  sublimate, 
came  into  use. 

Hygienic  Treatment. — The  patient  should  be  placed  in  an  airy  room,  and 
his  evacuations  should  be  promptly  disinfected  by  chlorine,  carbolic  acid,  or 
other  disinfectant,  and  removed  from  the  room.  Purity  of  the  air  in  the 
apartment  is  required ;  but  in  the  ventilation  draughts  of  air  through  the 
room  should  be  avoided,  on  account  of  the  liability  to  diphtheritic  croup, 
which  produces  about  one-third  of  the  deaths  from  diphtheria.  M.  Jules 
Simon  recommends  that  the  windows  of  the  sick-room  be  constantly  closed, 
and  that  ventilation  be  obtained  through  the  open  window  of  the  adjoining 
apartment.  In  bathing  the  patient  care  must  be  taken  that  he  be  not  chilled. 
Bathing  should  be  performed  expeditiously  in  a  warm  room,  with  perhaps 
some  increase  of  the  stimulants  administered.  The  patient  should  be  con- 
stantly in  bed,  and  the  temperature  of  the  apartment  should  be  from  70°  to 
75°  F.     A  uniform  temperature  of  the  apartment  at  about  73°  F.  is  safest. 

All  physicians  of  experience  recognize  the  importance  of  the  use  of  the 
most  nutritious  and  easily-digested  food  and  the  preservation  of  the  appe- 
tite, for  diphtheria  produces  rapid  destruction  of  the  red  corpuscles  and  loss 
of  flesh  and  strength,  and  it  may  soon  produce  a  state  of  dangerous  weak- 
ness. Beef  tea  or  the  expressed  juice  of  meat,  milk  with  farinaceous  food, 
etc.,  should  be  administered  every  two  or  three  hours  or  to  the  full  extent 
without  overtaxing  digestion.  I  have  sometimes  employed  the  pepsin  prepa- 
rations before  each  feeding,  with  apparently  good  results,  as  in  the  following 
formula : 

R.  Pepsin!  purl,  in  lamellis,  3j ; 

Acidi  muriat.  dilut.,  .^ij  ; 

Glycerinre,  ,^j ; 

Aquffi  purse,  ^iv.     Misce. 
Dose :  One  teaspoonful  before  each  feeding. 

In  cases  of  feeble  digestion  the  predigested  foods  are  often  very  useful, 
as  the  beef  peptonoids  of  Reed  and  Carnrick,  the  sarco-peptones  of  the 
Rudisch  Company,  and  peptonized  milk.  Failure  of  the  appetite  and  refusal 
to  take  food  are  justly  regarded  as  very  unfavorable  signs.  Trousseau  says : 
"  Alimentation  occupies  the  first  place  in  the  general  treatment ;  and  I 
27 


418  DIPHTHERIA. 

have  observed  that  the  severer  the  attack  the  more  imperative  is  the  neces- 
sity to  sustain  the  patients  with  nourishing  food.  Loss  of  appetite— -that  is, 
disgust  for  every  kind  of  food— is  one  of  the  most  alarming  prognostic  signs. 
We  must  try  to  overcome  the  loathing  of  food  by  every  possible  means ;  and 
to  get  nourishment  taken  I  sometimes  do  not  hesitate,  in  the  case  of  children, 
to  threaten  punishment.  When  the  patient  retains  his  appetite  for  food, 
there  is  good  hope  of  recovery."^  Occasionally,  when  great  dysphagia  is 
present,  whether  from  the  severity  of  the  pharyngitis  or  from  palatal  paral- 
ysis, it  is  necessary  to  resort  to  rectal  alimentation.  The  rectum  absorbs, 
but  does  not  digest,  and  it  is  capable  of  absorbing  peptonized  food  to  such  an 
extent  that  life  may  be  sustained  for  an  indefinite  time  without  stomach 
digestion  and  solely  by  rectal  alimentation.  For  the  purpose  of  rectal  ali- 
mentation I  have  usually  employed  peptonized  milk  containing  in  solution 
peptonized  beef,  as  the  sarco-peptones  of  the  Kudisch  Company.  If  this  is 
administered  through  a  No.  12  to  No.  14  elastic  catheter  introduced  far  enough 
to  reach  the  sigmoid  flexure,  and  retained  for  half  an  hour  by  a  compress 
pressed  closely  against  the  anus  by  the  fingers,  the  result  is,  I  think,  better 
than  when  we  depend,  as  Trousseau  did,  entirely  on  stomach  digestion.  One 
objection  to  the  use  of  the  brush,  instead  of  spraying  the  favices  with  the 
atomizer,  is  that  it  is  more  likely  to  cause  vomiting,  by  which  nutriment, 
that  is  so  much  required,  is  lost.  In  malignant  cases  of  diphtheria,  as  in 
scarlet  fever  of  a  similar  type,  patients  are  sometimes  allowed  to  slumber 
too  long  without  nutriment.  It  is  the  slumber  of  toxaemia,  and  should  be 
interrupted  at  stated  times  in  order  to  give  food  and  stimulants. 

Stimulants. — M.  Sanne,  in  his  treatise  on  diphtheria,  says,  "  De  tous  les 
antiseptiques  donnes  a  I'interieur,  I'alcool  est  de  beaucoup  le  plus  sur.  Plus 
I'infection  est  prononcee,  plus  il  faut  insister  sur  les  composes  alcooliques."  He 
states  that  Bricheteau  reports  the  history  of  a  patient  who  took  daily  during 
diphtheria  a  bottle  and  a  half  of  the  wine  of  Bordeaux,  without  the  least 
symptom  of  intoxication  or  headache.  A  similar  case  was  related  to  me  in 
which  nearly  one  and  a  half  pints  of  brandy  were  given  in  twenty-four 
hours  without  any  ill  efi'ect,  and  with  an  apparent  good  result  on  the  general 
course  of  the  disease.  The  same  rule  holds  true  in  diphtheria  as  in  other 
acute  infectious  maladies,  that  while  mild  cases  do  well  without  alcoholic 
stimulants,  they  are  required  in  cases  of  a  severe  type,  and  should  be  admin- 
istered in  large  and  frequent  doses  whenever  pallor  and  loss  of  appetite  or 
strength  and  flesh  indicate  danger  from  the  diphtheritic  or  septic  infection. 
It  matters  little  how  the  stimulant  is  administered,  whether  milk  punch  or 
wine  whey,  provided  that  the  proper  quantity  is  employed.  If  given  early 
and  frequently  in  grave  cases — as,  for  example,  one  teaspoonful  every  half 
hour  of  brandy  or  Bourbon  whiskey — it  does  seem  to  have  a  tendency  to 
render  the  disease  more  tractable ;  but  to  be  instrumental  in  saving  life  in 
malignant  cases  it  must  be  given  boldly  from  the  start.  If  there  be  marked 
diphtheritic  toxaemia  when  its  use  is  commenced,  it  will  not  save  life,  but  it 
may  prolong  it.  Although  the  liberal  employment  of  alcohol  is  apparently 
useful,  it  cannot  be  regarded  as  a  specific.  In  the  quarantine  wards  of  the 
New  York  Foundling  Asylum  in  May,  1878,  were  four  children  between  the 
ages  of  three  and  five  years  who  had  been  sick  a  few  days  with  severe  diph- 
theria, and  it  was  evident  at  a  glance  that  they  must  soon  perish  with  the 
ordinary  mild  sustaining  remedies.  Quinine,  iron,  the  most  nutritious  food, 
and  a  moderate  amount  of  alcoholic  stimulants  were  being  given,  and  we 
determined  to  increase  the  Bourbon  whiskey  to  a  teaspoonful  every  twenty 
or  thirty  minutes  day  and  night.  Nevertheless,  whatever  the  result  might 
have  been  with  the  earlier  commencement  of  this  treatment,  the  blood-poi- 

^  American  Lancet. 


TREATMENT.  419 

soning  was  now  too  profound,  and  one  after  the  other  died.  That  intoxica- 
tion is  almost  never  produced  in  this  disease  by  large  and  frequent  doses  of 
the  alcoholic  stimulant  is  probaVjl}-  in  part  due  to  its  quick  elimination  from 
the  system,  but  more  to  the  nature  of  diphtheria. 

In  fulfilling  the  indication  of  sustaining  treatment  the  vegetable  tonics 
have  long  been  used,  especially  cinchona  and  its  alkaloid  principle,  quinine. 
The  compound  tincture  of  cinchona  and  the  fluid  extract  have  been  used  and 
recommended  by  physicians  of  experience,  but  of  vegetable  agents  quinine 
has  been  and  is  still  more  frequently  prescribed  than  any  other.  But  the 
doses  employed  vary  greatly  in  size  and  frequency  in  the  practice  of  diifer- 
ent  physicians.  It  is  administered  for  its  antipyretic  effect  in  large  do.ses, 
so  that  twenty  or  thirty  grains  are  given  daily,  and  in  small  doses,  as  one  or 
two  grains  every  fourth  hour,  for  its  tonic  effect.  That  there  is  nothing 
antagonistic  in  the  action  of  quinine  to  the  diphtheritic  virus,  and  that  it  is 
beneficial  in  the  same  way  as  in  the  other  acute  infectious  diseases,  and  no  fur- 
ther, is,  I  think,  generally  admitted  by  physicians.  Large  and  frequent  do.ses 
do  not.  apparently,  produce  any  controlling  action  on  the  course  of  the  disease 
or  diminish  the  blood-poisoning.  Cases  might  be  cited  in  illustration.  In 
the  ease  of  a  child  of  four  years  with  malignant  diphtheria  forty-eight  grains 
administered  daily  had  no  appreciable  effect  in  staying  the  fatal  progress  of 
the  disease. 

Quiiiiae  in  doses  of  three  to  five  grains  has  been  prescribed  as  an  anti- 
pyretic in  diphtheria,  as  also  in  the  other  infectious  diseases  ;  but  as  an  anti- 
pyretic it  is  not  very  efiicient,  and  the  temperature  after  the  first  two  or  three 
days  in  diphtheria  is  not  often  so  elevated  that  an  antipyretic  is  required. 
As  a  tonic  in  doses  of  one  to  two  grains  it  is  probably  to  a  certain  extent 
beneficial,  and  it  has  been  highly  recommended  by  good  observers  for  its  local 
action  upon  the  fauces  when  used  by  insufflation.  The  late  Prof.  Rochester 
of  Buffalo  recommended  and  practised  in  the  treatment  of  diphtheria  the 
insufflation  of  sulphate  of  quinine,  in  powders  of  two  grains,  upon  the  faucial 
surface,  every  two  hours. ^  It  is  not  improbable  that  benefit  may  result  from 
its  local  action,  for  used  in  this  manner  it  is  antiseptic.  But  the  employment 
of  this  agent  by  insufflation  is  very  unpleasant  to  the  child,  and  is  likely  to 
be  resisted.  Given  in  solution  in  doses  of  two  grains,  as  in  the  following 
formula,  it  produces  some  local  action  on  the  fauces  if  drinks  be  withheld 
subsequently  for  a  few  minutes,  and  at  the  same  time  some  tonic  effect  prob- 
ably results  from  its  use  in  this  manner : 

R.  Quinise  sulphat.,  gss; 

Syr.  yerbae  santae  comp.,  5ij.     3Iisce. 

Give  one  teaspoonful  every  two  to  four  hours  to  a  child  of  five  years.  I 
have  often  prescribed  quinine  in  this  manner  with  apparent  benefit  in  the 
treatment  of  diphtheria. 

Tinctiirn  Ferri  Chlorid!. — All  physicians  who  are  familiar  with  diphtheria 
have  noticed  the  pallor  and  loss  of  appetite,  flesh,  and  strength  which  com- 
mence before  the  close  of  the  fir.st  week  in  severe  cases,  and  which  are  always 
unfavorable  symptoms,  indicating  as  they  do  rapid  and  progressive  deteriora- 
tion of  the  blood.  The  use  of  iron  is  at  once  suggested  as  the  proper  medici- 
nal agent  to  arrest  this  blood-change,  from  its  known  effect  in  increasing  the 
number  of  red  blood-corpuscles  and  the  amount  of  coloring  matter  in  these 
corpuscles.  By  its  effect  on  the  red  corpuscles,  which  are  the  carriers  of 
oxygen,  it  increases  the  functional  activity  of  organs  and  improves  the  gen- 
eral nutrition.     The  ferruginous  preparations,  therefore,  hold  an   important 

^  New  York  Medical  Journal. 


420  DIPHTHERIA . 

place  in  the  therapeutics  of  diphtheria.  The  one  which  has  stood  the  test 
of  experience  and  is  now  commonly  employed  is  the  tincture  of  the  chloride 
of  iron.  It  should  be  given  in  large  and  frequent  doses,  as  five  drops  hourly 
to  a  child  of  three  years. 

Ferguson^  regards  the  tincture  of  the  chloride  of  iron  as  the  most  val- 
uable of  all  remedies  for  diphtheria.  He  examined  the  blood  daily  or  every 
second  day  in  twenty  cases  of  diphtheria,  and  was  astonished  to  observe  how 
rapidly  the  red  blood-corpuscles  were  reduced  in  number,  those  remaining 
presenting  an  unhealthy  appearance.  He  believes  that  the  iron  partially 
arrests  the  blood-change.  He  administers  as  much  as  can  be  tolerated.  To 
a  child  of  ten  years  he  gives  hourly  one  teaspoonful  of  the  following  mix- 
ture in  water : 

R.  Tinct.  ferri  chloridi,         ,^  ; 

Syr.  simplic,  §iij.     Misce. 

If  the  stomach  do  not  tolerate  this  dose,  half  a  teaspoonful  is  administered 
every  half-hour.  An  infant  of  seven  months,  greatly  prostrated,  took  every 
hour  one  teaspoonful  of  the  following : 

R.  Tinct.  ferri  chloridi,        ^ij  ; 

Syr.  simplic,  ^iv.    Misce. 

A  lady  of  twenty-two  years,  having  an  excessive  formation  of  pseudo- 
membrane  and  a  very  fetid  breath,  took  daily  one  and  a  half  fluidounces 
of  the  iron  for  ten  days. 

M.  Jules  Simon  says :  ^  "  For  internal  treatment  from  three  to  six  drops 
of  the  tincture  of  the  chloride  of  iron  should  be  given  in  a  little  water  every 
two  or  three  hours ;  but  it  should  not  be  given  with  milk  or  gum-water  or 
from  a  metallic  spoon,  on  account  of  the  decomposition  which  occurs,  which 
may  produce  digestive  troubles."  Dr.  Whittier  believes  that  this  medicine, 
given  so  as  to  saturate  the  system,  is  the  best  that  can  be  employed.  In 
thirty-six  consecutive  cases  in  which  the  fauces  were  covered  with  the  exu- 
date, all  recovered  under  the  use  of  the  iron  as  the  principal  medicine.'  Dr. 
S.  Baruch  of  New  York  prescribes  hourly  doses  of  this  remedy  in  quantities 
varying  from  eight  to  twenty-five  drops  mixed  with  glycerin  and  water. 
Food  and  stimulants  are  administered  before  the  iron,  but  not  immediately 
afterward,  so  that  the  iron  may  have  a  local  action  upon  the  faucial  surface.* 
Dr.  Billington  recommends  hourly  teaspoonful  doses  of  the  following  mixture  ; 

R.  Tinct.  ferri  chloridi,       f^j  ; 
Glyceriuse, 
Aquse,  ad.  5j-     Misce. 

Prof.  Joseph  E.  Winters  says  that  he  has  given  two  drachms  of  the 
tincture  of  the  chloride  of  iron  every  half  hour  for  forty-eight  hours,  with 
manifest  benefit,  to  a  child  of  eight  years."  But  it  is  only  in  the  most  severe 
or  malignant  form  of  the  disease,  the  form  described  by  Sanne  as  septic 
phlegmonous,  that  such  large  doses  are  proper  or  are  required.  In  mild 
cases  from  three  to  five  drops  given  hourly  or  oftener  sufiice.  This  is  the 
dose  recommended  by  Jules  Simon  of  Paris. 

Several  recent  writers  make  the  plausible  statement  that  the  indication 
of  treatment  by  the  iron  is  to  saturate  the  system  as  soon  as  possible,  employ- 

^  Canadian  Practitioner.  ^  Le  Progrh   medical. 

^  Boston  Medical  and  Surgical  Journal.  *  New  York  Medical  Record. 

^  Diphtheria  and  its  Management,  1885.     (See  Ann.  Univ.  Med.  Sci.,  1888.) 


TREATMENT.  421 

ing  for  this  purpose  as  large  and  frequent  doses  as  can  be  tolerated  by  the 
stomach.  The  tolerance  of  a  drug  depends  largely  on  the  manner  in  which 
it  is  employed.  The  best  vehicle  for  the  tincture  of  the  chloride  of  iron  is 
glycerin  and  water.  It  may  be  conveniently  prescribed  with  two  or  three 
times  its  quantity  of  glycerin  and  a  certain  number  of  drops  administered  in 
water.  The  advice  of  Simon  should  be  borne  in  mind,  not  to  give  it  with 
gum-water  nor  with  milk  nor  from  a  metallic  spoon. 

That  now,  after  nearly  half  a  century  of  the  constant  use  of  iron  in  diph- 
theria in  both  hemispheres,  there  is  an  almost  unanimous  verdict  in  its  favor, 
renders  it  probable  that  the  few  who  have  not  observed  its  good  effects  have 
treated  unusually  bad  cases  or  have  given  the  medicine  in  small  and  inade- 
quate doses.  We  shall  see  that  the  opinions  of  physicians  have  not  remained 
equally  favorable  in  regard  to  the  use  of  the  agent  with  which  the  iron  has 
been  commonly  combined,  the  potassium  chlorate. 

Potassium  Chlorate. — This  agent  produces  a  curative  effect  on  buccal 
inflammations,  and  its  beneficial  action  when  employed  for  the  various  forms 
of  stomatitis  has  led  to  its  extensive  use  in  pharyngitis.  When  taken  inter- 
nally it  is  eliminated  in  part  by  the  salivary  glands,  so  that  it  continues  to 
exert  in  part  a  local  action  on  the  surface  of  the  mouth  and  fauces  until  it  is 
entirely  eliminated.  This  medicine,  the  potas.sium  chlorate,  has  of  late  years 
become  also  a  domestic  remedy,  but  the  laity  should  be  cautioned  in  reference 
to  its  use.  It  is  an  irritant  to  the  kidneys  in  large  doses,  producing  intense 
inflammatory  congestion  of  these  organs  and  arresting  their  function.  The 
melancholy  fate  of  Dr.  Fountaine  of  Davenport,  Iowa,  in  1861,  whose  life 
was  sacrificed  by  an  experimental  dose  of  potassium  chlorate,  is  remembered 
by  the  older  physicians.  Fountaine  took  half  an  ounce  in  a  gobletful  of 
warm  water  at  eight  A.  M.  Free  diuresis  occurred,  which  ceased  at  four 
p.  M.  Though  fatigued  and  pallid,  he  ate  a  hearty  supper.  During  the 
following  night  he  was  in  collapse,  with  vomiting  and  purging  and  severe 
abdominal  pain.  Early  in  the  following  morning  he  voided  two  ounces  of 
dark  urine,  after  which  no  urinary  secretions  occurred.  The  choleraic  symp- 
toms returned,  with  collapse,  but  he  again  rallied.  He  had  vomiting  and 
intense  and  constant  abdominal  pain  during  the  subsequent  six  days,  when 
death  occurred.  The  total  cessation  of  fecal  and  urinary  evacuations  for  six 
days  was  a  notable  fact.  At  the  autopsy  the  lesions  of  an  intense  and  gen- 
eral gastro-intestinal  inflammation  were  present,  the  mucous  membrane  hang- 
ing in  shreds  and  patches ;  the  bladder  was  empty,  and  its  mucous  membrane 
presented  a  similar  appearance  to  that  of  the  stomach  and  intestines.  The 
condition  of  the  kidneys  is  not  stated,  except  that  there  was  liquid  resem- 
bling urine  under  the  capsule  of  one  kidney  and  crystals  of  the  chlorate 
were  in  the  pelves  of  the  kidneys.  A  few  years  since,  in  my  practice,  a  child 
of  three  years  with  active  diphtheritic  pharyngitis  was  allowed  to  quench  its 
thirst  by  drinking  water  from  a  small  pitcher  in  which  three  drachms  of 
potassium  chlorate  had  been  dissolved,  and  which  had  been  ordered  as  a 
gargle.  In  the  morning  I  was  summoned  in  haste,  and  found  the  surface  of 
the  patient  cold  and  blue  and  pulse  feeble.  The  urine  was  totally  suppressed, 
and  instead  of  it  a  few  drops  of  blood  passed  from  the  urethra.  Death 
occurred  before  night. 

Jules  Sim  on  ^  says  that  potassium  chlorate,  acting  wonderfully  well  in 
diseases  of  the  mouth,  produces  no  beneficial  effect  in  diseases  of  the  fauces, 
and  it  weakens  the  little  patient  when  given  in  large  doses.  Dr.  J.  P.  Esch 
says  that  he  has  observed  that  the  potassium  chlorate  used  internally  in  diph- 
theria almost  invariably  produces  symptoms  of  nephritis.  Ferguson'  totally 
condemns  its  use  in  any  dose  or  mode  of  administration  in  diphtheria.     In 

'  Le  Progrhs  medical.  *  Canadian  Practitioner. 


422  DIPHTHERIA. 

every  case  in  which  he  employed  it,  if  albuminuria  were  present  it  increased 
the  amount  of  albumen.  Yon  Focke'  believes  that  any  benefit  which  may 
be  derived  from  the  potassium  chlorate  in  diphtheria  results  from  the  oxygen 
in  it.  To  render  the  oxygen  more  efficient,  he  adds  hydrochloric  acid.  He 
prepares  a  2  per  cent,  solution  of  the  chlorate,  with  a  IJ  per  cent,  solution 
of  the  acid,  and  administers  a  half-teaspoonful  to  two  teaspoonfuls,  according 
to  the  age,  every  one  to  two  hours.  All  the  benefit  obtained  from  this  mix- 
ture may  be  derived  from  a  prescription  long  used  and  favoralsly  known  in 
New  York,  and  probably  more  frequently  written  than  any  prescription 
for  diphtheria.  The  tincture  of  iron  in  the  mixture  contains  one  minim  of 
free  muriatic  acid  in  each  drachm,  but  a  small  amount  of  this  acid  is  added 
to  the  mixture  in  addition.  The  prescription,  with  some  variations  in  its  pro- 
portions in  the  practice  of  different  physicians,  is  as  follows : 

R.  Tinct.  ferri  cliloridi,  3ij~iy  i 

Potas.  chlorat.,  gj ; 

Acidi  muriat.  dilut.,  gtt.  x  ; 

Syr.  siniplic,  ^iv.     Misce. 
Dose :  One  teaspoonful  hourly  or  each  second  hour. 

After  such  an  extensive  use  of  potassium  chlorate  during  nearly  half  a 
century  its  therapeutic  uses  should  be  clearly  defined,  and  any  ill  effects 
which  may  result  fully  determined.  From  what  is  now  known  of  its  action, 
it  would  probably  be  better  to  abandon  its  use  in  diphtheria,  since  it  is  a 
remedy  of  doubtful  efficacy  for  throat  afi"ections.  If  it  be  employed,  it  should 
certainly  be  administered  in  small  doses  sufficiently  diluted.  If  it  be  pre- 
scribed, it  should  not,  I  think,  be  in  larger  quantity  than  half  a  drachm  in 
twenty-four  hours  for  a  child  of  five  years. 

The  remedies  mentioned  above  are  those  which  have  been  most  largely 
employed  for  internal  medication  by  physicians  of  the  present  and  the  pre- 
ceding generations  ;  but  the  belief  that  diphtheria  has  a  microbic  origin, 
that  the  action  of  the  microbes  gives  rise  to  poisonous  ptomaines,  -and 
that  the  virulence  of  the  disease  is  due  to  these  organisms  and  chemical 
products,  has  during  the  last  few  years  brought  into  prominence  the  germi- 
cide and  antiseptic  treatment.  The  attempt  is  now  made — and  apparently 
with  considerable  success — to  cure  the  patient  by  antagonizing  and  destroy- 
ing the  cause  of  diphtheria.  We  look  with  interest  and  for  enlightenment  to 
the  results  of  treatment  by  the  antiseptics,  and  compare  them  with  the  results 
obtained  by  the  use  of  tonics,  stimulants,  and  alimentation,  which  have  been 
heretofore  employed. 

Among  the  most  useful  of  the  statistics  bearing  upon  the  action  of  germi- 
cide and  antiseptic  remedies  in  the  treatment  of  diphtheria  are  the  following, 
made  by  N.  Lunin  in  the  hospital  of  Oldenburg  in  1882.^  In  this  hospital 
296  children  had  diphtheria,  and  164,  or  55  per  cent.,  died.  The  treatment 
by  corrosive  sublimate  consisted  in  brushing  the  pharynx  every  two  hours 
with  a  solution  of  1  part  to  1000,  or  in  spraying  by  the  irrigator  of  Rauch- 
fuss  with  a  solution  of  1  part  to  5000.  The  patients  subjected  to  this 
treatment  numbered  57 :  43  of  them  had  the  fibrinous  form  of  the  dis- 
ease, and  14  the  septic  phlegmonous  form ;  13  of  each  class  died,  or  45 
per  cent,  of  the  whole  number.  The  tincture  of  chloride  of  iron  Lunin 
employed  in  small  doses,  only  one  drop  every  quarter-hour,  or  two  drops 
every  half-hour,  in  94  cases,  43  having  the  fibrinous  form  and  51  the  sep- 
tic phlegmonous  form.  The  total  mortality  was  56.3  per  cent.  Irrigation 
of  the    fauces  was   also   employed  in  these  cases  with  a  3  per  cent,  solu- 

'  Wien.  med.  Wochenschr.  ^  Archivfdr  Kinderheilk.,  1886. 


TREATMENT. 


423 


tion  of  boric  acid.  Luniii  made  use  of  cliinoliiie  in  28  cases — 19  of  the 
fibrinous  form  and  9  of  the  septic  phleginonoiis  form  :  15  died,  or  53  per 
cent.  This  agent  was  prescribed  in  a  5  per  cent,  solution,  the  medium  being 
half  water  and  lialf  alcohol.  Twenty-nine  children  were  treated  by  resorcin,  a 
solution  of  10  per  cent,  being  applied  by  the  brush  twice  hourly,  and  irrigation 
with  a  1  per  cent,  solution  once  hourly.  ()5  per  cent.  died.  A  solution  of 
bromine  and  bromide  of  potassium  was  applied  from  one  to  three  times  hourly 
to  the  fauces  in  33  patients,  but  69.7  per  cent.  died. 

Finally,  23  infants  were  treated  by  turpentine,  a  tablespoonful  twice  daily, 
and  in  some  of  the  cases  an  additional  hourly  dose  during  two  or  three  days. 
The  mortality  was  43.4  per  cent.  In  the  fibrinous  form  the  percentage  of 
deaths  from  the  diff'erent  modes  of  treatment  was  as  follows : 


Percentage. 

By  turpentine 8.30 

"'  resorcin 20.00 

"   corrosive  sublimate 30.20 


Percentage. 

By  chinoline 31.60 

"    tinct.  ferri  chloridi 32.60 

"    bromine 46.70 


In  the  septic  form  the  deaths  were  as  follows  : 


Percentage. 

By  tinct.  ferri  chloridi 76.5 

"    turpentine 81  0 

"    bromine 88.9 


Percentage. 

By  resorcin 89.5 

"    corrosive  sublimate 92.9 

"    chinoline 100.0 


Therefore,  according  to  Lunin's  statistics,  turpentine  was  the  most  useful 
agent  in  the  fibrinous  form  of  diphtheria,  and  the  tincture  of  the  chloride 
of  iron  in  the  septic  phlegmonous  form. 

Hydi-argijri  Chloridum  Corrosivum  (^Hydrargtjriperchloridum^  Br.  Phar.). — 
The  use  of  this  agent  in  the  treatment  of  diphtheria  is  based  on  the  theory 
of  the  microbic  origin  of  this  disease.  Corrosive  sublimate  is  the  most  active 
and  certain  of  the  germicide  agents  employed  in  medicine,  whether  used 
locally  or  internally.  It  quickly  destroys  all  micp-organisms  with  which 
it  comes  in  contact,  and  in  safe  medicinal  doses  it  is  believed  to  penetrate  all 
parts  of  the  system.  The  employment  of  corrosive  sublimate  in  the  treat- 
ment of  diphtheria  is  not  new,  since  it  appears  that  the  late  Dr.  Tappan  of 
Steubenville,  Ohio,  prescribed  it  with  apparent  benefit  in  1860-61  ;  but  it 
was  seldom  prescribed  as  a  remedy  in  this  disease  until  within  the  last  four 
or  five  years.  The  establi.shment  of  the  theory  of  the  microbic  origin  of 
diphtheria,  and  a  knowledge  of  the  fact  that  the  sublimate  is  the  most 
efficient  germicide,  have  made  it  the  favorite  remedy  with  many  physicians. 
Of  course  its  employment  demands  caution,  and  is  justified  only  by  the  fact 
that  the  disease  for  which  it  is  prescribed  has  hitherto  been  very  fatal  with 
other  modes  of  treatment.  Though  this  agent  is  now  widely  used  for 
diphtheria,  medical  journals  thus  far  contain  very  few  reports  of  its 
supposed  toxic  or  injurious  action,  while  many  physicians  believe  that  it 
diminishes  the  virulence  of  diphtheria  and  increases  the  percentage  of 
recoveries. 

In  ordinary  cases  the  following  may  perhaps  be  regarded  as  about  the 
proper  quantities  which  should  be  administered  in  divided  doses  in  twenty- 
four  hours :  For  a  child  of  two  years,  gr.  i  (gr.  ^^  every  two  hours)  ;  for  a 
child  of  four  years,  gr.  \  (gr.  J^  every  two  hours)  ;  for  a  child  of  six  years, 
gr.  1  (gr.  Jy  every  two  hours)  ;  and  for  a  child  of  ten  years,  gr.  h  (gr.  -J^ 
every  two  hours).  Thus,  if  we  employ  the  vehicle  which  Dr.  Tappan  u.sed 
a  quarter  of  a  century  ago,  the  following  prescription  might  be  written  for  a 
child  of  six  years : 


424  DIPHTHERIA. 

R.  Hydrarg.  chlor.  corros.,  gr.  j  ; 

Alcoholi,  3ij  ; 

Elix.  bismuthi  et  pepsinii,  q.  s.  ad  ^iv.      Misce. 
Dose  :  One  teaspoonful  every  two  hours. 

According  to  the  statement  of  physicians,  considerably  larger  doses  have 
been  administered  with  safety  and  apparent  benefit,  and  in  severe  cases, 
attended  by  profound  blood-poisoning,  such  as  Lunin  designates  septic  phleg- 
monous, certainly  the  maximum  medicinal  dose  is  required  if  we  depend  on 
the  sublimate  as  the  main  remedy.  Dr.  Grant  (Bey)  administered  to  a  child 
of  four  years  one-half  grain  every  half-hour  till  six  doses  were  taken,  and 
then  hourly  during  the  first  day,  every  second  hour  on  the  second  day,  and 
on  subsequent  days  at  longer  intervals.  Dr.  A.  Jacob!  states  that  an  infant 
a  year  old  may  take  one-half  grain  every  day  for  many  days  in  succession 
with  very  little,  if  any,  intestinal  disorder  and  with  no  stomatitis.  Althoixgh 
certain  children  may  tolerate  doses  so  large  as  those  recommended  by  Dr. 
Grant  (Bey),  safer  doses  are  those  which  we  have  recommended  above,  and 
they  seem  to  be  sufficient  for  protracted  use.  Dr.  P.  Werner  ^  recommends 
in  the  treatment  of  diphtheria  the  sublimate  dissolved  in  distilled  water,  in 
half-hourly  doses  or  at  a  little  longer  interval,  so  that  the  following  quantities 
are  taken  in  twenty-four  hours  :  For  an  infant  of  one  and  a  half  years,  0.015 
(grain  0.231)  of  the  sublimate  in  120.0  (4  fl.oz.)  of  water ;  for  a  child  at  the 
age  of  six  to  seven  years,  0.3  in  180  (grain  0.45  to  6  oz.)  of  water.  The 
quantity  is  to  be  given  in  divided  doses  in  the  twenty-four  hours.  At  night, 
if  the  child  sleep,  the  doses  should  be  less  frequent  and  proportionately 
larger  than  in  the  day-time.  Dr.  I.  N.  Love  of  St.  Louis  states  that  he  has 
employed  the  sublimate  in  doses  of  one-one-hundredth  to  one-fiftieth  grain 
every  hour  or  second  hour,  according  to  the  age,  preceded  by  large  draughts 
of  water.     Its  action  as  thus  used  seemed  to  be  both  local  and  constitutional. 

Those  who  denounce  the  use  of  mercurials  in  diphtheria,  like  Jules 
Simon  and  one  at  least  of  our  distinguished  American  writers — grouping 
together  calomel,  the  oleate,  the  unguentum,  the  cyanide,  the  biniodide,  and 
corrosive  sublimate,  condemning  them  in  a  body — on  the  ground  that  they 
enfeeble  the  system,  do  injustice  to  the  therapeutic  virtues  of  the  sublimate. 
Medicines  having  the  same  base  often  differ  widely  in  their  action  upon  the 
system  ;  and  it  is  the  common  and  probably  correct  belief  that  the  sublimate 
in  safe  medicinal  doses  does  not  enfeeble  the  system,  but  in  some  instances 
acts  rather  as  a  tonic. 

In  my  practice  excellent  results  have  apparently  occurred  from  the  local 
use  of  corrosive  sublimate — its  use  by  the  atomizer.  If  the  sublimate  be 
administered  internally  at  the  same  time,  care  must  be  taken  not  to  employ 
too  much.  The  solution  which  I  have  prescribed  with  the  atomizer  consists 
of  two  grains  of  the  sublimate  to  one  pint  of  water,  and  in  spraying  the 
fauces  the  bulb  of  the  atomizer  is  compressed  from  three  to  five  times.  In 
ordinary  cases  the  spray  is  used  every  second  hour.  Oatman  of  Nyack, 
New  York,  has  lost  but  1  patient  in  23  by  the  following  local  treatment : 
Cotton  is  firmly  wound  around  the  end  of  a  stick  about  the  size  of  a  lead- 
pencil,  being  drawn  out  as  it  is  wound,  and  made  to  project  beyond  the  end. 
This  is  dipped  into  a  solution  of  the  bichloride  of  mercury,  two  grains  to  the 
pint  (1  to  3840),  and  passed  into  the  throat  until  it  touches  the  posterior 
wall  of  the  pharynx.  It  is  then  instantly  withdrawn  and  burnt.  This 
treatment  is  repeated  hourly  with  a  new  swab  each  time,  until  the  inflam- 
mation begins  to  subside,  which  is  usually  in  forty-eight  hours.  Jules 
Stiimf  ^  treated   31   cases,   with   2   deaths,   by   inhalation  of  the   sublimate, 

^  St.  Petersburg,  med.  Woctienschr.,  1886.  ^  Munch,  med.  Wochenschr. 


TREATMENT.  425 

using  the  apparatus  of  Richardson.  For  infants  under  the  age  of  two  years 
he  employs  1  part  to  4000  ;  from  five  to  six  years,  1  part  to  2000 ;  for  those 
over  six  years,  1  part  to  1000.  Dr.  Thomas  Welcher  recommends  in  tlie 
treatment  of  diphtheria,'  used  as  a  gargle  or  employed  as  a  spray,  a  solution 
of  corrosive  sublimate  of  1  to  1000.  In  most  instances,  when  this  local 
treatment  had  been  employed  a  few  times  at  intervals  of  one  to  two  hours, 
the  pharyngeal  disease  began  to  abate  and  the  general  condition  improved. 
Dr.  Welcher  also  employs  small  doses  of  the  sublimate  internally.  It  is 
evident  from  the  experience  of  other  physicians  that  when  this  agent  is  used 
as  a  spray  in  so  strong  a  solution  as  1  to  1000,  it  should  be  used  with  caution. 
Two  or  three  compressions  of  the  bulb  will  be  sufficient.  Prof.  A.  Jacobi 
recommends  for  washing  the  nares  a  solution  of  corrosive  sublimate  of  from  1 
part  to  2000  to  1  part  to  10,000,  with  or  without  10  to  50  parts  of  table-salt 
or  (JO  to  300  parts  of  boracic  acid. 

The  medical  journals  during  the  last  three  or  four  years  contain  abundant 
testimony  to  the  beneficial  results  of  both  the  internal  and  the  local  use  of 
corrosive  sublimate  in  diphtheria.  An  important  question  evidently  arises — 
to  wit,  how  to  use  this  active  agent  internally  and  locally  at  the  same  time 
without  administering  too  large  a  quantity.  Some  physicians  administer 
the  amount  that  can  safely  be  employed  in  twenty-four  hours  dissolved  in 
water  and  in  frequent  doses  (every  hour  or  second  hour),  and  if  no  drinks  be 
given  subsequently  for  a  few  minutes  the  local  effect  upon  the  fauces  is  to  a 
considerable  extent  obtained.  Perhaps  this  is  the  safest  and  best  mode  of 
employing  this  very  efficient  and  useful  antiseptic  agent  in  the  treatment  of 
diphtheria. 

Calomd. — Dr.  Simon  Baruch  begins  the  treatment  of  all  cases  of  diph- 
theria not  attended  by  diarrhoea  by  a  dose  of  four  to  eight  grains  of  calomel, 
followed,  if  necessary,  by  a  laxative.^  He  cites  the  experience  of  Dr. 
Coester,  who  administered,  in  the  preliminary  treatment  of  diphtheria, 
calomel  in  69  cases,  and  lost  only  1.  Prof.  Simon  of  Paris  in  the  treatment 
of  diphtheria  discards  (1)  blisters,  which  are  always  followed  by  the  repro- 
duction of  pseudo-membrane;  (2)  bleeding  and  mercurials,  which  enfeeble 
the  patient ;  (3)  preparations  of  opium,  which  produce  rapid  depression  of 
the  vital  powers ;  and  (4)  potassium  chlorate  in  large  doses.  The  reference 
of  Simon  to  mercurials  is  probably  more  particularly  to  calomel.^ 

On  the  other  hand.  Dr.  Geo.  B.  Fowler  considers  calomel  the  best  remedy 
with  which  to  combat  diphtheria.  When  croupy  symptoms  supervene  he 
increases  the  dose  from  gr.  i  to  gr.  :J,  or  even  1  grain,  every  hour.*  Dr.  I. 
N.  Love  remarks  that  the  most  marked  recent  recommendation  of  the  use  of 
calomel  in  diphtheria  is  from  the  pen  of  Dr.  William  H.  Daly,  chairman  of  the 
Laryngological  Section  of  the  Ninth  International  Medical  Congress.^  Dr. 
Daly's  method  is  to  administer  the  calomel  two  to  five  grains  every  one,  two, 
or  three  hours  until  free  catharsis  follows,  and  then  at  longer  intervals,  but 
so  that  three  or  four  daily  evacuations  are  produced.  The  editor  of  the 
Therapeutic  Gazette  writes :  "  We  have  so  frequently  seen  an  apparently 
severe  attack  of  diphtheria  abruptly  aborted  in  its  inception  under  the 
influence  of  large  doses  of  calomel  that  we  can  scarcely  believe  that  the 
drug  has  no  pronounced  effect.  A  grain  of  it  should  be  put  dry  in  the 
mouth  of  the  child  every  hour  or  two  until  frequent,  very  loose,  liquid 
evacuations  are  produced." 

In  addition  to  those  already  mentioned,  other  physicians  of  ample  expe- 
rience have  recommended  calomel  in   the  treatment  of  diphtheria,  some  in 

*  Deutsche  med.  Zeit.  ^  Neiv  York  Medical  Record. 

'  Jour,  de  Med.  de  Paris.  *  New  York  Medical  Record. 

^  Weekly  Medical  Review. 


426  DIPHTHERIA. 

laxative  doses  and  only  at  the  beginning  of  the  attack,  and  others  in  doses 
of  the  fractional  part  of  a  grain  every  two  to  four  hours  during  the  sickness. 
The  majority  of  physicians — very  properly,  in  my  opinion — discourage  the 
employment  of  calomel  in  laxative  doses,  believing  that  it  tends  to  weaken 
the  patient  and  increase  the  anajmia,  which  in  all  cases  of  severe  diphtheria 
soon  becomes  very  manifest,  whatever  the  treatment ;  but  a  single  laxative 
dose  is  perhaps  sometimes  useful.  It  may  do  good,  as  in  other  infectious 
diseases,  to  unload  the  primse,  viae,  in  the  commencement  of  the  attack,  so  that 
the  remedies  to  be  employed  are  more  readily  absorbed  and  without  alteration 
by  admixture  with  chemical  products  in  the  intestinal  tract.  What  change 
calomel  undergoes  so  that  it  can  be  absorbed  has  not  been  clearly  ascertained. 

Turpentine. — This  has  been  highly  recommended  recently  by  physicians 
of  experience,  when  used  locally  as  well  as  internally,  for  its  prompt  action 
in  arresting  the  formation  and  extension  of  the  pseudo-membrane  and  as  an 
antidote  to  the  diphtheritic  virus.  Dr.  Rewentauer  states  that  an  infant  of 
two  years  treated  by  other  remedies  began  to  have  symptoms  indicating  inva- 
sion of  the  larynx  on  the  fourth  day.  Tracheotomy  was  resolved  upon,  but 
previous  trial  was  made  of  pure  turpentine  in  a  teaspoonful  dose.  The  croup- 
iness  ceased,  other  symptoms  improved,  and  the  patient  recovered  without 
tracheotomy.^ 

Delthil  and,  following  him,  Schenker  employed  a  mixture  of  coal-tar  and 
turpentine,  which  was  burnt  in  the  room  occupied  by  the  patient  either  con- 
stantly or  several  times  through  the  day.  Schenker's  observations  led  him  to 
believe  that  the  benefit  from  this  treatment  occurred  chiefly  from  the  turpen- 
tine, and  largely  from  its  general  effect  on  the  system.  He  therefore  decided 
to  employ  turpentine  internally  in  doses  of  ten  minims  to  one  teaspoonful, 
one  to  three  times  daily,  in  milk,  sugar-water,  or  gruel.  At  the  same  time  he 
employed  it  as  a  spray.  Alcoholic  stimulation,  cleanliness,  and  a  diet  of  beef 
tea,  milk,  and  egg  were  enjoined.  Of  36  cases  which  Dr.  Schenker  treated 
by  turpentine,  31  recovered. 

Rose  of  Hamburg  employed  turpentine  in  teaspoonful  doses  mixed  with 
spirit  of  ether  (ether  one  part,  alcohol  three  parts)  three  times  daily.  A  tea- 
spoonful of  a  2  per  cent,  solution  of  salicylate  of  sodium  was  also  given  every 
two  hours.  Under  this  treatment  the  temperature  and  pulse  diminished,  other 
symptoms  improved,  and  in  58  cases  thus  treated  95  per  cent,  recovered.^ 
Sigel  also  prescribed  turpentine  in  teaspoonful  doses  in  47  cases,  in  14  of  which 
the  question  of  tracheotomy  arose.  A  manifest  reduction  of  temperature 
followed  the  use  of  the  turpentine.  The  percentage  of  deaths  in  all  thus 
treated  was  14.9,  while  of  those  treated  by  corrosive  sublimate,  salicylic  acid, 
potassium  chlorate,  etc.,  32.5  per  cent.  died.  Dr.  Llewellyn  Eliot  also  reports 
good  results  from  the  vaporization  of  turpentine. 

The  recent  recommendation  of  turpentine  in  the  treatment  of  diphtheria 
by  many  physicians  of  large  experience  and  sound  judgment,  among  whom 
we  may  mention  Drs.  S.  Baruch  and  A.  Jaeobi,  has  extended  and  established 
the  use  of  this  agent.  Its  supposed  efficacy  depends  on  the  fact  that  it  is 
antiseptic  and  germicidal,  and  that  when  vaporized  and  inhaled  or  taken  by 
the  stomach  it  penetrates  all  parts  of  the  system.  The  descriptions  long 
given  in  the  text-books  of  the  physiological  action  of  turpentine  have  had 
the  tendency  to  induce  physicians  to  employ  it  in  small  doses.  But  I  am  not 
aware  that  any  writer  has  recorded  ill  effects  from  the  use  of  turpentine  in 
diphtheria,  although  it  has  been  employed  by  a  considerable  number  of  phy- 
sicians in  the  last  year  or  two,  and  in  quantities  which  exceed  the  medicinal 
doses  mentioned  in  text-books. 

It  is  well   known  that  the   constitutional   effects  of  the  oleum  terebin- 

^  Centralbl.f.  kiln.  Med.  ^  Therap.  Monatschr. 


TREATMENT.  427 

thinae,  even  to  impaired  vision,  strangury,  and  bloody  urine,  may  be  obtaincsd 
by  the  i)rolonged  inhalation  of  its  vapor;'  and  I  have  employed  the  vaj)or 
of  the  oil  of  turpentine  during  the  last  two  or  three  years  with  such  appa- 
rent good  results  that  T.  confidently  recommend  the  mode  of  using  turpentine 
as  recommended  in  our  remarks  under  the  head  of  Prophylaxis.  Turpentine 
will  probably  in  the  future  be  a  very  important  remedy  in  the  treatment  of 
diphtheria,  whether  taken  by  the  stomach  or  received  as  a  spray. 

FilorarjriiH'. — Certain  physicians  have  recommended  pilocarpine  in  the 
treatment  of  diphtheria,  because, it  is  supposed  that  the  salivary  and  mucous 
secretions  which  it  produces  aid  in  throwing  oflP  the  pseudo-membrane.  Dr. 
Lax  states  that  the  10  patients  treated  by  him,  some  of  them  severely  sick,  all 
recovered.^     He  employed  the  following  prescription  : 

R.  Pilocarpini  hydrochlorat.,  gr.  J  to  f ; 

Acidi  hydrochlorici,  gtt.  ij-iij  ; 

Pepsin i,  gr.  x-xij  ; 

Aqua?  destillat.,  ^xviiss.     Misce. 
Dose :  A  teaspoonful  or  tablespoonful  in  wine. 

Guttmann  treated  in  a  year  and  a  half  81  cases  by  this  remedy  without 
a  death.  Gelsner  and  Delewsky  also  report  good  results.  On  the  other 
hand,  I  have  seen  the  most  disastrous  eflPects  from  the  use  of  pilocarpine  in 
diphtheria,  the  secretions  filling  the  bronchial  tubes  and  being  expectorated 
insufficiently  and  with  great  difficulty.  Death  resulted.  The  symptoms 
which  occurred  were  like  those  in  extreme  oedema  of  the  lungs.  I  cannot 
therefore  recommend  its  use.  Its  employment  appears  too  hazardous,  espe- 
cially in  young  and  feeble  children. 

Sodimn  Benzoate. — Dr.  1.  N.  Love  recommends  the  sodium  benzoate 
in  five-,  ten-,  or  fifteen-grain  doses.^  He  remarks  that  Salkowski  in  1879 
noticed  that  this  drug  largely  increased  the  secretions  by  the  kidneys  of  nitrog- 
enous and  sulphurous  compounds,  and  concluded  that  it  would  aid  in 
depurating  the  blood  of  noxious  matters.  Salkowski,  Fleck,  and  Buckholtz 
ascertained  that  the  benzoate  arrested  the  growth  of  micro-organisms  in 
putrid  liquid,  and  Graham  Brown  that  diphtheritic  liquids  became  non- 
contagious by  the  addition  of  the  benzoate.  Helferich,  Graham  Brown,  and 
Sanne,  from  experiments  made  on  animals,  consider  the  benzoate  of  sodium 
a  specific  against  the  virus  of  diphtheria.*  On  the  other  hand,  M.  Dumas, 
surgeon  to  the  Hopital  de  Cette,  has  not  derived  any  marked  benefit  from  its 
use,  and  Dr.  A.  Jacobi  says  that  it  does  not  deserve  the  eulogies  bestowed 
upon  it  from  theoretical  reasonings.^ 

Such  are  the  more  important  remedies,  used  internally,  which  have  been 
up  to  the  present  time  employed  in  the  treatment  of  diphtheria.  The  num- 
ber, it  is  seen,  is  large,  and  most  of  them  are  no  doubt  useful  in  certain  cases. 
Diphtheria,  being  a  disease  of  variable  type,  must  be  treated  according  to  the 
indications  in  each  case.  The  internal  remedies  which  in  my  opinion  have 
been  most  useful,  and  which  should  be  most  frequently  employed,  are  the 
tincture  of  the  chloride  of  iron,  quinine,  corrosive  sublimate,  turpentine,  and 
the  alcoholic  preparations. 

Among  the  other  remedies  which  have  been  recommended  by  good 
observers,  we  may  mention  the  following  :  Copaiba  and  cubebs  are  employed 
and  recommended  by  distinguished  French  physicians.  Jules  Simon  pre- 
scribes copaiba  and  cubebs  for  patients  over  the  age  of  five  or  six  years.* 

^  SlUle  and  Makh.  ^  Medical  JVeK's. 

^  Weekly  Medical,  Revien:  *  Im  France  medicale. 

^  New  York  Medical  Record.  ^  Le  Progres  medical. 


428  DIPHTHERIA. 

Dr.  I.  H.  Fruitnight  has  employed  the  sodium  hyposulphite  in  8  cases, 
giving  hourly  drachm  doses  of  the  following  :  R.  Sodii  hyposulph.,  gj  ;  Aquae, 
f^ij.  The  result  was  favorable.  Illingworth'  recommends  the  biniodide  of 
mercury.  Dr.  C.  B.  Galentine  recommends  the  internal  use  of  hydrate  of 
chloral,  given  with  the  potassium  chlorate  to  a  child  of  six  years  in  about 
22-grain  doses.  Herbert  L.  Snow  recommends  sulphurous  acid,  Dr.  Hofmokl 
the  hydrogen  dioxide,  and  E.  S.  Smith  the  oil  of  eucalyptus  and  Warburg's 
tincture.  In  diphtheria,  therefore,  as  in  other  diseases  which  in  a  large  pro- 
portion of  cases  end  favorably  whatever  the  treatment,  the  number  of  recom- 
mended remedies  is  large. 

Local  Treatment — Solvents. — The  belief  is  becoming  prevalent  in  the 
profession  that  the  early  destruction  and  removal  of  the  exudate  from  the 
faucial  or  nasal  surface  is  not  an  imperative  duty,  as  was  formerly  practised 
under  the  teachings  of  Bretonneau  and  Trousseau,  provided  that  thorough 
disinfection  of  the  pseudo-membrane  and  the  surrounding  and  underlying 
tissues  be  eflfected.  Patients  are  injured  by  irritating  lotions  or  instrumental 
treatment  designed  to  remove  the  pseudo-membrane,  which  immediately  reap- 
pears in  greater  extent  and  thickness  than  at  first,  on  account  of  the  increase 
in  the  inflammation  in  consequence  of  the  severe  measures  employed.  The 
employment  at  short  intervals  of  mild  but  efficient  antiseptic  applications  in 
place  of  the  stronger  and  irritating  lotions  formerly  used  has  been  a  great 
improvement  in  the  treatment  of  diphtheria.  But  antiseptic  lotions,  vapors, 
or  sprays  are  inadequate  to  produce  complete  disinfection  if  the  pseudo-mem- 
brane has  great  thickness.  Its  under  surface,  which  is  in  immediate  relation 
with  the  lymphatics  and  blood-vessels,  and  from  which  systemic  poisoning 
occurs  from  absorption  of  the  diphtheritic  germ,  septic  matter,  or  ptomaines, 
is  probably  not  reached  by  the  antiseptic  sprays  or  lotions  as  commonly 
employed.  Any  painless  and  unirritating  application  which  diminishes  the 
thickness  of  the  pseudo-membrane  by  its  solvent  action,  or,  better,  entirely 
dissolves  and  removes  it,  is  therefore  useful.  Of  the  unirritating  solvents, 
alkalies,  pepsin,  trypsin,  and  papayotin  have  been  chiefly  used,  and  have  in 
the  highest  degree  the  confidence  of  the  profession.  The  efficiency  of  solvent 
treatment  depends  largely  on  the  manner  in  which  it  is  employed,  the  kind 
of  instrument  used,  and  the  frequency  of  the  application.  The  solvent  agent 
heretofore  most  largely  used  has  been  lime-water  or  the  spray  of  slaking 
lime.  Its  solvent  action  is  probably  due  chiefly  to  its  alkalinity,  but  its 
alkalinity  and  its  solvent  action  can  be  greatly  increased  by  adding  to  it  the 
sodium  bicarbonate.  From  observing  its  efiiects  in  a  considerable  number  of 
cases  the  writer  recommends  with  confidence  the  following  formula : 

R.  01.  eucalypti,  gij  ; 

Sodii  benzoat.,  3J  J 

Sodii  bicarbonat.,  gij ; 

Glycerinfe,  ,:^ij ; 

Aquae  calcis,  Oj.     Misce. 

To  be  used  with  the  hand-atomizer  from  three  to  five  minutes  every  half- 
hour,  or  with  the  steam  atomizer  almost  constantly.  This  alkaline  spray 
not  only  exerts  a  solvent  action  on  the  pseudo-membrane,  but  also  renders 
the  muco-pus  thinner,  less  viscid,  and  therefore  so  changes  its  character  by 
diminishing  its  viscidity  that  it  is  more  easily  expectorated. 

The  use  of  pepsin  as  a  solvent  is  suggested  from  its  well-known  action  in 
digesting  nitrogenous  substances.  It  has  been  employed  with  varying  results. 
It  is  well  known  that  some  of  the  preparations  in  the  shops  are  much  more 

^  British  Medical  Journal. 


TREATMENT.  429 

active  than  others,  and  hence  perhaps  a  chief  reason  for  the  difference  in  the 
results  obtained.  It  is  well  to  remind  the  reader  that  it  should  be  employed 
alone  or  with  an  acid,  for  it  is  comparatively  inert  if  used  with  an  alkali. 

Ros.sbach  states'  that  he  has  used  a  solution  of  papaijotin^  or  vegetable 
pepsin,  frequently  applied  to  the  fauces.  In  young  children  a  few  minims 
may  be  placed  on  the  tongue  every  five  minutes.  If  the  drug  be  good,  he 
states  that  the  membrane  is  dissolved  in  two  or  three  hours.  Dr.  Jacobi 
says  that  this  agent  is  readily  dissolved  in  twenty  parts  of  water.'^  It  ma}', 
he  says,  be  brushed  over  the  surface  or  used  as  a  spray.  Mixed  with  water 
and  glycerin  in  greater  concentration  (1  to  4—8),  it  has  been  used  by  him 
with  fair  results.  Dr.  J.  K.  Bauduy,  Jr.,  also  writes  favorably  of  the  solv- 
ent action  of  papayotin  on  the  pseudo-membrane.^ 

Tri/psii)i,  unlike  pepsin,  is  an  active  solvent  in  an  alkaline  medium,  and  it 
may  be  added  to  the  alkaline  mixture  described  above.  Dr.  F.  C.  Fernald 
relates  the  case  of  a  boy  of  six  and  a  half  years  who  had  perforation  of 
each  membrana  tympani  and  began  to  complain  of  sore  throat.  A  pseudo- 
membrane  appeared  upon  the  tonsillar  portion  of  the  fauces,  and  the  right 
auditory  canal  was  covered  with  a  diphtheritic  exudate,  entirely  occluding 
it,  so  that  liquids  did  not  flow  from  the  external  ear  to  the  fauces  as  formerly. 
The  ear  was  filled  every  half-hour  with  the  following  mixture  :  R.  Trypsin., 
gr.  XXX  ;  Sodii  bicarb.,  gr.  x. ;  Aquse  destillat..  5J.  The  pseudo-membrane  grad- 
ually dissolved  and  disappeared,  the  passage  through  the  ear  and  Eustachian 
tube  became  open,  and  the  patient  recovered.*  Dr.  E.  N.  Liell  also  relates 
a  case  in  which  trypsin  apparently  produced  a  solvent  action  on  the  pseudo- 
membrane.  Probably,  therefore,  in  the  present  state  of  our  knowledge  we 
can  apply  no  better  solvent  mixture  upon  the  diphtheritic  pseudo-membrane 
than  trypsin  added  to  the  alkaline  solution  described  above. 

Alburainuria. — This  being  due  to  septic  nephritis,  patients  have  seemed 
to  me  to  be  more  benefited  by  the  tincture  of  the  chloride  of  iron,  in  fre- 
quent and  rather  large  doses,  than  by  any  other  remedy.  If  while  this  is 
being  used  a  marked  diminution  in  the  quantity  of  urine  occurs,  it  may  be 
necessary  to  employ  diuretics  and  laxatives,  as  in  scarlatinous  nephritis. 
The  potassium  bitartrate  or  acetate,  and  perhaps  the  more  laxative  salines, 
may  be  needed  under  such  circumstances.  But  marked  diminution  of  urine 
— and  especially  anuria — in  diphtheria  ends  fatally,  with  few  exceptions, 
according  to  my  observations,  whatever  the  treatment. 

Paralysis. — The  loss  of  the  tendon  reflexes,  and  palatal  and  multiple 
paralysis,  require  the  same  stimulating  and  sustaining  remedies  which  are 
appropriate  for  the  primary  disease,  diphtheria.  Iron  and  other  tonics,  nutri- 
tious and  easily-digested  diet,  massage,  and  in  some  instances  electricity, 
suffice  to  restore  the  use  of  the  affected  muscles,  but  sometimes  weeks  and 
even  months  elapse  before  their  use  is  fully  restored.  So  long  as  the  paraly- 
sis does  not  affect  any  vital  organ,  a  favorable  prognosis  may  be  expressed, 
although  recovery  may  be  slow. 

On  the  other  hand,  it  is  evident  from  its  nature  and  from  the  cases 
which  have  been  related  that  cardiac  paralysis  is  exceedingly  dangerous, 
and  must  be  treated  promptly  and  by  the  most  active  remedies.  As  we 
have  seen,  the  attack  of  cardiac  paralysis  is  usually  sudden,  with  little  fore- 
warning, and  is  often  fatal  before  the  physician,  promptly  summoned,  is 
able  to  arrive.  The  patient  should  be  as  quiet  as  possible  in  bed,  with  the 
head  low,  and  alcoholic  stimulants  should  be  administered  at  once.  In  the 
sudden  seizures,  such  as  have  been  related  above,  hypodermic  injections  of 
brandy  act  most  promptly  in  sustaining  the  heart-action.     Ammonia,  cam- 

'  St.  Peter shurg.  vied.  Wocheiischr.,  1886.  ^  New  York  Medical  Record. 

^  Medical  Weekly  Revieiv.  *■  Mediccd  News. 


430  DIPHTHERIA. 

phor,  musk,  and  the  electrical  current  may  be  useful  auxiliaries.  The  pre- 
digested  beef  preparations,  peptonized  milk,  and  other  concentrated  foods 
designed  for  those  with  feeble  digestion  are  useful.  If  the  urgent  symp- 
toms are  relieved  by  these  measures,  such  remedies  should  be  employed  as 
are  useful  in  other  forms  of  diphtheritic  paralysis.  .  The  patient  is  ordinarily 
feeble,  anaemic,  and  with  poor  digestion.  The  beef  extracts  and  concentrated 
foods  should  be  continued.  Iron,  quinine  in  moderate  doses,  and  alcoholic 
stimulants  are  indicated.  The  use  of  the  electric  current  is  suggested  by 
the  nature  of  the  attack.  Many  physicians  believe  that  they  have  obtained 
benefit  from  its  use  in  the  treatment  of  the  more  common  forms  of  diphthe- 
ritic paralysis,  while  others  speak  doubtfully  of  its  efl&cacy.  If  there  be 
reason  from  the  symptoms  to  suspect  the  presence  of  central  lesions  in  the 
nervous  system,  the  galvanic  current  in  short  sittings  has  been  recommended, 
and  not  the  faradic.  In  ordinary  cases  either  the  direct  or  the  induced  cur- 
rent may  be  employed. 

Strychnine  is,  however,  regarded  by  good  observers  as  the  most  efficacious 
nerve-stimulant  in  the  various  forms  of  diphtheritic  paralysis.  Oertel's 
objection,  expressed  twenty  years  ago,  to  the  use  of  strychnine  in  this  disease,, 
that,  acting  as  an  excitant  of  the  spinal  cord,  it  is  likely  to  aggravate  central 
lesions,  was  founded  on  a  wrong  understanding  of  the  pathology  of  the 
paralysis.  Prof.  Henoch  cured  diphtheritic  paralysis  in  three  weeks  by 
hypodermic  injections  of  strychnine.  W.  Reinard^  states  that  a  boy  three 
and  a  half  years  of  age  fifteen  days  after  the  appearance  of  the  diphtheritic 
patches  on  the  tonsils  had  paralysis  of  the  inferior  extremities  and  the  velum 
palati,  a  tottering  gait,  nasal  voice,  and  difficult  deglutition.  At  the  end  of 
twelve  days  death  seemed  imminent,  the  paresis  of  the  lower  extremities  had 
become  a  complete  paraplegia,  and  the  paralysis  of  the  upper  extremities  and 
of  the  muscles  of  the  nucha,  larynx,  and  thorax  was  complete.  He  was 
vmable  to  sustain  himself  in  the  sitting  posture,  his  head  falling  heavily  on 
his  chest.  He  had  also  dyspnoea,  hoarse  cough,  tracheal  rales,  and  aphonia,, 
probably  from  cardio-pulmonary  paralysis.  Reinard  made  a  hypodermic- 
injection  each  day  of  one  milligramme  (about  one-sixty-fifth  of  a  grain)  of 
sulphate  of  strychnine  in  the  nucha.  Improvement  occurred  in  twenty-four 
hours  in  the  tonicity  of  the  muscles.  On  the  third  day  the  cardiac  and  pul- 
monary paralysis  had  so  improved  that  the  tracheal  rales  had  ceased.  The 
respiration  was  more  normal  and  deglutition  possible.  On  the  fifteenth  day 
of  this  treatment  and  after  fifteen  injections  the  patient  was  considered 
cured.  Dr.  Grerasimow^  relates  the  case  of  a  child  six  years  of  age  who  had 
paralysis  of  the  velum,  pharynx,  larynx,  and  lower  extremities.  Six  weeks 
after  the  commencement  of  paralytic  symptoms  subcutaneous  injections  of 
strychnine,  two  centigrammes  (or  about  one-thirty-first  of  a  grain),  were 
given  daily.  With  this  treatment  the  patient  improved,  and  after  seven 
injections  of  this  strength,  followed  by  twelve  of  one-twenty-second  of  a. 
grain,  the  cure  was  complete. 

With  such  strong  testimony  in  favor  of  the  use  of  strychnine,  it  is  per- 
haps remarkable  that  physicians  of  experience  state  that  they  have  not 
observed  any  marked  benefit  from  its  use  in  the  treatment  of  diphtheritic 
paralysis.  At  a  meeting  of  the  New  York  Clinical  Society,  held  December 
23,  1887,^  Dr.  Holt  stated  that  he  was  yet  to  be  convinced  that  strychnine 
possessed  any  specific  value  in  this  disease,  though  it  was  of  much  value  as 
a  general  tonic.  At  the  same  meeting  Dr.  A.  A.  Smith  stated  his  belief  that 
tonics  and  time  did  more  for  diphtheritic  paralysis  than  anything  else.  He 
had  used  electricity  and  strychnine,  and  had  never  been  able  to  satisfy  him- 

^  Deutsche  med.  Wocheiischr.,  1885,  No.  19.  ^  Med.  Obosr.,  No.  20. 

^  New  York  Medical  Journal,  Jan.  14,  1888. 


PERTUSSIS.  431. 

self  that  electricity  did  any  f^^ood,  and  the  effects  of  strychnine  seemed  to  be 
not  specific,  but  those  of  a  general  tonic.  On  the  other  hand,  Dr.  Thatcher 
of  New  York  has  reported  a  case  in  which  galvanism  was  employed  on  the 
two  paralyzed  upper  extremities  alternately,  on  each  for  a  week  at  a  time. 
It  was  invariably  found  that  the  arm  receiving  the  electricity  gained  more 
rapidly  than  the  one  untreated,  the  strength  being  tested  by  the  dynamom- 
eter. This  test  seems  to  have  been  conclusive  as  showing  the  efficacy  of 
galvanization. 


CHAPTER    VIII. 

PERTUSSIS. 

Pertussis  is  a  highly  contagious  disease  attended  and  manifested  by  a 
catarrh  of  the  air-passages.  This  catarrh  gives  rise  to  a  cough  which  does 
not  differ,  during  the  inception  and  in  the  declining  period,  from  that  in  an 
ordinai-y  catarrh,  but  during  the  middle  period  of  the  malady  is  spasmodic. 
Exceptionally,  the  system  is  so  mildly  affected  that  the  spasmodic  element  of 
the  cough  is  lacking  through  the  whole  course  of  the  malady  or  is  confined 
to  a  brief  period.  This  distinctive  symptom — namely,  the  peculiar  cough — 
has  been  attributed  to  the  irritating  and  disturbing  action  of  the  specific 
principle  on  the  nerves  which  control  the  muscles  of  respiration.  It  is 
attributed  to  the  impression  produced  upon  the  filaments  of  the  pneumogas- 
tric,  especially  upon  those  of  the  internal  branch  of  the  superior  laryngeal 
nerve,  by  the  mucus  which  collects  in  the  larynx  and  trachea,  and  which  is 
known  to  contain  the  contagious  principle  in  abundance.  This  cough  con- 
sists in  a  series  of  forcible  and  loud  expirations,  followed  by  a  noisy  and 
difficult  inspiration.  Its  special  character  is  due  to  spasmodic  contraction  of 
the  muscles  of  expiration,  and  notably  of  the  small  muscles  of  the  larynx, 
so  as  to  produce  narrowing  or  even  closure  of  the  aperture  of  the  glottis. 
Each  pai-oxysm  of  the  cough  usually  ends  (not  always)  in  the  expectoration 
of  viscid  mucus.  With  rare  exceptions  pertussis  affects  the  same  individual 
but  once.  Killiet  and  Barthez  report  a  case  of  its  second  occurrence,  and 
West  another  case.  I  have  attended  two  adult  patients,  both  women  of 
intelligence,  who  stated  that  they  had  had  previous  attacks  in  early  life. 
Pertussis  usually  prevails  as  an  epidemic,  but  is  occasionally  sporadic,  at 
which  time  its  type  is  mild.  It  is  highly  contagious  through  the  breath  of 
the  patient  or  from  exhalations  from  his  surface.  Pertussis  is  probably  a 
disease  of  antiquity,  but  there  is  no  clear  description  of  it  prior  to  the  six- 
teenth century.  Some  have  thought  that  it  was  alluded  to  in  the  writings 
of  Hippocrates,  and  the  Arabian  physician  Avieenna  who  lived  in  the  tenth 
century,  in  describing  the  "  violent  cough  of  children,"  which  is  attended  by 
the  spitting  of  blood  and  lividity  of  the  face,  probably  alluded  to  it  (Rilliet 
and  Barthez).  Baillon  in  1578  described  a  cough  which  appeared  in  Paris, 
attacked  chiefly  children,  and  was  so  violent  that  it  caused  bleeding  from 
the  nose  and  mouth,  and  often  vomiting.  Willis  in  1682  and  Schenck  in 
1695  also  described  a  convulsive  cough  which  we  can  apparently  identify 
as  pertussis.  In  the  eighteenth  century  whooping  cough  was  described  by 
many  observers  in  different  parts  of  Europe,  anions  whom  we  mav  mention 
Alberte  (1728),  Brendel  (1747),  De  Basseville  (1752),  Forbes  (1755),  Cullen, 
Butter,  and  Danz.    In  the  present  century,  whooping  cough,  being  eminently 


432  PERTUSSIS. 

contagious  and  of  such  a  nature  that  the  patients  are  allowed  to  mingle  in 
society,  is  widely  disseminated,  and  epidemics  of  it  are  of  frequent  occur- 
rence. 

Incubative  Period. — It  is  not  improbable  that  this  varies  in  different 
cases.     Some  writers  believe  that  it  is  usually  from  two  to  seven  days.     In 

one   instance   I  was  able  to   ascertain  it  accurately.     Mrs.  B ,  having  a 

cough  for  two  weeks,  which  was  afterward  ascertained  to  be  that  of  pertussis, 
came  from  Boston  to  a  family  in  New  York.  She  remained  with  this  family 
from  2  p.  M.,  January  2,  1879,  till  the  evening,  when  she  left  the  city. 
During  her  stay  she  held  and  kissed  an  infant  that  was  previously  well  and 
had  never  been  removed  from  the  floor  on  which  it  was  born.  Pertussis  was 
not  at  that  time  prevailing  in  New  York.  On  the  6th,  or  four  days  after 
exposure,  the  infant  began  to  cough,  and  this  proved  to  be  the  beginning  of 
a  severe  attack. 

Age. — Most  cases  of  pertussis  are  between  the  ages  of  one  year  and 
eight  years,  but  it  occasionally  occurs  in  adults  and  even  old  people  who 
have  not  been  attacked  previously.  It  is  rare  under  the  age  of  three 
months,  but  through  the  kindness  of  Dr.  Ewing  of  New  York  I  was  enabled 
to  see  a  new-born  infant  with  pertussis  whose  mother  had  had  the  disease 
during  the  two  months  preceding  her  confinement.  This  infant  was  fifteen 
minutes  old,  and  during  the  washing  had  the  first  convulsive  seizure,  which 
appeared  to  consist  chiefly  of  a  spasm  of  the  laryngeal  muscles,  with  tempo- 
rary suspension  of  the  respiration,  and  attended  by  deep  lividity  of  the  fea- 
tures, with  some  frothing  from  the  mouth.  These  attacks  occurred  nearly 
every  hour,  with  intervals  of  complete  cessation  of  symptoms.  The  mucus 
between  the  lips  finally  became  stained  with  blood,  and  death  occurred  on 
the  third  day.  The  mother,  the  intelligent  wife  of  a  clergyman,  believes 
that  the  infant  had  similar  attacks  before  its  birth,  for  she  frequently  expe- 
rienced in  the  last  weeks  of  gestation  what  seemed  to  be  strong  convulsive 
movements  in  the  foetus,  the  duration  of  which  corresponded  with  that  of 
the  attacks  in  the  infant.  A  similar  case  is  related  by  Rilliet  and  Barthez,^ 
and  another  by  Keating.^  These  cases  throw  light  on  the  pathology  of  per- 
tussis, for  they  show  that  the  specific  principle  may  enter  the  blood. 

Causes. — Climate,  race,  and  nationality  do  not  seem  to  exert  any  decided 
influence  on  the  spread  of  pertussis.  Females  are  somewhat  more  liable  to 
be  attacked  than  males  and,  as  we  have  seen,  a  large  majority  of  the  cases 
occur  between  the  ages  of  one  and  ten  years.  Letzerich  about  the  year 
1870  supposed  that  he  had  discovered  the  cause  of  pertussis  in  a  microbe, 
which,  received  upon  the  surface  of  the  air-passages  in  inspiration,  increases 
rapidly  and  produces  the  spasmodic  cough  by  its  irritating  action  or  the  irri- 
tating properties  which  it  imparts  to  the  mucus.  In  the  first  stage  of  per- 
tussis he  found  only  the  spores  of  the  microbe,  and  at  a  more  advanced 
stage,  in  addition  to  the  spores,  he  discovered  filaments.  He  placed 
mucus  holding  the  cryptogam  upon  the  fauces  of  the  rabbit,  and  witnessed 
the  production  of  pertussis  in  this  animal.  Recently,  Burger^  of  Bonn 
states  "  that  the  micro-organism  of  pertussis  is  visible  with  a  power  of  340  to 
600  diameters,  appearing  as  little  rods  of  unequal  size.  With  a  higher  power  it 
is  seen  that  the  rods  have  the  biscuit  form.  The  groups  of  bacteria  are  irreg- 
ularly disseminated  or  disposed  in  line,  and  bear  some  resemblance  to  the 
leptothrix  buccalis.  The  method  of  preparation  is  very  simple.  A  small  quan- 
tity of  the  expectoration  is  pressed  between  two  cover-glasses,  exposed  to  the 
flame  of  a  Bunsen  burner  to  coagulate  the  albumen  ;  the  coloring  matter  is 

^  Treatise  on  the  Diseases  of  Children. 

^  System  of  Medicine  hy  American  Authors:  Lea  Bros.,  Philadelphia,  1885. 

'  Berlin,  klin.  Wochenschrift ;  London  Medical  Record,  May  15,  1884. 


PATHOLOGICAL  ANATOMY.  433 

then  added  (watery  solution  of  fuclisin  or  of  methyl  violet) ;  it  is  then 
washed  thoroughly  in  water,  or  the  coloring  matter  removed  by  washing  in 
alcohol,  the  bacteria  alone  remaining  colored.  These  bacilli  are  not  found  in 
any  other  expectoration  ;  they  are  so  abundant  that  it  is  difficult  to  contest 
their  action  ;  their  frequency  is  always  in  direct  relation  with  the  inten- 
sity of  the  disease."  Dr.'I*oulet'  also  confirms  the  statement  of  a  special 
micro-organism  in  pertussis  from  his  examinations.  In  the  St.  Peterahnrgher 
med.  Worh.,  1887,  a  "careful  observer,"  Dr.  Afanasieff,  also  states  that  he 
has  discovered  a  bacillus  in  the  sputum  of  pertussis  which  differs  from  all 
other  bacilli.  It  occurs  in  the  form  of  small  rods,  single,  in  pairs,  or  in 
chains.  The  length  of  the  bacillus  is  O.G  to  2.2  micromillimetres.  Its  cul- 
tures exhibit  peculiar  qualities.  Inoculated  in  animals,  it  produces  symptoms 
like  those  of  human  pertussis,  and  the  aii*-passages  of  these  animals  exhibit- 
ed the  appearance  of  congestion  and  catarrh.  In  the  *SV.  Petershurgher  med. 
Wocli..  in  1888,  another  distinguished  Russian  observer,  Seintschenko,  writes 
that  after  many  experiments  he  is  able  to  make  the  following  statements: 
1.  The  bacillus  of  Prof.  Afanasieff  is  specific;  2.  Bacilli  may  be  found  in 
the  sputum  about  the  fourth  day  of  the  disease,  in  some  cases  earlier ;  3. 
They  multiply  in  the  tissues  of  the  body,  and  as  they  increase  the  severity 
of  the  disease  increases ;  4.  The  bacilli  disappear  before  the  entire  cessa- 
tion of  the  attacks  of  coughing,  or  when  the  paroxysms  are  reduced  to  two 
or  four  daily  ;  5.  With  complications — such  as,  for  example,  a  catarrhal  pneu- 
monia— there  is  a  great  increase  in  the  number  of  whooping-cough  bacilli 
found  in  the  sputum  ;  6.  A  pneumonia  developing  under  these  circumstances 
differs  from  ordinary  attacks  of  catarrhal  pneumonia ;  7.  The  bacillus  of 
whooping  cough  is  of  value,  not  only  in  etiology  and  diagnosis,  but  in  the 
prognosis,  of  the  disease. 

Lesions  have  been  discovered  in  certain  fatal  cases  which  have  been  sup- 
posed to  throw  light  on  the  etiology  of  pertussis,  but  which  are  now  known 
to  have  been  merely  coincidences  or  results  of  the  disease.  Such  are  con- 
gestion of  the  spinal  cord  and  its  meninges,  hypersemia  of  the  pneumogas- 
trics,  and  tumefaction  of  the  tracheo-bronchial  glands,  which  it  was  claimed 
produced  the  spasmodic  cough  by  compressing  the  recurrent  laryngeal 
nerve. 

Pathological  Anatomy. — Catarrhal  inflammation  of  the  air-passages 
is  uniformly  present.  It  occasionally  occurs  on  the  mucous  surfaces  of  the 
nostril  and  pharynx,  but  is  often  absent  from  these  parts.  In  the  majority 
of  patients  the  inflammation  affects  the  surface  of  the  glottis  and  that  below 
the  glottis.  Herff  examined  his  own  larynx  during  paroxysms  of  pertussis. 
He  observed  a  moderate  inflammatory  hyperfemia  of  the  respiratory  tract 
during  the  entire  course  of  the  disease.  The  inflammation  extended  from 
the  posterior  nares  to  the  bifurcation  of  the  trachea,  but  was  most  marked 
in  the  following  locations  :  over  the  cartilages  of  Santorini,  Wrisberg,  and  the 
arytenoid,  and  the  posterior  wall  of  the  larynx,  between  the  vocal  cords  and 
the  epiglottis,  and  on  the  under  surface  of  the  epiglottis.  The  vocal  cords 
themselves  were  not  affected.  During  the  paroxysm  a  pellet  of  mucus  was 
observed  upon  the  posterior  surface  of  the  larynx  on  a  level  with  the  glottis, 
and  when  this  was  removed  the  cough  ceased.  Irritation  of  this  part  of  the 
larynx  uniformly  excited  a  cough.  Sometimes  certain  alveoli  are  found 
distended  by  a  thick  muco-pus,  producing  an  appearance  like  minute 
tubercles. 

A  common  lesion  found  in  the  lungs  of  those  who  have  perished  with 
this  malady  is  emphysema,  afi"ecting  chiefly  the  peripheral  portions  of  the 
upper  lobes.     It  is  usually  vesicular  emphysema,  occurring  from  over-dis- 

^  La  Scalpel ;  London  Medical  Record,  May  15,  1884. 
28 


434  PERTUSSIS. 

tension  of  the  air-cells,  but  in  some  instances  the  air  has  escaped  into  the 
connective  tissue,  causing  interstitial  emphysema.  According  to  my  recol- 
lection of  fatal  cases  which  have  occurred  from  time  to  time  in  the  institu- 
tions of  New  York,  and  in  which  I  have  made  post-mortem  examinations, 
the  upper  lobes  were  exsanguine  and  inflated  to  nearly  the  fullest  extent 
possible  within  the  thorax,  while  other  portions  of  the  lungs  presented  areas 
of  pneumonic  or  more  or  less  complete  atelectatic  solidification.  Pneumonia, 
atelectasis,  and  small  extravasations  of  blood  in  the  lungs  are,  indeed,  com- 
mon lesions.  Hyperplasia  of  the  bronchial  glands  is  also  common,  and 
hyperplasia  has  also  been  occasionally  observed  of  other  lymphatic  glands, 
as  the  mesenteric.  An  ulcer  under  the  tongue  which  observers  have  fre- 
quently noticed  is  now  attributed  to  the  pressure  of  the  tongue  on  the  lower 
incisors  during  the  cough. 

In  fatal  cases  small  extravasations  of  blood  in  or  upon  the  brain  are  com- 
mon, as  is  also  passive  congestion  of  the  sinuses,  veins,  and  capillaries,  men- 
ingeal and  cerebral,  attended  with  more  or  less  transudation  of  serum  within 
the  ventricles  of  the  brain  and  between  the  meninges.  Large  dark  and  soft 
clots,  and  occasionally  some  that  ar-e  white  or  yellow,  are  common  in  the 
intracranial  sinuses,  especially  if,  as  often  happens,  death  have  occurred  in 
convulsions  which  supervened  upon  the  severe  spasmodic  cough. 

Symptoms. — Pertussis  consists  of  three  stages :  first,  that  of  catarrh  of 
the  air-passages ;  secondly,  the  stage  of  spasmodic  cough,  or,  for  brevity,  the 
spasmodic  stage ;  thirdly,  the  stage  of  decline. 

The  Jirst  period  is  characterized  by  the  symptoms  of  coryza  and  bron- 
chitis, which  present  nothing  peculiar  or  different  from  ordinary  catarrh  of 
the  same  parts,  unless  occasionally  the  cough  be  more  frequent  and  teasing. 
Trousseau  has  known  it  to  be  repeated  forty  or  fifty  times  per  minute.  The 
eyes  present  a  moderately  suffused  appearance,  and  there  is  sneezing,  with 
defluxion  from  the  nostrils,  but  less  than  in  the  commencement  of  measles. 
The  cough,  which  begins  as  soon  as  the  catarrh  affects  the  larynx,  is  accom- 
panied by  little  or  no  expectoration.  The  pulse  and  respiration  are  moderately 
accelerated,  and  such  other  symptoms  as  commonly  accompany  catarrh  of  a 
mild  grade  are  present — to  wit,  increased  heat  of  surface,  thirst,  and  impaired 
appetite. 

The  duration  of  the  first  stage  varies  in  different  cases.  In  severe  whoop- 
ing cough  it  may  last  only  two  or  three  days,  and  in  mild  cases  be  protracted 
to  five  or  six  weeks.  It  may  be  absent  especially  in  very  young  infants.  We 
have  alluded  above  to  the  new-born  infant,  in  whom  there  is  no  first  stage,  a 
glottic  spasm  occurring  soon  after  birth.  The  first  stage  commonly  ends  in 
from  eight  to  fifteen  days.  In  fifty-five  cases  observed  by  Dr.  West  its  aver- 
age duration  was  twelve  days  and  seven-tenths  of  a  day.  It  is  stated  above 
that  the  first  stage  in  rare  instances  continues  during  the  entire  course  of  per- 
tussis ;  at  least  no  spasmodic  cough  occurs.  In  two  such  cases  which  I  now 
recall  to  mind,  both  girls,  the  inflammatory  symptoms  abated  somewhat  after 
the  first  few  days,  and  an  occasional  easy  cough  remained,  like  that  of  simple 
bronchitis,  and  it  continued  during  a  period  corresponding  with  the  ordinary 
duration  of  pertussis.  The  diagnosis  would  have  been  doubtful,  except  for 
the  occurrence  of  pertussis,  with  its  regular  stages,  in  other  children  of  the 
same  families. 

Second  Period. — This  may  commence  quite  abruptly,  but  ordinarily  its 
beginning  is  gradual.  While  the  cough  commonly  has  the  character  present 
in  the  first  stage,  it  is  now  and  then  observed  to  be  more  severe  and  spas- 
modic, especially  at  night  and  when  the  patient  is  in  any  way  excited.  The 
spasmodic  element  increases,  so  that  in  the  course  of  a  week  all  doubt  as  to 
the  nature  of  the  disease  is  removed. 


SYMPTOMS.  435 

The  severity  of  the  cougli  in  tlie  second  sta^je  varies  considerably  in  dif- 
ferent cases.  It  sometimes  connnences  (juite  abruptly,  with  little  warning, 
but  commonly  there  is  premonition  of  it,  and  the  child  endeavors  to  repress 
it.  He  experiences  a  tickling  sensation  in  the  throat  or  median  line  of  the 
chest,  or  a  feeling  of  constriction.  He  leaves  his  playthings  and  rests  his 
head  on  his  mother's  lap  or  takes  hold  of  some  firm  object  for  support;  his 
face  has  a  grave  or  even  anxious  appearance,  while  the  pulse  and  respiration 
are  somewhat  accelerated.  Immediately  the  cough  begins.  It  consists  in  a 
series  of  short  and  hurried  expirations,  which  expel  a  large  part  of  the  air 
contained  in  the  lungs,  followed  by  a  hurried  inspiration,  which  is  difficult 
and  noisy  on  account  of  the  spasmodic  contraction  of  the  laryngeal  muscles 
and  narrowing  of  the  glottic  aperture.  The  sound  which  accompanies  the 
inspiration,  and  which  is  often  absent,  especially  in  infants,  is  designated  the 
whoop.  The  forcible  expirations  and  difficulty  experienced  in  expelling  the 
air  from  the  lungs  on  account  of  the  constriction  of  the  glottis  afford  expla- 
nation of  the  emphysematous  distension  of  the  air-cells  in  the  upper  lobes 
which   we  have  seen  is  so  common   in  severe  pertussis. 

There  may  be  a  single  series  of  expirations  terminating  in  the  manner 
stated,  but  often  there  are  several  such  series  embraced  in  a  paroxysm.  The 
cough  commonly  ends  in  the  expulsion  of  frothy  mucus  from  the  bronchial 
tubes,  and  sometimes  in  vomiting.  During  the  cough  there  is  temporary 
arrest  of  blood  in  the  lungs,  leading  to  congestion  in  the  right  cavities  of  the 
heart  and  throughout  the  systemic  circulation  ;  therefore  the  face  is  flushed 
and  swollen,  and  occasionally  hemorrhage  occurs  under  the  conjunctiva  or 
from  one  of  the  mucous  surfaces.  The  most  frequent  hemorrhage  is  epis- 
taxis.  When  the  cough  ceases,  the  normal  respiration  is  restored,  the  fulness 
of  the  vessels  immediately  abates ;  but  often  puffiness  of  the  features  is 
observed,  due  to  serous  infiltration  of  the  subcutaneous  connective  tissue, 
and  continuing  for  days  or  weeks  during  the  period  when  the  cough  is  most 
severe.  The  paroxysm  lasts  from  a  quarter  to  a  half  or  even  a  whole  minute, 
and  in  that  time,  in  cases  of  ordinary  severity,  there  are  often  as  many  as  fif- 
teen or  twenty  series  of  expirations. 

At  the  close  of  the  paroxysm,  if  there  be  no  complication,  the  symptoms 
soon  abate ;  the  temperature,  pulse,  and  respiration  become  normal,  and  there 
is  no  evidence  of  disease.  The  cough  in  the  second  stage  is  much  more  fre- 
quent in  one  case  than  another.  At  the  height  of  this  stage  it  is  generally 
more  severe  if  it  occur  at  long  intervals  than  when  frequent.  During  the 
weeks  in  which  pertussis  is  most  severe  there  is,  on  the  average,  about  one 
paroxysm  of  coughing  in   each   hour. 

The  cough  increases  in  severity  till  the  third  week  of  the  second  stage,  or 
the  thirtieth  to  the  thirty-fifth  day  of  the  disease,  after  which  it  remains  sta- 
tionary for  a  certain  time.  It  is  apt  to  be  more  frequent  in  the  night  than 
day-time.  Sometimes  it  occurs  while  the  child  is  quiet;  it  may  even  awaken 
him  from  sleep,  but  it  is  often  also  produced  by  mental  excitement  or  by 
physical  exertion.  Anger  or  fright  gives  rise  to  it,  and  therefore  the  child  is 
likely  to  cough  when  being  examined  by  the  physician  or  when  his  wishes  are 
not  complied  with.  The  ordinary  duration  of  the  second  stage  is  from  thirty 
to  sixty  days.  It  may,  however,  be  considerably  longer  or  shorter  than 
this. 

The  fhird  stage,  which  commences  at  the  time  when  the  spasmodic  cough 
begins  to  abate,  is  short,  not  continuing  longer  than  two  or  three  weeks.  A 
protracted  stage  of  decline  indicates  some  complication.  While  the  sputum 
in  the  second  stage  is  mucous  and  frothy,  that  in  the  third  stage  is  more 
opaque  and   puriform. 

In  the  third  as  in  the  second  stage,  if  there  be  no  complication,  the  pulse 


436  PERTUSSIS. 

and  resiDiration  in  the  intervals  of  tlie  paroxysms  are  nearly  or  quite  natural. 
Febrile  excitement  may,  however,  now  and  then  occur  from  trifling  causes,  or, 
indeed,  without  any  apparent  cause.  The  digestion  and  the  general  health  in 
uncomplicated  pertussis  remain  unimpaired,  with  the  exception  of  more  or 
less  emaciation,  which  is  likely  to  occur  in  all  but  the  mildest  cases  in  conse- 
quence of  the  frequent  vomiting.  After  complete  recovery  it  is  not  unusual 
for  the  spasmodic  cough  to  reappear  at  times  for  one  or  even  two  years.  The 
cough  of  ordinary  simple  laryngitis  or  bronchitis  assumes  this  character. 

Complications. — These,  like  the  symptons,  are  chiefly  of  a  twofold 
character — to  wit,  inflammatory  and  neuropathic.  From  the  nature  of 
the  cough  in  pertussis,  it  would  naturally  be  supposed  that  the  spasmodic 
aff"ection  which  is  now  designated  internal  convulsions,  and  which  is  charac- 
terized by  spasm  of  certain  muscles  of  respiration,  would  be  a  frequent  com- 
plication. It  does  sometimes  occur  in  young  children,  but  it  is  not  common. 
Clonic  convulsions  aff"ecting  the  external  muscles  are,  on  the  other  hand,  not 
infrequent.  They  occur  chiefly  in  the  second  stage,  when  the  cough  is  most 
severe,  and  in  infancy  much  more  frequently  than  in  childhood.  They  are 
likely  to  be  general  and  severe,  or,  if  not  of  this  character  at  first,  to  become 
such.  The  convulsions  commence  in  most  instances  in  or  directly  after  the 
paroxysm  of  coughing,  but  they  sometimes  occur  in  the  interval  when  the 
child  is  quiet. 

Rilliet  and  Barthez  remark :  "  Almost  all  infants  succumb  to  this  com- 
plication, ordinarily  in  the  twenty -four  hours  which  follow  the  first  attack ; 
nevertheless,  life  may  be  pi'olonged  during  two  or  three  days "  (article 
Coqueluche).  In  m}'^  own  practice  this  complication  usually  ended  fatally 
before  bromide  of  potassium  and  chloral  were  employed,  but  with  the  proper 
use  of  these  agents  it  can  often  be  arrested.  In  the  month  of  June,  1867,  I 
was  attending  a  little  girl  two  years  and  four  months  old  who  had  reached 
the  fifth  week  of  pertussis  when  she  was  seized  with  general  clonic  convul- 
sions. The  mother,  who  was  requested  to  keep  a  record  of  the  number  of 
convulsions,  stated  that  there  were  twenty  in  all  occurring  within  forty-eight 
hours.  They  aff'ected  both  sides,  the  shortest  lasting  only  three  or  four 
minutes,  the  longest  seventy-five  minutes.  The  treatment  in  this  case, 
which  eventuated  favorably,  will  be  noticed  hereafter. 

In  those  who  die  of  convulsions  occurring  in  whooping  cough  the  most 
constant  lesion  is  congestion  of  the  cerebral  veins  and  sinuses,  often  with 
transudation  of  serum.  This  congestion  is  due  in  part  to  the  cough  which 
precedes  the  convulsions  and  in  part  to  the  convulsions  themselves.  At  the 
autopsies  which  I  have  made  of  two  infants  who  died  in  hospital  practice 
from  whooping  cough,  accompanied  by  convulsions,  all  the  cerebral  sinuses 
were  filled  with  clots,  which  were  generally  soft  and  dark  ;  but  in  the  lateral 
sinuses  clots  were  found  which  were  light-colored.  The  light  color  of  a  clot, 
either  in  a  vein  or  sinus,  indicates  its  ante-mortem  formation. 

The  gravity  of  the  convulsive  attack  can  be  ascertained  by  observing 
whether  the  patient  readily  recovers  consciousness.  Its  return  indicates  that 
there  is  no  serious  congestion.  On  the  other  hand,  great  drowsiness  remain- 
ing or  a  semi-comatose  state  indicates  persistent  congestion,  and  perhaps  even 
the  formation  of  clots  in  the  sinuses  of  the  brain.  Death  from  convulsions 
is  usually  preceded  by  coma.  Occasionally  meningeal  apoplexy  supervenes 
upon  the  congestion,  and  death  is  immediate. 

The  most  frequent  inflammatory  complications  are  bronchitis  and  pneu- 
monitis. Inflammation  of  the  bronchial  tubes  of  a  mild  grade,  we  have  seen, 
is  a  common  accompaniment  of  pertussis,  but  when  it  extends  to  the  minuter 
tubes  or  becomes  so  severe  as  to  cause  acceleration  of  respiration,  it  is  prop- 
erly a  complication.     Both  bronchitis  and  pneumonitis,  occurring  as  compli- 


COMPLICATIONS.  437 

cations,  are  developed,  with  few  exceptions,  in  the  second  stage.  Bronchitis 
is  accompanied  by  accelerated  respiration  and  pulse  and  increased  tempera- 
ture.    Tlie  danger  is  proportionate  to  the  amount  of  dyspnoea. 

Pneumonitis  is  a  less  common  complication  than  bronchitis,  but  it  occurs 
more  frequently  in  pertussis  than  in  any  other  constitutional  malady  of  early 
life,  excepting  measles.  The  congestion  which  results  and  remains  in  the  lung 
when  the  cough  is  frequent  and  severe  favors  the  development  of  pneumonia. 
The  symptoms  and  physical  signs  which  accompany  this  inflammation  and 
serve  for  its  diagnosis  are  the  same  as  in  the  primary  form  of  the  disease, 
and  are  described  elsewhere.  Bronchitis  or  pneumonia  usually  moderates 
the  severity  of  the  spasmodic  cough,  for  when  the  inflammatory  element  in 
pertussis  increases  the  spasmodic  abates.  On  the  abatement  of  the  inflam- 
mation, however,  the  cough  usually  regains  its  former  convulsive  character. 
The  fiict  may  be  stated  in  this  connection  that  any  complication  or  intercur- 
rent disease  which  is  attended  by  decided  febrile  reaction  ordinarily  renders 
the  cough  for  the  time  less  spasmodic. 

The  occurrence  of  bronchitis  or  pneumonia  is  shown  by  the  elevated  tem- 
perature, acceleration  of  pulse  and  respiration,  short  and  frequent  cough. 
These  symptoms  do  not  cease  so  long  as  the  inflammation  continues,  whereas 
in  uncomplicated  pertussis  the  patient  seems  nearly  or  quite  well  between  the 
coughs.  In  pneumonia  the  respiration  is  accompanied  by  the  expiratory 
moan,  and  in  both  bronchitis  and  pneumonia  there  is  more  or  less  depression 
of  the  inframammary  region  during  inspiration.  These  symptoms,  in  con- 
nection with  the  physical  signs,  render  diagnosis  in  most  instances  easy. 
Although  the  general  character  of  the  cough  is  changed,  a  cough  now  and 
then  occurs,  even  when  the  inflammation  is  pretty  severe,  sufficiently  spas- 
modic to  indicate  the  nature  of  the  primary  afi"ection.  Capillary  bronchitis 
and  pneumonia  are  always  serious  complications. 

Not  only  is  more  or  less  emphysema  a  common  complication  of  severe 
pertussis,  but  bronchiectasis  also  occurs  in  certain  cases,  due  to  the  same 
conditions.  Emphysema  is  a  common  lesion  in  young  and  feeble  infants, 
even  when  there  is  no  history  of  any  previous  severe  disease  of  the  respira- 
tory organs.  I  have  found  it  one  of  the  most  common  lesions  in  infants  of 
feeble  constitutions  who  die  in  the  hospitals  and  asylums  of  New  Yoi'k,  but 
it  is  usually  interstitial  and  confined  to  a  small  part  of  the  upper  lobes.  It 
is  not  accompanied  by  that  general  distension  of  the  alveoli  and  consequent 
enlargement  of  the  lobes  which  occur  in  the  emphysema  of  pertussis.  Its 
chief  cause  in  these  feeble  and  wasted  infants  appears  to  be  impaired  nutri- 
tion and  change  in  the  molecular  state  of  the  pulmonary  tissue.  The  same 
molecular  change  often  occurs  in  severe  and  protracted  pertussis,  and  there- 
fore serves  as  an  additional  and  efficient  cause  of  the  emphysema. 

The  following  was  a  not  unusual  case  of  this  disease  as  it  occurs  in  the 
tenement-houses  and  asylums  of  New  York.  At  the  meeting  of  the  New 
York  Pathological  Society,  October  14,  1868,  I  exhibited  emphysematous 
lungs  removed  from  an  infant  who  died  at  the  age  of  nineteen  months  at 
the  commencement  of  the  fourth  week  of  pertussis.  Death  occurred  from 
thrombosis  in  the  lateral  sinuses  of  the  cranium,  resulting  from  the  severe 
spasmodic  cough,  eclampsia,  and  feebleness  of  the  circulation,  as  the  infant 
was  previously  in  a  reduced  state  from  chronic  entero-colitis.  At  the  autopsy 
the  superior  lobes  of  both  lungs  were  found  exsanguine,  doughy  to  the  feel, 
and  enlarged  so  as  to  rise  above  the  level  of  the  other  lobes.  The  resiliency 
and  elasticity  of  the  lung-tissue  in  these  lobes  were  evidently  greatly  impaired, 
and  their  air-cells  in  a  state  of  over-distension.  The  other  lobes  were  healthy, 
except  that  one  of  them  was  the  seat  of  catarrhal  pneumonia.  In  this  case 
there  had  been  no  disease  affecting  the  respiratory  apparatus  previous  to  the 


438 


PEBTUSSIS. 


pertussis,  so  that  the  incipient  vesicular  emphysema  was  referable  to  the 
severe  cough  and  impaired  nutrition  of  the  lungs. 

Occasionally  we  meet  cases  of  severe  pertussis  in  which,  while  there  is 
over-distension  of  the  alveoli  of  the  upper  lobes,  collapse  occurs  over  a  greater 
or  less  extent  of  the  lower  lobes.  Collapse,  like  emphysema,  may  continue 
for  weeks  or  months  subsequently  to  pertussis,  and  then  gradually  disappear, 
but  in  the  following  case,  rare  in  my  experience,  it  was  permanent :  John 
O'Neil,  aged  five  and  a  half  years,  was  brought  to  the  Bureau  for  the  Relief 
of  the  Out-door  Poor  in  New  York  in  December,  1876.  He  lived  in  the 
underground  basement  of  a  tenement-house,  and  was  supported  by  charity, 
except  at  intervals,  when  his  father,  who  was  dissipated,  could  obtain  work. 
At  the  age  of  fifteen  months  he  had  a  glandular  swelling  on  the  right  side  of  the 
neck,  which  suppurated,  and  three  months  later  one  on  the  opposite  side,  which 
also  suppurated.  At  the  age  of  two  and  a  half  years  he  had  bronchitis, 
the  cough  of  which  did  not  abate  till  two  months  subsequently.  When  near 
the  age  of  three  years  he  had  measles,  and  the  cough  from  this  disease  lasted 
three  or  four  months.  In  the  summer  of  1875,  or  about  one  year  subse- 
quently to  the  measles,  he  contracted  pertussis,  which  was  severe,  but  was 
allowed  to  run  its  course  without  treatment.  It  lasted  four  months,  never, 
however,  confining  him  to  bed  or  materially  impairing  his  appetite.  One 
morning  about  the  close  of  the  second  month  of  the  malady  the  parents  first 
observed  depression  of  the  right  side  of  the  thorax.  This  gradually  increased 
a  few  weeks,  and  has  been  permanent.  The  parents  stated  that  he  had  never 
been  confined  to  the  house  or  without  appetite  except  during  the  week  of 
measles. 

Since  his  recovery  from  pertussis  he  has  had  his  usual  appetite  and  gen- 
eral health,  but  crying  or  excitement  commonly  brings  on  a  pretty  severe 
cough.  The  depression  of  the  thorax,  examined  in 
front,  begins  quite  abruptly  in  the  line  of  the  left 
costo-chondral  articulations.  Circumferential  meas- 
urement of  the  left  side  from  the  middle  of  the 
sternum  to  the  spine,  the  tape  lying  a  little  below 
the  nipple,  gives  eleven  and  a  half  inches,  while  cor- 
responding measurement  of  the  right  side  gives  seven 
and  a  half  inches  ;  pulse  136,  sounds  of  the  heart  nor- 
mal ;  respiration  44.  On  auscultation  over  the  right 
side  of  the  chest  we  observed  bronchial  respiration 
and  a  feeble  bronchophony,  with  perhaps  slight  vocal 
fremitus.  The  accompanying  figure  is  from  a  pho- 
tograph by  Mr.  Mason,  photographer  to  Bellevue 
Hospital.  My  first  impression  on  observing  this 
case  was  that  it  was  one  of  unexpanded  lung  which 
had  been  compressed  by  a  pleuritic  eff"usion,  but  it  is 
seen  that  the  history  points  clearly  to  pertussis  as 
the  cause  of  the  deformity.  The  depression  oc- 
curred somewhat  suddenly  when  the  cough  was  most 
severe  and  when  there  was  no  fever,  loss  of  appetite, 
or  other  symptom  of  pleuritis.  The  patient  had  not 
presented  any  marked  evidence  of  rachitis,  but  was 
decidedly  strumous. 

Pertussis  is  sometimes  complicated  by  the  erup- 
tive fevers.      There  does  indeed  seem  to  be  some 
afiinity  between  it  and  measles,  so  that  many  epi- 
demics of  the  two  have  been  observed  at  about  the  same  time.     During  my 
term  of  service  in  the  New  York  Foundling  Asylum,  in  May,  1878,  measles 


Fig.  28. 


DIAGNOSIS.  439 

and  pertussis  prevailed  in  tlie  wards  at  the  same  time.  Eighteen  of  the 
children  who  were  havinj^-  pertussis  contracted  measles,  and  the  Sisters,  who 
were  very  intelligent  and  taitliful  observers,  and  were  requested  by  me  to 
notice  the  effect  of  the  complication,  stated  that  with  few  exceptions  the 
severity  of  the  whooping  cough  was  increased  during  the  continuance  of 
the  exanthem.  This  is  contrary  to  the  general  belief  of  the  effects  of 
intercurrent  febrile  diseases. 

Diagnosis. — During  the  period  of  invasion  it  is  impossible  to  diagnosticate 
pertussis.  Its  nature  can  only  be  conjectured  from  a  known  exposure  or  from 
the  epidemic  occurrence  of  the  disease.  In  the  second  stage,  which  is  cha- 
racterized by  the  spasmodic  cough,  diagnosis  is  ordinarily  easy,  and  often  the 
parents  are  able  to  announce  the  nature  of  the  disease  when  the  physician  is 
called.  Still,  a  mistake  is  sometimes  made  :  a  spasmodic  cough  very  similar 
to  that  of  pertussis  occasionally  occurs  in  other  maladies.  Young  infants 
with  bronchitis  frequently  experience  great  difficulty  in  the  expectoration  of 
mucus,  which  collects  in  the  air-passages  and  provokes  a  suffocative  cough. 
The  following  facts  will  aid  in  making  the  diagnosis  :  Bronchitis,  accompanied 
by  a  suffocative  cough,  is  an  acute  disease,  and  the  cough  occurs  at  an  early 
period,  usually  in  the  first  week.  It  lacks  the  inspiratory  sound  or  the  whoop, 
and  is  associated  with  constantly  accelerated  respiration  and  well-marked  febrile 
symptoms,  dependent  on  the  inflammation.  Moreover,  the  cough  is  occasion- 
ally suffocative,  according  to  the  amount  of  mucus  in  the  tubes.  The  spas- 
modic cough  of  pertussis,  on  the  other  hand,  is  preceded  by  the  stage  of  inva- 
sion, and  it  occurs  only  in  the  second  stage,  when  the  febrile  symptoms  have 
abated.  Again,  the  suffocative  cough  of  bronchitis  rarely  ends  in  vomiting, 
which  is  common  in  the  cough  of  pertussis. 

The  only  other  disease  with  which  there  is  much  likelihood  of  confound- 
ing pertussis  is  bronchial  phthisis.  The  points  of  differential  diagnosis  are 
the  following :  the  one  epidemic  and  spreading  by  contagion,  the  other  non- 
contagious and  isolated ;  the  one  embraced  in  three  distinct  stages  and  much 
shorter,  the  other  chronic  and  presenting  no  stages,  but  commencing  with 
mild,  non-febrile  symptoms  and  progressively  becoming  more  severe  ;  in  the 
one  an  absence  of  symptoms  in  the  intervals  of  the  cough,  provided  that 
there  be  no  complication,  in  the  other  constant  symptoms,  such  as  are  com- 
mon in  tubercular  disease.  The  previous  health  and  the  presence  or  absence 
of  a  tubercular  cachexia  should  be  considered  in  determining  the  nature  of 
the  disease.  Usually  in  bronchial  phthisis  the  lungs  are  also  affected,  so  that 
auscultation  and  percussion  may  furnish  positive  proofs  of  the  nature  of  the 
cough. 

The  attacks  of  suffocative  cough  which  ai'e  produced  by  the  lodgment 
of  a  foreign  body  in  the  larynx  or  lower  down  in  the  air-passages  bear  a 
close  resemblance  to  those  of  pertussis.  The  diagnosis  can  be  made  by  the 
history,  for  in  the  one  case  there  is  a  preliminary  catarrhal  stage,  and  in  the 
other  the  cough  begins  abruptly,  and  usually  after  the  known  swallowing  of 
the  offending  substance,  which  produces  dyspnoea  and  a  spasmodic  cough  as 
soon  as  it  entei's  the  larynx.  The  presence  of  the  body  can  also  be  deter- 
mined in  a  large  proportion  of  cases  by  the  laryngoscope  and  auscultation. 

Prognosis. — A  larger  proportion  doubtless  recover  under  the  better  ther- 
apeutics of  the  present  time  than  in  former  years.  According  to  Hirsch 
(ii.  p.  105),  72,900  persons  perished  from  this  disease  in  England  and  "Wales 
between  1848  and  1855,  or  1  in  every  40  who  died ;  and  AVilde's  reports 
show  that  it  stands  fifth  as  regards  mortality  among  the  epidemic  diseases 
of  Ireland.  In  New  York  City,  during  the  half  century  ending  with  1853, 
4840  died  of  pertussis,  or  1  died  from  this  disease  in  every  76  of  deaths 
from  all  causes. 


440  PERTUSSIS. 

As  a  rule,  the  older  the  child  the  better  the  prognosis.  Young  infants 
may  die  of  suffocation  due  to  the  glottic  spasm.  Eclampsia  with  extreme 
passive  congestion  of  the  encephalon  is  a  not  infrequent  complication  in 
children  under  the  age  of  five  years,  and  it  is  apt  to  terminate  fatally.  It 
may,  however,  be  averted  in  most  cases  by  proper  treatment  when  threaten- 
ing. In  rare  instances  death  may  occur  in  or  immediately  after  a  paroxysm 
of  coughing,  in  consequence  of  rupture  of  a  cerebral  or  meningeal  vessel 
and  the  effusion  of  blood,  or  from  stasis  and  coagulation  of  blood  in  the 
venous  system,  especially  if  convulsions  have  supervened  upon  frequent 
and  protracted  paroxysms  of  coughing.  Other  complications  which  are 
likely  to  arise  under  conditions  which  favor  their  development,  and  which 
greatly  increase  the  danger  and  render  the  prognosis  unfavorable,  are  capil- 
lary bronchitis,  pneumonia,  diphtheria,  and  in  the  summer  season  intestinal 
catarrh. 

Feebleness  of  system  and  antecedent  and  accompanying  chronic  disease 
increase  the  danger.  Pertussis  sometimes  produces  so  much  emaciation  and 
loss  of  strength,  in  consequence  of  the  severity  and  frequency  of  the  cough 
and  the  repeated  vomiting,  that  intercurrent  diseases  which  in  favorable 
states  of  the  system  would  probably  end  in  recovery  are  very  apt  to  prove 
fatal. 

I  usually  inform  the  family  that  the  patient  is  doing  well  if  he  seem 
entirely  well  between  the  paroxysms  ;  but  if  he  appear  ill,  whether  with  som- 
nolence, fretfulness,  fever,  loss  of  appetite,  accelerated  breathing,  or  diarrhoea, 
he  is  not  doing  well,  and  probably  has  some  complication  which  requires 
attention. 

Treatment. — In  the  catarrhal  stage  the  treatment  should  be  the  same 
as  in  mild  idiopathic  bronchitis.  Demulcent  and  soothing  cough  mixtures 
are  required.  Care  should  be  taken  to  employ  nothing  which  reduces  the 
strength  or  impairs  the  general  health.  If  there  be  much  bronchitis  with 
accelerated  breathing  and  frequent  cough,  mild  counter-irritation  to  the  chest 
and  the  use  of  the  oil-silk  jacket  are  proper. 

Therapeutic  measures  are  chiefly  indicated  in  the  second  stage  or  that 
of  convulsive  cough.  Proper  treatment  may  control  the  severity  of  the 
cough,  and  abridge  the  duration  of  the  second  stage,  and  prevent  or  control 
complications.  Pertussis  has  received  a  great  variety  of  treatment.  The 
enumeration  of  the  medicines  and  modes  of  treatment  which  have  had  their 
season  of  repute  and  been  employed  by  intelligent  physicians  would  occupy 
too  much  time.  The  treatment  should  vary  in  some  respects  according  to 
the  case,  but  a  small  number  of  medicines  suffices  even  in  the  most  severe  and 
obstinate  forms  of  the  malady.  Knowledge  and  appreciation  of  the  patho- 
logical state  in  pertussis  assist  us  to  the  choice  of  the  proper  remedies.  The 
specific  principle  of  pertussis  produces  but  little  depression  of  the  vital  pow- 
ers. It  does  not  impair  the  appetite  by  its  direct  action  on  the  nutritive 
function,  nor  does  it  produce  those  profound  blood-changes  which  we  observe 
in  scarlet  fever  and  diphtheria.  It  affects  the  system  injuriously  by  the  sever- 
ity of  the  cough,  the  vomitings  and  consequent  loss  of  nutriment,  and  the 
complications  which  frequently  occur,  some  of  which  involve  fatal  conse- 
quences. 

Remedies  are  required  which  diminish  the  sensitiveness  of  the  laryngo- 
tracheal surface,  which  destroy  the  specific  principle  in  those  parts  where  the 
local  manifestions  of  the  disease  occur,  or  control  its  action  ;  that  is,  in  the 
larynx  and  trachea.  The  use  of  inhalations  is  at  once  suggested  as  most 
likely  to  fulfil  the  indications,  since  by  inhalation  the  medicine  employed  is 
brought  into  immediate  contact  with  the  parts  which  are  chiefly  concerned 
in  the  disease. 


TREATMENT.  441 

CarhoUc  Arid. —  During  an  epidemic  of  pertussis  a  few  years  since  in 
the  New  York  Foundling  Asylum,  after  trial  of  the  older  remedies  without 
any  marked  result,  carbolic  acid,  half  a  drachm  to  eight  ounces  of  glycerin 
and  water,  was  employed  by  inhalation  from  three  to  six  minutes,  and  at 
intervals  of  two  to  six  hours  according  to  the  severity  of  the  cough.  The 
result  was  apparently  better  than  with  the  other  remedies,  since  the  cough 
became  less  frequent  and  severe.  Carbolic  acid  seems  to  have  an  anaes- 
thetic eflPect  on  the  laryngo-tracheal  surface.  It  is  also  an  efficient  anti- 
septic and  germicide  agent,  so  that  if  inhaled  frequently  it  probably 
destroys  the  specific  principle  in  the  mucus  and  epithelial  cells  of  the  air- 
passages.  It  has  been  in  my  practice  conveniently  employed  in  the  croup- 
kettle.  Three  teaspoonfuls  of  the  saturated  solution  of  carbolic  acid  are 
added  to  water  sufficient  to  cover  the  bottom  of  the  croup-kettle  to  the  depth 
of  two  inches,  and  when  it  is  brought  nearly  to  the  boiling-point,  the  vapor  is 
inhaled  a  few  minutes  every  hour  or  second  hour  through  the  tube.  If  an 
equal  quantity  of  the  oil  of  eucalyptus  be  added,  the  inhalations  are  more 
agreeable  and  the  germicide  effect  is  probably  increased.  Dr.  Keating'  rec- 
ommends the  following  formula  for  inhalation  : 


:.  Acidi  carbolici 

cryst., 

gr- 

ir 

Sodii  biborat., 

Sodii  bicarb., 

da. 

•gr- 

X 

Glycerinse, 

Aquffi, 

da. 

a- 

An  alkali,  as  in  the  above  mixture,  is  believed  to  render  the  mucus  more 
fluid,  and  water,  even  when  not  medicated,  increases  its  fluidity  and  ren- 
ders expectoration  more  easy.  Pick  also  highly  recommends  carbolic  acid 
in  the  treatment  of  pertussis  (Archiv  f.  Kinderheilk.,  1886),  and  believes 
that  when  not  effectual  it  is  too  much  diluted.  He  adds  fifteen  to  twenty 
drops  to  a  roll  of  cotton,  which  is  introduced  into  a  mask.  The  patient 
inhales  the  vapor  of  the  gas  several  times  each  day,  and  the  cotton  wad  is 
renewed  three  times.  The  duration  and  severity  of  the  disease  were  dimin- 
ished by  the  inhalation,  and  no  ill  results  occurred  in  any  case.  Miller  has 
also  used  carbolic  acid  internally  in  doses  of  one  minim  in  children  over  the 
age  of  five,  with,  he  states,  good  results ;  but  its  use  by  inhalation  appears  to 
be  equally  or  more  effectual,  and  is  devoid  of  the  risks  which  attend  its 
internal  use  (^Medical  Register.,  1888). 

Cocaine. — This  has  been  quite  largely  used  as  an  application  to  the  throat 
on  account  of  its  anaesthetic  effect,  but  its  action  is  evanescent,  so  that  in 
order  to  obtain  the  full  benefit  from  its  use  it  is  necessary  to  apply  it  often. 
Labrie  states  that  the  repeated  application  to  the  throat  of  a  5  per  cent,  solution 
immediately  diminishes  the  number  of  paroxysms  (Land.  Med.  Rev.,  1888). 
Holt,  in  discussing  the  safety  of  its  use  (iV.  Y.  Med.  Jour..  1888),  states, 
"  1st.  It  must  be  used  with  great  caution  in  young  children  under  all  cir- 
cumstances ;  2d.  The  spray  is  never  to  be  recommended,  since  an  uncertain 
quantity  is  given  ;  3d.  Solutions  stronger  than  4  per  cent,  should  not  be 
used  in  children  under  two  years  ;  4th.  In  cases  where  it  was  tried  he  failed 
to  see  any  notable  benefit."'  Probably  cocaine  will  not  come  into  general 
use,  because  frequent  applications  would  be  necessary  in  order  that  its  effect 
be  continuous,  and  this  would  apparently  be  dangerous  ;  still,  it  might  be  occa- 
sionally used  in  order  to  obtain  temporary  respite  from  the  cough  when  it 
involves  danger  in  consequence  of  its  frequency  and  severity. 

Antipyrine. — This  agent  is  now  largely  used,  and  many  physicians  have 
written   in   its   favor.     Sonnenberger    regards,  it    as   a    specific   ( Thcrapeut. 

1  Medical  Navs,  Feb.  28,  1885. 


442  PEBTUSSIS. 

Monatschrifte,  1888).  He  prescribes  it  in  doses  of  as  many  centigrammes 
(one-sixth  grain)  as  the  child  is  months  old,  and  as  many  decigrammes  (one 
and  a  half  grains)  as  it  is  years  old,  three  times  daily.  He  says  that  the 
earlier  it  is  employed  the  better  is  the  result.  Genser  administers  only  one 
and  a  half  grains  daily  for  each  year  of  the  age,  and  he  found  that  it  dimin- 
ished the  frequency  and  severity  of  the  cough  (^Algenieine  Med.  Cont.  Zeit., 
1888).  Laborderie  reports  the  complete  cure  of  pertussis  by  the  use  of 
antipyrine  in  twelve  to  sixteen  days.  He  says:  "(1)  Children  take  anti- 
pyrine  without  difficulty,  and  as  a  rule  easily  bear  its  effects ;  (2)  The  spas- 
modic condition  is  rapidly  calmed,  and  in  a  few  days  the  disease  declines ; 
(3)  Its  action  is  so  prompt  and  free  from  accidents  that  it  becomes  a  valuable 
remedy  in  a  malady  which  may  be  of  prolonged  duration  and  give  rise  to 
many  complications  "  (^Bull.  gen.  de  Therap.,  1888).  In  my  practice  anti- 
pyrine has  also  in  some  cases  been  a  very  important  remedy,  reducing  the 
severity  of  the  paroxysms.  I  have  administered  it  in  small  or  moderate 
doses  every  third  or  fourth  hour  in  combination  with  an  alcoholic  stimulant. 
Antipyrine  is  especially  useful  in  cases  attended  by  fever. 

Quinine. — The  use  of  quinine  in  whooping  cough  was  strongly  recom- 
mended by  Binz,  who  attributed  the  good  effects  which  he  had  observed  to  its 
germicide  action.  It  has  been  employed  with  apparently  good  results,  both 
locally  and  internally.  Kolover  prescribes  the  following  solution  as  a  spray  : 
R.  Quiniae  sulph.,  gr.  50  ;  Acidi  sulphur.,  gtt.  30 ;  Aquae  destillat.,  §5t.  The 
fauces  are  sprayed  with  this  every  two  hours  for  the  first  three  days,  and 
three  hours  for  the  rest  of  the  week,  when  treatment  is  no  longer  necessary 
(iy'  Union  Med.,  1887).  Bachen  employs  insufflation  into  the  nostrils  of  fifteen 
grains  of  a  finely  triturated  powder  of  twenty  parts  of  quinine  and  one  of 
benzoin  {Lond.  Med.  Rec,  1887).  Swett  also  prescribed  the  insufflation  of 
quinine  morning  and  evening,  and  observed  improvement  after  the  first  day. 
Forchheimer  and  the  late  Prof.  Rochester  have  likewise  recommended  the  local 
use  of  quinine.  The  internal  use  of  quinine  has  been  supposed  to  be  useful 
by  diminishing  reflex  irritability  (Schlakow  and  Eulenberg).  It  is  undoubt- 
edly a  useful  remedy  in  those  common  cases  in  which  febrile  symptoms  arise 
from  bronchitis  or  broncho-pneumonia. 

Paulet  ^  recommends  the  evaporation,  over  a  suitable  fire,  of 

R.  Spirits  of  thvmol,         grammes    10 
Alcohol,       "  "        250 

Water,  "        750 

Keating  also  recommends  the  same  agent  in  the  follwing  formula : 

R.  Thymol,  gr.  xv ; 

Alcoholis,  ,^iij  ; 

Glycerinse,  .^ss ; 

Aquse,  ^xxxiv.     Misce. 

Internal  remedies,  formerly  much  used,  now  occupy  the  second  place  in 
the  therapeutics  of  pertussis.  Belladonna  has  been  largely  employed,  since 
it  appears  to  diminish  the  spasmodic  element  in  the  cough  of  pertussis. 
Brown-Sequard,  in  remarks  made  before  the  United  States  Medical  Associa- 
tion in  May,  1860,  maintained  that  the  duration  of  pertussis,  so  far  as  its 
nervous  element  is  concerned,  might  be  abridged  to  a  few  days  by  doses  of 
atropia  sufficiently  large  to  cause  toxical  effect ;  but  in  one  ease  which  I  saw 
in  consultation,  in  which  one  teaspoonful  of  tincture  of  belladonna  was  given  by 
mistake  to  a  child  of  about  three  years,  the  subsequent  cough,  though  mild,  did 

1  London  Medical  Record,  May  15,  1884. 


TREATMENT.  443 

not  lose  its  spasmodic  clement,  ('hildreri  re(iuirc  a  larger  proportionate  dose  of 
belladonna  than  adults,  and  it  can  be  safely  administered  in  gradually  increas- 
ing doses  until  physiological  effects  are  produced,  when  some  mitigation  in 
the  cough  may  be  expected.  Probably  the  action  of  the  drug  is  on  the 
respiratory  centres  in  the. medulla,  and  not  directly  on  the  muscles  of  respira- 
tion. The  effect  of  belladonna  in  controlling  the  spasmodic  cough  is  most 
marked  when  physiological  symptoms  are  produced,  and  some  children  require 
larger  doses  than  others.  Thus  1  gradually  increased  the  doses  of  belladonna 
to  twelve  drops  for  a  child  of  three  and  a  half  years  who  had  severe  pertussis, 
without  producing  the  characteristic  efflorescence,  while  smaller  doses  from 
the  same  bottle  produced  this  effect  in  older  children.  Rarely  I  have  discon- 
tinued the  belladonna  on  account  of  diminished  flow  of  urine,  which  this 
agent  may  or  may  not  have  produced,  and  very  rarely  on  account  of  suddenly 
developed  muscular  weakness,  which  I  had  reason  to  think  the  belladonna 
caused.  This  occurred  in  the  case  alluded  to  above,  in  which  twelve  drops 
of  the  tincture  were  given,  so  that  the  muscles  seemed  flabby  and  the  trunk 
and  head  were  supported  with  difficulty.  The  tincture  of  belladonna  is  con- 
venient for  use,  and  most  of  that  in  the  shops  is  active  and  reliable.  The 
doses  which  I  ordinarily  found  to  be  sufficient  when  prescribing  belladonna 
for  pertussis,  and  which  also  produced  efflorescence,  were  as  follows :  to  a 
child  of  two  years  three  drops,  and  to  one  of  six  or  eight  years  eight  or  ten 
drops,  morning  and  evening.  I  always,  however,  commenced  with  a  smaller 
number,  and  continued  to  administer  the  dose  which  produced  the  local  effects 
alluded  to,  unless  the  cough  were  moderated  by  smaller  doses.  In  the  majority 
of  cases  I  have  noticed  no  decided  effect  till  the  rash  was  produced,  when  the 
symptoms  improved,  the  cough  becoming  less  frequent  or  less  severe.  By 
the  belladonna  treatment  the  spasmodic  stage  may  not  only  be  rendered  mild, 
but  be  abridged  to  two  or  three  weeks.  In  some  cases  the  severe  cough  begins 
to  yield  almost  immediately  under  full  doses  of  this  agent,  but  in  other  cases 
its  continuance  for  some  days  is  necessary,  with  other  remedies  as  adjuvants, 
before  there  is  any  appreciable  benefit  from  its  use.  But  since  the  germicide 
treatment  of  pertussis  has  come  into  use,  it  is  probable  that  belladonna  will 
be  entirely  superseded  by  those  agents  which  are  believed  to  exert  a  destruct- 
ive effect  on  the  supposed  cause. 

Sn/j)hi(t: — Much  benefit  is  said  to  result  from  fumigating  the  room 
occupied  by  the  patients  with  burning  sulphur.  The  children  having  the 
disease  are  attired  in  clean  clothes  and  removed,  and  the  room  which  they 
have  occupied,  containing  the  furniture,  clothes,  and  toys,  is  fumigated  five 
hours  with  burning  sulphur,  after  which  the  doors  and  windows  are  thrown 
open.  The  children  sleep  in  the  same  room  during  the  following  night. 
Immediate  improvement  is  said  to  follow.  This  treatment  of  pertussis  is 
recommended  by  Manby,  Gelhert,  Mohn,  and  others. 

The  distinguished  Brazilian  physician  Moncorvo  advises,  and  uniformly 
employs,  local  treatment  with  a  solution  of  resorcin.  In  an  interesting  paper 
read  before  the  Pediatric  Section  of  the  Ninth  International  Medical  Con- 
gress in  1887  he  states  that  he  employs  resorcin  as  a  local  antiseptic  on 
account  of  its  slight  irritating  properties,  its  great  solubility,  and  its  absence 
of  odor.  Beginning  with  a  1  per  cent,  solution,  he  had  increased  it  to  8  per 
cent.  He  first  applies  to  the  periglottic  region  a  10  per  cent,  solution  of 
hydrochlorate  of  cocaine,  which  diminishes  the  reflex  excitability  of  the  laryn- 
geal mucous  membrane  and  renders  the  paroxysms  less  frequent,  and  then 
applies  the  resorcin. 

Bleyer  recommends  the  use  of  the  peroxide  of  hydrogen  (H2O2)  as  the 
most  powerful  antiseptic  and  germicide  in  existence.  He  sprays  the  laryngeal 
space  with  the  following  : 


444  PERTUSSIS. 

R.  Ch.  Marchand's  peroxide  of  hydrogen  (15  vol.  chemically  pure),  5 j  ; 

Aquae,  3V. 

At  the  same  time  the  nares  are  irrigated  with  the  following : 

R.  Peroxide  of  hydrogen,  5ij  ; 

Aquae,  ^iij.     Misce.^ 

Previously,  Dr.  B.  W.  Richardson  had  stated  that  he  obtained  good  results 
from  drachm  doses  of  the  peroxide  given  five  or  six  times  daily.'' 

Cresoline,  a  product  of  coal-tar,  having  the  formula  CgHjCHsO,  vaporized 
in  the  nursery  by  a  flame  underneath,  also  has  its  advocates. 

All  the  remedies  mentioned  above  have  apparently  been  sufficiently 
employed  to  justify  the  belief  that  when  judiciously  employed  they  diminish 
the  severity  and  duration  of  the  paroxysmal  stage  of  pertussis.  Additional 
observations  are  required  in  order  to  determine  the  comparative  efficiency  of 
these  agents. 

Since  the  paroxysms  are  likely  to  be  more  severe  at  night,  and  the  patient 
consequently  is  deprived  of  the  required  sleep,  a  medicine  is  needed  which 
will  procure  some  hours  of  rest  and  thereby  diminish  the  number  of  parox- 
ysms. For  this  purpose  the  hydrate  of  chloral  is  especially  useful,  given  in 
doses  of  two  to  five  grains  according  to  the  age,  and  perhaps  repeated.  It 
does  not  seem  to  me  that  chloral  exerts  any  marked  influence  upon  the 
cough  ;  it  appears  to  be  useful  chiefly  in  the  manner  stated — to  wit,  by  pro- 
curing prolonged  sleep. 

One  of  the  chief  dangers  from  pertussis  we  have  seen  to  be  the  occur- 
rence of  passive  congestion  of  organs,  especially  of  the  brain,  with  the 
liability  to  hemorrhages,  serous  eff'usion,  and  eclampsia.  This  is  in  great 
part  prevented  by  the  action  of  the  medicines  mentioned  above,  which 
diminish  the  severity  of  the  cough  or  its  frequency.  But  when  there  are 
great  and  frequent  congestions  of  the  nervous  centres,  producing  eclampsia 
or  premonitions  of  eclampsia,  the  use  of  one  of  the  bromine  compounds  is 
indicated  for  its  prompt  and  decided  action  in  averting  the  danger.  Even 
if  the  symptoms  be  not  urgent,  its  tranquillizing  effect,  and  especially  its 
prompt  action  in  diminishing  reflex  irritability,  render  it  one  of  the  most 
useful  agents  in  pertussis.  If  there  be  sudden  twitching  of  the  muscles, 
marked  stupor,  headache  or  fretfulness,  or  adduction  of  the  thumbs  across 
the  palms  of  the  hands  during  the  cough,  I  never  fail  to  give  the  bromide 
of  potassium  in  sufficiently  large  and  frequent  doses  ;  and  now  eclampsia 
occurs  much  more  rarely  in  a  case  which  I  treat  from  the  commencement 
than  in  former  years. 

The  complications  of  pertussis  require  prompt  treatment.  Whenever 
the  child  feels  ill  between  the  paroxysms,  he  should  be  carefully  examined, 
and  some  complication  will  probably  be  found  which  requires  treatment.  If 
the  bronchitis  have  increased  so  as  to  become  a  complication  or  pneumonia 
have  arisen,  the  whole  chest  should  be  covered  with  a  light  flaxseed  poultice 
containing  one-sixteenth  part  of  mustard,  while  quinine  and  ammonia  with 
alcoholic  stimulants  are  given  at  regular  intervals.  Cerebral  accidents  are 
best  arrested  by  the  warm  foot-bath,  cold  to  the  head,  and  by  the  bromide 
and  chloral. 

Diphtheria  not  infrequently  supervenes  as  a  complication  in  a  locality 
where  it  is  endemic  or  epidemic,  and  if  mild  it  is  often  overlooked.  Recently 
I  have  seen  a  case  in  which  diphtheria  complicating  pertussis  had  continued 
four  days,  without  being  recognized  by  the  attending  physician,  the  symp- 
toms being  attributed  to  other  causes.     The  diphtheritic  patch  in  these  cases. 

1  Omaha  Clinic,  1888.  ^  Asdepiad,  1883. 


ETIOLOG  Y—INCUBA  TION.  445 

appears  upon  the  well-known  sore  under  the  tongue,  in  addition  to  its  occur- 
rence upon  other  parts.  The  secondary  form  of  diphtheria  requires  the  same 
treatment  as  the  primary  form. 

Hauke  in  1862  published  experiments  which  showed  that  both  carbonic 
acid  and  ammoniacal  vapors  when  inhaled  increa.se  the  cough,  while  the 
inhalation  of  oxygen  produced  no  cough  and  was  agreeable  to  the  patient. 
Hence  children  in  close  and  crowded  apartments  suffer  most  severely  from 
pertussis,  and  tliose  who  are  taken  to  parks  or  the  country,  where  vegetation 
absorbs  the  carbonic  acid,  not  only  obtain  benefit  from  the  general  invigor- 
ating influence,  but  also  as  regards  the  cough.  The  fact  that  fresh  and  pure 
air  benefits  the  cough  has  indeed  long  been  known,  and  has  influenced  practice, 
for  patients  are  almost  universally  allowed  to  be  much  of  the  time  in  the 
open  air  and  are  taken  to  the  parks  and  upon  excursions.  Nevertheless,  cau- 
tion is  this  regard  is  required,  for  exposure  in  wet  weather  or  to  sudden 
changes  of  temperature  is  very  likely  to  develop  bronchitis  or  pneumonia. 

Prophi/laxis. — Pertussis  is  very  contagious,  and  it  appears  to  be,  in  nearly 
all  instances,  if  not  in  all,  contracted  by  inhaling  the  breath  of  the  patient. 
I  have  never  observed  a  case  in  which  it  seemed  to  be  communicated  through 
a  third  person,  and  it  is  not,  I  think,  usually  contracted  by  children  living  in 
the  same  house  if  there  be  no  personal  contact.  There  is  not,  therefore,  that 
urgent  need  of  personal  disinfection  and  of  caution  on  the  part  of  the  phy- 
sician and  nurse  in  their  subsequent  intercourse  with  healthy  children,  as  in 
the  case  of  the  eruptive  fevers. 


CHAPTER  IX. 

MUMPS. 

Synonyms. — Parotitis,  Parotiditis. — Mumps  is  a  constitutional  or  blood 
disease  with  local  manifestations.  It  occurs  chiefly  in  childhood,  youth,  and 
early  manhood,  cases  being  rare  in  infancy  and  old  age.  Its  chief  character- 
istic, by  which  it  is  readily  recognized,  is  inflammation  of  the  salivary  glands, 
causing  swelling  and  tenderness. 

Etiology. — This  disease  is  highly  contagious,  and  it  commonly  occurs  as 
an  epidemic.  It  is  usually  communicated  through  the  air,  which  is  tainted 
by  the  breath  or  by  exhalations  of  a  patient,  but  cases  are  recorded  in  which 
it  seems  to  have  been  communicated  by  a  third  person  or  by  infected  articles. 
Thus  Roth  relates  a  case  in  which  it  appears  to  have  been  communicated  by 
a  physician,  and  another  case  in  which  it  was  attributed  to  the  use  of  bedding 
in  which  a  patient  with  mumps  had  slept  (^Bost.  M.  and  S.  Jour.,  1887). 

Mumps  is  probably  a  microbic  disease,  but  the  nature  of  the  microbe  has 
not  been  clearly  ascertained.  The  investigations  of  Ollivier  are  confirmatory 
of  those  of  Capelan  and  Charin  on  the  occurrence  of  peculiarly-shaped 
micrococci  in  the  blood  and  urine  of  patients  with  mumps  (Haldemann,  in 
the  Jour.  Am.  Med.  Assoc,  1887).  Pasteur  found  in  the  blood  in  mumps 
rod-shaped  bacteria  one  millimetre  broad  and  two  millimetres  long,  but 
attempts  to  inoculate  animals  were  fruitless  (^Annual  of  Med.  Sci.,  vol.  i., 
1889). 

Incubation. — Dr.  Dukes  states  that  the  incubative  period  appeared  to  be 
from  sixteen  to  twenty  days  in  32,  and  perhaps  34,  of  42  cases.  Henoch 
believes  that  the  incubative  period  is  usually  about  fourteen  days.     Goodhart 


446  MUMPS. 

relates  a  case  which  occurred  fourteen  days  after  exposure,  and  in  two  others 
the  incubation  appeared  to  be  twenty-one  days.  Ringer  says  that  the  incu- 
bative period  varies  from  eight  to  twenty-two  days.  Flint  says  that  the  incu- 
bation varies  from  ten  to  eighteen  days.  Bristowe  states  that  the  average  is 
about  fourteen  days  ;  and  his  opinion,  I  think,  is  correct. 

Symptoms. — Mumps  begins  with  languor  and  fever,  the  temperature  in 
some  cases  rising  to  103°,  and  if  the  fever  be  considerable,  headache  and 
vomiting  are  common.  In  a  few  hours,  usually  as  early  as  the  first  visit  of 
the  physician,  the  patient  complains  of  pain  and  tenderness  in  the  depression 
below  one  ear  and  posterior  to  the  ramus  of  the  jaw.  Notwithstanding  the 
fever,  the  features  are  often  pallid.  Along  with  the  pain  and  tenderness^ 
swelling  begins  in  the  site  of  the  parotid  gland  on  one  side,  and  more  fre- 
quently, it  is  said,  on  the  left  than  right.  In  most  instances  the  swelling 
soon  begins  upon  the  opposite  side,  so  that  the  disease  is  bilateral.  Excep- 
tionally, it  begins  on  the  two  sides  simultaneously.  Rarely  only  one  side  is 
affected.  The  swelling  gradually  increases  ;  it  fills  the  depression  under  the 
ear,  extends  forward  and  upward  upon  the  cheek,  and  downward  to  a  greater 
or  less  extent  upon  the  neck.  It  reaches  its  maximum  from  the  third  to  the 
sixth  day.  The  most  prominent  point  at  this  time  is  immediately  underneath 
the  lobule  of  the  ear,  which  is  pressed  outward  by  the  swelling  of  the  gland. 
The  tumor  yields  on  pressure,  but  is  elastic  and  tense,  and  the  fulness 
immediately  returns  when  the  pressure  is  removed.  The  skin  covering  it 
preserves  its  normal  appearance  or  it  presents  a  faint  blush.  The  fever,  more 
or  less  intense,  does  not  usually  continue  more  than  two  to  four  days,  but 
occasionally  it  remains  longer.  The  pressure  which  movements  of  the  jaw 
and  of  the  pharyngeal  muscles  produce  on  the  gland  renders  mastication, 
swallowing,  and  even  speech,  painful  and  difficult.  The  submaxillary  glands,^ 
and  also  the  sublingual,  are  occasionally  involved,  so  that  the  features  are 
greatly  disfigured  by  the  swelling.  The  swelling  is  at  its  maximum  between 
the  third  and  sixth  days,  after  which  it  begins  to  decline,  and  between  the 
tenth  and  twelfth  days  it  has  entirely  disappeared. 

Occasionally,  during  an  epidemic  of  mumps  we  observe  cases  in  which 
the  parotids  are  but  slightly  or  not  at  all  affected,  and  the  chief  manifesta- 
tions of  the  disease  are  in  the  submaxillary  glands,  which  undergo  the  cha- 
racteristic inflammatory  changes.  Rarely  the  tonsils  are  also  tumefied.  Free 
perspiration  occurs  in  certain  patients  at  the  commencement  of  convalescence. 

Anatomical  Characters. — The  opinion  expressed  by  Virchow  has  been 
generally  accepted,  that  inflammation  of  the  gland-ducts  occurs,  with  conse- 
quent cedema  of  the  connective  tissue.  The  oedema  extends  also  to  the  con- 
nective tissue  adjacent  to  the  gland. 

Complications  ;  Sequels. — The  swelling  of  the  salivary  glands  some- 
times suddenly  abates,  and  in  the  male  the  testicles  and  epididymis,  and  in 
the  female  the  mammary  glands  or  ovaries,  are  involved,  with  sometimes  more 
or  less  oedema  of  the  labia  majora.  Occasionally  these  inflammations,  which 
are  less  frequent  in  young  children  than  in  those  nearer  the  age  of  puberty, 
when  the  sexual  organs  are  becoming  more  developed,  occur  without  subsid. 
ence  of  the  parotid  swelling.  They  cause  considerable  increase  in  the  fever 
and  constitutional  disturbance,  but  with  proper  treatment  decline  in  six  or 
eight  days,  pursuing  the  same  course  as  the  parotid  inflammation.  Some- 
times repellant  applications  to  the  neck  appear  to  produce  the  metastasis,  as 
in  the  following  case:  On  March  19,  1877,  I  was  requested  to  see  a  young 
gentleman  of  eighteen  years.  He  had  been  well  till  March  14th,  when  he 
complained  of  pain  below  his  ears,  and  his  mother  applied  a  towel  wrung  out 
of  cold  water  around  his  neck.  On  the  following  day  slight  swelling  was 
observed  under  the  angle  of  the  lower  jaw  on  the  right  side  (submaxillary 


DIA  GNOSIS— TREA  TMENT.  447 

gland),  and  the  cold  application  was  continued.  On  the  17th  the  swelling 
had  disappeared,  but  the  fever  and  headache  had  greatly  increased,  so  that 
he  was  compelled  to  lie  in  bed.  On  the  10th,  at  my  first  visit,  he  had  such 
violent  headache  and  was  so  intolerant  of  light  and  noise  that  I  greatly  feared 
that  he  had  acute  encephalitis.  All  swelling  under  the  ears  was  gone  ;  the 
left  testicle  was  tender  and  beginning  to  swell ;  axillary  temperature  102°. 
The  cold  cloths  were  removed  from  the  neck  and  ap{)lied  to  the  head,  and 
potass,  bromid.,  gr.  xxv,  administered  every  third  hour.  20th.  Axillary 
temperature  104°  ;  symptoms  unabated  and  alarming.  Ordered  six  leeches 
to  be  applied  upon  the  temples  and  left  groin,  and  a  purgative ;  and  two 
drops  of  the  tincture  of  aconite  to  be  given  with  each  dose  of  the  bromide. 
21st.  Temperature  103°.  States  that  numbness  and  a  pricking  sensation 
which  he  had  felt  in  both  legs  during  the  last  forty-eight  hours  had  ceased 
(possibly  from  the  aconite).  23d.  Is  convalescent ;  has  no  return  of  the 
swelling  under  the  cars  and  the  orchitis  has  abated. 

Several  writers  mention  the  fact  that  in  rare  instances  orchitis  precedes 
the  parotiditis.  Thus,  Eustace  Smith  mentions  a  case  in  which  the  orchitis 
preceded  by  sixteen  hours  the  symptoms  referable  to  the  salivary  glands. 
The  complications  alluded  to  which  involve  the  sexual  organs  occur  more 
frequently  at  puberty  or  in  youth  than  in  childhood. 

It  is  said  that  deafness  sometimes  occurs  during  mumps,  due  to  extension 
of  inflammation  along  the  Eustachian  tube  to  the  middle  ear,  and  if  the  treat- 
ment proper  for  otitis  media  be  employed,  this  form  of  deafness  abates, 
Dalby  mentions  another  form  of  deafness  which  comes  on  suddenly,  and  is 
supposed  to  be  due  to  injury  of  the  auditory  nerve,  since  no  appreciable  lesion 
is  observed  of  the  auditory  apparatus.  The  impairment  of  hearing  in  this 
form   of  deafness  is  likely  to  be  permanent. 

Diagnosis. — If  the  physician  have  seen  but  few  cases  of  mumps,  there 
is  danger  that  he  may  mistake  the  swelling  for  an  inflamed  cervical  gland,  or 
vice  versa  ;  but  an  inflamed  cervical  gland  presents  to  the  finger  a  hardness 
almost  like  that  of  cartilage,  and  it  is  circumscribed  or  round,  and  does  not 
invest  the  ear.  These  characteristics  contrast  with  the  elasticity,  seat,  and 
shape  of  the  parotid  swelling,  which  extends  forward  upon  the  cheek  and 
surrounds  and  elevates  the  lobule  of  the  ear.  Tumefaction  resulting 
from  diphtheritic  or  any  other  form  of  faucial  inflammation,  or  from  peri- 
ostitis aff"ecting  the  root  of  the  posterior  molar,  may  be  detected  by  exam- 
ining the  fauces  and  interior  of  the  mouth.  Inflammation  of  the  parotid 
sometimes  occurs  in  debilitated  states  of  the  system,  as  in  or  after  severe 
typhoid  fever,  scarlet  fever,  measles,  etc.  Occurring  under  such  circum- 
stances, the  gland  usually  suppurates.  The  difierential  diagnosis  between 
this  form  of  parotiditis  and  mumps  can  be  made  by  the  history  of  the  case, 
because  mumps  rarely  occurs  as  a  complication  of  another  disease  and  does 
not  cause  suppuration. 

Prognosis. — The  result  as  regards  life  is  favorable.  The  orchitis,  if 
bilateral,  sometimes  destroys  the  virility  of  the  individual.  Permanent  impair- 
ment of  hearing  may  also  occur  as  stated  above. 

Treatment. — This  is  simple.  In  ordinary  cases  it  sufiices  to  cover  the 
swelling  with  oakum  or  carded  wool.  If  the  tenderness  or  pain  be  consider- 
able, the  gland  should  be  covei'ed  with  spongiopilin  soaked  in  water,  and 
gently  i-ubbed  with  tincture  of  belladonna  and  glycerin  in  equal  parts.  If 
the  patient  have  severe  headache,  with  high  temperature,  more  active  meas- 
ures are  required,  especially  if  delirium  he  also  present.  Saline  laxatives 
should  be  given,  a  warm  general  bath  or  mustard  foot-bath  employed,  and 
antipyrine  with  one  of  the  bromides  prescribed.  The  following  prescription 
will  be  useful  for  a  child  of  ten  years  : 


448  MUMPS. 

R.  Antipyrine,  gj ; 

Potas.  bromidi,  ^iij.     Misce. 

Divid.  in  chart  No.  xv.     Give  one  powder  in  a  wineglassful  of  water  every  three  or 
four  hours  until  the  fever  abates. 

Dr.  Dukes  states  that  rise  of  temperature  is  a  premonitory  warning  of  a 
complication,  especially  of  orchitis  in  the  male,  and  the  early  application  of  a 
poultice  diminishes  its  severity.  If  a  complication  occur,  fomentations  should 
be  constantly  applied  over  the  inflamed  part,  and  phenacetin  or  antipyrine 
given  at  regular  intervals  to  reduce  the  fever. 


SEOTIOI^   III. 

OTHER    GENERAL    DISEASES. 


CHAPTER    I. 


INTERMITTENT    FEVER. 

This  is  a  constitutional  malady  produced  by  a  miasm  which  emanates 
from  the  soil.  I  have  notes  of  36  cases  of  this  disease  occurring  under  the 
age  of  three  and  a  half  years.  Several  of  these  patients  were  treated  in 
private  practice,  and  the  rest  in  institutions  with  which  I  have  been  con- 
nected. In  children  above  the  age  of  three  and  a  half  years  intermittent 
fever  differs  but  little  from  that  of  the  adult,  while  in  those  under  this  age 
it  presents  certain  peculiarities.  Of  the  36  cases  which  I  have  observed,  19 
had  the  quotidian  form,  10  the  tertian,  2  the  tertian  becoming  afterward 
quotidian,  1  the  quotidian  becoming  afterward  tertian,  while  in  the  remain- 
ing 4  cases  the  form  of  the  disease  is  not  stated.  In  quotidian  ague  the 
malaria  has  been  supposed  to  act  more  powerfully  on  the  system  or  the  sys- 
tem is  more  susceptible  to  its  influence  than  in  the  tertian  form,  and  hence 
the  fact  that  the  quotidian  is  the  prevailing  type  of  ague  in  tropical  regions, 
where  vegetation  is  luxuriant,  marshes  extensive,  and  the  heat  intense. 
According  to  this  theory,  the  feeble  resisting  power  in  the  system  of  the 
infant  explains  the  fact  that  it  has  quotidian  more  frequently  than  tertian 
intermittent,  although  the  latter  is  much  more  common  in  the  adult  in  this 
climate. 

Facts  demonstrate  that  infants  sometimes  receive  intermittent  fever  from 
their  mothers.  If  mothers  during  gestation  have  malarious  cachexia,  their 
infants,  whether  born  at  full  time  or,  as  often  happens,  prematurely,  are  apt 
to  be  small,  thin,  and  feeble,  and  occasionally  they  have  soon  after  birth  dis- 
tinct paroxysms  of  the  ague.  Dr.  Stokes  related  the  case  of  a  pregnant 
woman  with  ague  who  believed  that  she  noticed  periodical  tremors  of  her 
foetus,  but  I  suspect  that  she  was  mistaken  as  regards  the  cause,  for  the 
paroxysm  of  intermittent  in  young  children  is  not  ordinarily  accompanied  by 
tremors. 

The  youngest  infant  in  my  practice  who  apparently  derived  the  ague  from 
its  mother,  and  probably  through  the  foetal  circulation,  had  the  following  his- 
tory :  Its  mother  had  occasional  attacks  of  tertian  intermittent  during  the 
two  years  preceding  her  confinement,  and  her  baby  when  one  week  old  was 
observed  to  have  the  same  disease,  occurring  also  each  second  day,  the  cold- 
ness and  blueness  in  the  first  stage  of  the  paroxysm  lasting  from  half  an 
hour  to  one  hour. 

29  449 


450  INTERMITTENT  FEVER. 

It  is  not  fully  ascertained  whether  a  nursing  infant  may  contract  inter- 
naittent  fever  by  lactation,  but  if  it  be  admitted  that  it  is  sometimes  com- 
municated to  the  foetus  through  the  maternal  circulation,  it  does  not  seem 
improbable  that  the  specific  principle  occasionally  enters  the  milk  as  well  as 
other  secretions.  I  have  frequently  remarked  the  presence  of  the  disease  in 
nursing  infants  whose  mothers  were  affected,  and  in  one  instance  an  infant  at 
the  breast,  whose  mother  had  the  ague,  having  contracted  it  in  a  suburban 
village,  but  now  living  in  a  non-malarious  part  of  the  city,  presented  evident 
symptoms  of  the  disease.  Similar  observations  by  Frank,  Burdel,  and  others 
do  not  indeed  fully  prove  the  communicability  of  intermittent  fever  by  lac- 
tation, but  render  it  highly  probable. 

The  period  of  incubation  in  the  infant  varies  greatly,  as  in  the  adult. 
When  the  malaria  is  concentrated  and  unusually  active  or  the  condition  of 
system  is  favorable  for  its  reception,  the  disease  may  commence  soon  after 
exposure.  Thus,  in  tropical  regions  travellers  exposed  for  a  single  night 
have  been  known  to  sicken  within  twenty-four  hours,  but  in  our  cooler  lati- 
tude a  longer  incubative  period  is  the  rule.  In  the  infant,  however,  in  our 
climate,  intermittent  fever  often  begins  in  a  very  short  time  after  exposure, 
though  there  may  be  an  incubative  period  of  some  weeks.     The  following 

have  been  my  observations  relating  to  this  point :  A.  M ,  female,  eight 

months  old,  remained  two  days  on  Long  Island  in  October,  1870,  and  three 

days  after  her  return  to  the  city  a  quotidian  commenced.     P.  S ,  male, 

eleven  months  old,  remained  three  days  on  Long  Island,  and  a  quotidian  com- 
menced four  days  after  his  return.     K ,  nine  months  old,  remained  on 

Staten  Island  one  week,  and  eleven  days  after  his  return  a  tertian  commenced. 

Gr.  K ,  aged  three  years,  remained  a  day  and  a  night  on  Staten  Island  in 

18*70 ;  three  weeks  afterward  intermittent  fever  commenced,  preceded  by  a 

week  of  languor.     A.  U ,  female,  aged  two  years  and  two  months,  had 

the  first  paroxysm  of  a  tertian  two  and  a  half  weeks  after  returning  from  a 
visit  of  one  week  in  Hoboken.  As  there  was  no  malaria  in  the  portions  of 
the  city  where  these  infants  resided,  the  incubative  periods  are  nearly 
ascertained. 

Etiology. — The  cause  is  believed  to  be  a  microbe  which  exists  in  the 
soil  and  upon  and  near  its  surface.  Wherever  the  cause  exists  intermittent 
fever  is  endemic,  and  for  a  series  of  years,  until  the  character  of  the  soil  is 
changed  by  drainage.  The  morbific  agent  is  more  abundant  and  active  at 
night  than  in  the  day-time,  and  in  wet  than  in  dry  seasons.  It  ascends  from 
the  soil  to  the  lower  and  not  the  higher  strata  of  the  air,  so  that  those  who 
sleep  in  the  basement  or  ground-floor  of  a  house  are  more  frequently  aflfected 
by  the  malaria  than  those  in  the  upper  story.  Intermittent  fever  is  never 
contracted  through  the  breath  or  exhalations  of  a  patient  or  through  infected 
articles  of  clothing  or  furniture.     It  is  not,  therefore,  contagious. 

The  organism  which  causes  malarial  fever  is  not  fully  ascertained.  The 
so-called  ague-plant  discovered  by  Prof.  Salisbury  in  1866,  and  the  bacillus 
detected  by  Klebs  and  Tommasi  Crudeli  in  the  soil  of  malarial  regions,  which 
they  supposed  to  be  the  cause  of  the  malarial  fevers,  are  now  believed  to  be 
innocent  organisms  as  regards  these  diseases. 

More  importance  attaches  to  the  organisms  discovered  in  the  malarial  blood 
by  Laveran  in  1861.  They  occur  in  the  red  blood-corpuscles  and  are  also  free 
in  the  blood.  Their  average  size  is  about  one-third  that  of  the  red  blood- 
corpuscles,  but  some  are  smaller  and  others  larger  than  this.  Some  of  them 
contain  dark-brown  granules,  and  others  are  without  pigment.  In  fresh  blood 
these  bodies  exhibit  amceboid  movements,  changing  their  forms  like  the  white 
blood-corpuscles.  That  they  are  living  organisms  we  infer  from  their  move- 
ments.    They  have  been   found   nowhere   except  in  the  blood  of   malarial 


SYMPTOMS.  451 

patients,  and  chiefly  during  the  paroxysms.  Marchiaf'ava  and  Celli  state 
that  they  have  produced  malarial  fever  in  a  person  previously  healthy  by 
injecting  blood  containing  these  organisms  into  a  vein  ;  and  they  found  the 
same  organisms  in  his  blood  after  the  fever  had  appeared.  They  believe  that 
these  bodies  are  parasites  having  amoeboid  movements,  and  that  they  pene- 
trate the  red  blood-corpuscles,  which  they  destroy  in  proportion  to  the  degree 
of  encroachment,  and  produce  in  them  the  characteristic  malarial  pigment. 
Osier  also  describes  at  length  the  various  forms  which  this  organism  assumes, 
the  crescentic  form  appearing  especially  in  chronic  cases.  He  states  that 
quinine  is  a  specific  against  these  organisms,  causing  them  to  disappear  (Brit. 
3Ied.  Jour..  1887).  Councilman  of  Baltimore  examined  this  organism,  and 
noticed  its  highly  polymorphic  nature,  presenting  globular,  crescentic,  rosette, 
and  flagellate  forms.  He  states  that  the  administration  of  fifteen  grains  of 
quinine  daily  for  three  or  four  days  causes  the  almost  total  disappearance  of 
the  organism.  But  the  crescentic  organism  of  malarial  cachexia  is  not  mate- 
rially aff"ected  by  the  quinine  {Tlieraj^eutic  Gaz.,  1887).  Subsequent  investi- 
gations have  therefore  tended  to  substantiate  the  opinion  of  Laveran,  that 
malaria  is  caused  by  an  organism  having  amoeboid  movements  which  pene- 
trates and  destroys  the  red  blood-corpuscles. 

Whatever  may  be  the  nature  of  the  malarial  poison,  it  often  clings 
tenaciously  to  the  system,  and  is  probably  reproduced  in  it  even  under 
circumstances  favorable  for  its  elimination.  Thus,  at  one  of  my  cliniques 
at  Bellevue  Hospital  Medical  College  in  1871,  a  child  ten  years  old  was  pre- 
sented who  had  had  evei-y  year  for  seven  years  attacks  of  intermittent  fever. 
The  disease  was  contracted  at  the  age  of  three  years  in  Harlem,  and  the  sub- 
sequent residence  of  the  family  had  been  in  a  part  of  the  city  where  there 
was  no  malaria. 

Symptoms. — In  infancy,  and  especially  prior  to  the  age  of  eighteen 
months,  the  symptoms  diifer  in  certain  respects  from  those  which  charac- 
terize the  malady  in  the  adult,  and  are  universally  known.  In  childhood  the 
symptoms  are  similar  to  those  in  the  adult,  and  need  not  therefore  be  described 
in  this  connection. 

In  the  infant  the  type,  as  we  have  seen,  is  quotidian,  with  now  and  then  a 
tertian.  Advancing  beyond  the  age  of  eighteen  months,  we  meet  more  and 
more  cases  of  the  tertian  type,  and  in  childhood  the  tertian  is  the  common 
form.  I  have  known  the  quotidian  in  the  infant,  when  cured,  to  reappear 
a  few  weeks  later  as  a  tertian  ;  but  ordinarily  it  remains  quotidian,  unless 
the  patient  have  reached  the  age  at  which  the  tertian  type  predominates. 

The  paroxysm  in  the  young  infant  presents  three  stages,  as  in  the  adult, 
but  while  the  second,  or  febrile,  is  well  marked,  the  first  and  third  are  much 
less  pronounced.  The  patient  does  not  shake  (exceptionally  one  does  even 
within  the  first  year)  in  the  first  stage,  but  a  slight  tremor  may  or  may  not 
be  observed.  The  countenance  presents  a  sunken  appearance,  the  lips  and 
fingers  are  livid,  while  portions  of  the  surface  not  livid  are  pallid,  with  the 
goose-flesh  appearance,  which  is,  however,  less  marked  than  in  children  of  a 
more  advanced  age.  The  blood  leaves  the  surface,  which  consequently 
shrinks,  while  it  accumulates  in  the  veins  and  internal  organs  ;  the  pulse  is 
feeble  and  readily  compressed ;  the  surface  grows  cool  from  the  diminished 
supply  of  blood,  but  the  breath  is  warm,  and  the  internal  temperature,  so 
far  from  being  reduced,  is  elevated  two  or  three  degrees.  The  parents  may 
be  alarmed  at  the  sudden  sinking  of  the  vital  powers  and  seek  medical 
advice,  but  in  other  instances  the  first  stage  is  so  slight  that  it  passes  unper- 
ceived  till  they  have  been  taught  to  watch  for  it,  and  the  second  stage  first 
attracts  attention. 

In  the   second   or  febrile   stage,  which   immediately  succeeds,  the   pulse 


452  INTERMITTENT  FEVER. 

becomes  full  and  rapid,  120  to  130  or  140  beats  per  minute,  and  tbe  exter- 
nal as  well  as  internal  temperature  is  elevated  as  in  few  other  diseases 
(104°-108°).  The  face  is  flushed,  surface  dry,  and  head  painful,  as  evinced 
by  the  features.  This  stage  lasts  about  two  or  three  to  six  or  eight  hours. 
The  third  stage,  or  that  of  perspiration,  succeeds,  which  terminates  the  suf- 
fering of  the  patient  till  the  following  paroxysm.  In  infancy  the  perspi- 
ration is  not  abundant,  and  in  the  first  half  of  this  period  is  nearly  absent. 
In  the  interval  of  the  paroxysm  the  patient  appears  well,  except  a  degree  of 
languor. 

In  24  of  the  cases  of  infantile  intermittent  which  I  have  treated  my 
notes  describe  the  character  of  the  paroxysms.  In  16  of  these  there  was 
no  chill  or  trembling  in  the  first  stage,  but  blueness  and  coolness  of  the 
extremities  and  features  and  sudden  prostration.  This  stage  lasted  from 
ten  minutes  to  one  hour.  In  the  8  remaining  cases  the  infants  were  observed 
to  tremble  or  shake  as  in  adult  cases.  The  perspiration  of  the  third  stage 
was  in  nearly  all  cases,  when  observed,  slight  and  of  short  duration,  but  in 
some  it  was  not  observed. 

During  the  cold  stage  passive  congestion  of  the  internal  organs  occurs  to 
a  greater  or  less  extent,  but  the  circulation  is  equalized  during  the  reaction 
of  the  second  stage.  The  spleen,  whose  capsule  is  distensible,  soon  enlarges 
in  many  patients  in  consequence  of  the  frequent  and  great  congestions,  con- 
stituting the  "ague  cake."  This  enlargement  is  more  common  in  children 
than  adults.  Since  my  attention  has  been  particularly  directed  to  this  sub- 
ject, I  have  been  able  to  feel  the  enlarged  spleen,  by  examination  through 
the  abdominal  walls,  in  probably  one-third  of  the  cases  under  the  age  of  ten 
years.  This  organ  returns  to  the  normal  size  after  the  ague  is  cured.  From 
the  intimate  relation  of  the  spleen  to  the  composition  of  the  blood,  it  is  evi- 
dent that  the  character  of  this  fluid  must  be  afi'ected  if  intermittent  fever  be 
protracted.  The  blood  becomes  more  and  more  impoverished  and  a  state  of 
decided  hydrsemia  supervenes.  A  few  weeks'  continuance  of  the  ague  suf- 
fices to  produce  decided  pallor  of  the  features  and  surface  generally,  and  as 
all  watery  blood  is  prone  to  transudation,  such  patients  not  infrequently 
present  more  or  less  oedema  of  the  face,  ankles,  and  other  parts.  Sometimes 
also,  especially  under  unfavorable  hygienic  circumstances,  purpuric  spots 
(purpura  hsemorrhagica)  appear  under  the  skin,  affording  additional  proof  of 
the  change  which  the  blood  has  undergone. 

In  long-continued  cases  of  malarial  disease  in  the  adult  waxy  degenera- 
tion of  organs  is  apt  to  occur,  as  well  as  melanjemia.  Pigment-cells,  flakes, 
and  particles  appear  in  the  blood,  the  coats  of  the  minute  arteries,  and  in 
various  organs,  as  spleen,  liver,  etc.  In  the  child  these  results  are  more 
rare. 

Intermittent  fever  in  children,  if  proper  remedial  measures  are  employed 
at  an  early  period,  is  ordinarily  not  dangerous,  and  is  quite  amenable  to 
treatment ;  but  that  comparatively  infrequent  and  fatal  form  of  it  desig- 
nated the  pernicious  occurs  more  frequently  in  children  than  adults.  In 
New  York  City,  where  the  type  of  malarial  diseases  is  mild,  I  have  never 
met  a  case  of  pernicious  intermittent  in  the  adult,  but  I  can  recall  to  mind 
such  cases  in  children,  two  of  them  fatal.  This  form  of  the  fever  occurs  in 
a  smaller  proportionate  number  of  cases  in  infancy  than  in  childhood,  proba- 
bly because  the  cold  stage  is  less  pronounced.  In  the  pernicious  ague  the 
system  is  overpowered — it  does  not  react  in  a  degree  commensurate  with  the 
intensity  of  the  disease.  The  patient  enters  the  cold  stage,  becomes  stupid, 
and,  if  not  relieved  by  prompt  and  efficient  measures,  passes  into  fatal  coma. 
A  type  of  the  disease,  therefore,  which  would  not  be  pernicious  in  a  robust 
individual   may  be   such  in  one   of  a  broken-down   constitution   and  feeble 


TREATMENT.  453 

reactive  power.  In  most  cases  occurring  in  children  the  coma  is  preceded 
by  eclampsia,  which  is  apt  to  be  general  and  protracted. 

p]clampsia  increases  the  passive  congestion  of  the  cerebro-spinal  axis 
already  present  in  this  stage,  and  if  not  speedily  relieved  may  end  in  trans- 
udation of  serum  over  the  surface  of  the  brain,  and  perhaps  meningeal 
apoplexy,  causing  fatal  coma.     This  has  occurred  twice  in  my  practice. 

Sometimes  in  young  children  the  diagnosis  of  intermittent  fever  is  doubt- 
ful, either  because  the  disease  has  not  continued  sufficiently  long  or  there 
has  not  been  the  characteristic  paroxysm.  The  patient  may  be  feverish  and 
fretful,  with  anorexia  and  evidences  of  headache,  but  without  the  usual  dis- 
tinctive symptoms.  I  have  sometimes  in  such  cases  been  able  to  establish 
the  diagnosis  by  detecting  enlargement  of  the  spleen.  In  examining  for  the 
"  ague  cake  "  the  child  must  lie  quietly  on  its  back,  and  the  fingers,  placed 
midway  between  the  epigastrium  and  umbilicus,  be  carried  gently  but  with 
firm  pressure  outward  in  the  direction  of  the  spleen,  when  the  anterior  edge 
of  this  organ  will  be  felt  if  it  be  enlarged.  It  is  impossible  to  make  the 
examination  when  the  child  cries,  on  account  of  the  contraction  of  the 
abdominal  muscles. 

Treatment. — It  is  evident  that  no  time  should  be  lost  in  applying  appro- 
priate remedies  in  a  case  of  infantile  ague,  for,  although  the  first  paroxysm 
may  be  mild,  the  next  may  be  more  severe  and  attended  with  danger. 
Moreover,  the  sooner  the  disease  is  cured  the  less  liable  it  seems  to  be 
to  return.  Therefore  we  prescribe  at  once  the  sulphate  of  quinia  or  cin- 
chona, one  and  a  half  grains  of  the  latter  producing  the  effect  of  about 
one  grain  of  the  former.  Our  experience  in  the  children's  class  in  the  Out- 
door Department  has  been  chiefly  with  the  sulphate  of  cinchona  on  account 
of  its  cheapness,  and  there  has  yet  been  no  case  of  ague  which  it  has  failed 
to  control.  A  recent  writer  has  published  statistics  showing  his  success  in 
curing  intermittent  fever  by  this  agent,  but  nothing  in  thei'apeuties  is  more 
easy  than  to  cure  this  disease  in  our  climate  by  either  of  the  sulphates  men- 
tioned. The  chief  difficulty  consists  in  preventing  a  return.  To  an  infant 
of  two  years  I  prescribe  one  grain  of  sulphate  of  quinia  or  the  equivalent  of 
sulphate  of  cinchona  three  times  daily,  till  all  symptoms  of  the  ague  have 
disappeared ;  then  twice  a  day  during  the  subsequent  week,  and  afterward 
once  a  day  for  some  days,  and  finally  twice  or  thrice  a  week.  It  is  only  by 
the  protracted  use  of  the  drug  in  occasional  doses  that  the  return  of  the 
intermittent  can  be  prevented. 

It  is  important  in  administering  these  sulphates  to  infants  to  employ  a 
vehicle  which  will,  so  far  as  possible,  disguise  the  bitterness.  The  vehicle 
which  I  prefer  for  their  administration  is  the  elixir  adjuvans,  elixir  tarax. 
comp.,  or,  better  still,  the  syrupus  yerbae  santae  comp.  The  following  formula 
is  for  a  child  of  three  years : 

R.  Quinise  sulphat.,  gr.  xvj  ; 

Syr.  pruni  virginiani, 
Syr.  yerbpe  santse  comp.,       da.  5J.     Misce. 

The  following  is  also  a  good  formula  : 

B.  Quiniffi  sulphat.,  gr.  xvj  ; 

Syr.  yerbre  santae  comp.,  ^ij.     Misce. 

One  teaspoonful  three  to  five  times  daily.  The  first  dose  should  be  given 
immediately  after  the  fever  abates.  In  this  climate  two  or  three  days  suffice 
to  cure  the  disease,  after  which,  by  daily  but  gradually  diminished  use  of 
medicine  in  the  manner  stated  above,  the  return  of  the  malady  is  prevented. 


454  REMITTENT  FEVER. 

Protracted  cases  attended  by  anaemia  require  the  use  of  iron  in  addition  to 
the  remedy  which  is  designed  to  control  the  disease. 

For  children  with  irritable  stomachs,  who  cannot  retain  the  salts  of  quinine 
which  are  ordinarily  prescribed,  the  tannate  may  be  employed  in  powder  or 
lozenges  with  chocolate ;  but  in  order  to  produce  the  same  effect  the  dose 
must  be  two  and  a  half  times  greater  than  that  of  the  sulphate  or  muriate. 
The  protracted  cachexia  which  follows  an  attack  of  malarial  fever  is  best 
treated  in  children,  as  it  is  in  adults,  by  arsenic,  especially  the  liquor  potassae 
arsenit,  and  iron.  Quinine  is  much  less  efficient  in  curing  this  cachexia  than 
these  agents. 


CHAPTER    II. 

EEMITTENT  FEVEE. 

If  a  physician  were  to  consult  the  standard  treatises  on  diseases  of  chil- 
dren in  order  to  ascertain  the  nature  of  remittent  fever,  he  would  rise  from 
the  perusal  with  no  clear  idea  of  it.  One  tells  us  that  the  remittent  fever 
of  children  is  identical  with  typhoid  fever  of  adults ;  another,  that  it  is  a 
gastro-intestinal  inflammation ;  and,  finally,  Hillier  believes  that  there  is 
properly  no  such  disease,  and  that  the  term  should  be  dropped  from  the 
nosology  of  diseases  of  children.  There  is,  however,  a  remittent  fever  of 
children  as  well  as  adults,  and  much  of  the  confusion  which  exists  in  refer- 
ence to  it  arises  from  the  fact  that  writers  have  not  kept  in  view  what  con- 
stitutes a  fever. 

Febrile  action  which  has  a  local  cause  is  not  an  essential  fever,  and  should 
not  be  described  as  such.  It  happens  that  in  children  a  symptomatic  remit- 
tent fever  arises  from  a  variety  of  local  causes,  as  dentition,  intestinal  worms, 
subacute  gastro-intestinal  inflammation,  etc.  But  all  such  cases  should  be 
excluded  from  our  consideration  of  remittent  fever  as  clearly  as  we  distin- 
guish the  continued  fever  of  pneumonia  or  bronchitis  from  that  of  typhus  or 
typhoid. 

There  is  an  essential  remittent  fever  of  children  due  to  malaria.  The 
same  conditions  which  produce  intermittent  fever  do,  in  a  certain  proportion 
of  cases,  produce  a  fever  which  does  not  intermit,  but  continues  with  more 
or  less  pronounced  exacerbations  a  certain  number  of  days,  when  it  ceases  or 
becomes  intermittent.  Those  who  practise  in  malai'ious  localities  notice  a 
larger  proportion  of  cases  of  remittent  fever  among  children  than  adults, 
because  their  constitutions  are  less  able  to  resist  the  malarial  poison,  so  that 
an  exposure  which  in  an  adult  would  produce  milder  disease — to  wit,  a  ter- 
tian ague — frequently  causes  a  quotidian  or  remittent  in  the  child. 

In  hot  countries,  where  the  malarial  poison  is  more  active  and  the  diseases 
due  to  malaria  more  severe  than  in  the  temperate  regions,  cases  of  remittent 
fever  due  to  the  marsh  miasm  are  more  common  than  in  the  temperate 
regions.  The  "jungle  fever"  of  India  is  a  malarial  remittent  fever  of  a 
severe  type. 

In  my  opinion,  the  term  "remittent  fever,"  if  retained  in  nosology, 
should  be  restricted  to  those  fevers  of  a  remitting  type  which  are  due  to 
marsh  miasm,  so  that  it  differs  from  intermittent  fever  in  the  fact  of  a 
greater  intensity  and  not  in  its  essential  nature.  The  one  disease  is  cha- 
racterized by  intervals  of  apyrexia,  and  the  other  by  periods  of  a  diminution, 
but  not  cessation,  of  the  febrile  symptoms. 


TREATMENT.  455 

In  New  York  City,  and  probubly  in  other  localities  in  the  temperate  zone, 
a  continued  fever  of  a  mild  type  not  infrequently  occurs  in  children,  espe- 
cially in  the  spring  and  autumn,  running  a  course  of  one  to  two,  three,  or 
even  four,  weeks,  with  in  many  cases  a  slight  increase  in  the  latter  part  of 
the  day.  Children  with  tlus  fever  are  languid,  moderately  thirsty,  and  with- 
out appetite.  They  complain  in  the  first  days  of  headache.  Their  tongue  is 
moderately  furred.  They  have  a  slight  cough,  no  diarrhoea,  a  temperature  of 
101°  or  102°,  and  many  of  them  do  not  feel  ill  enough  to  go  to  bed,  except 
at  the  usual  hours  of  sleep,  during  the  whole  progress  of  the  disease,  which 
continues  a  variable  time,  from  one  to  three  weeks.  This  disease  physicians 
of  New  York  sometimes  designate  remittent,  sometimes  malarial,  and  occa- 
sionally, the  severe  cases,  typho-nialarial.  I  have  noticed  that  this  light 
form  of  fever  occasionally  occurs  in  a  household  or  asylum  in  connection 
with  typical  cases  of  typhoid  fever,  and  therefore  am  led  to  regard  it  as  a 
mild  form  of  this  disease.  Thus  in  a  family  in  West  Fifty-fourth  street  two 
children  had  this  fever  so  mildly  that  they  were  every  day  dressed  and  sitting 
quietly  in  the  room,  but  their  aunt,  a  lady  of  about  thirty  years,  who  took 
care  of  them,  sickened  with  a  severe  typical  and  protracted  typhoid  fever 
while  she  was  attending  them.  In  the  Roman  Catholic  Orphan  Asylum  of 
this  city  typhoid  fever  occurred  some  years  ago,  and  some  of  the  cases  were 
of  the  mild  form  described  above,  but  two  or  three  were  fatal,  and  the  cha- 
racteristic lesions  of  typhoid  fever  were  discovered  at  the  autopsies.  There- 
fore this  mild  continued  fever,  having  perhaps  a  slight  but  scarcely  apprecia- 
ble morning  remission,  should  not,  in  my  opinion,  be  designated  remittent, 
malarial,  or  typho-malarial — terms  which  have  been  applied  to  it — but  be 
regarded  as  a  mild  typhoid  fever.  It  seems  to  me  that  typhoid  fever,  like 
diphtheria,  does  sometimes  present  so  mild  a  type  in  childhood  that  the 
patients  are  not  confined  to  bed,  and  their  sickness  terminates  in  one  or  two 
weeks,  instead  of  three  or  four,  as  stated  in  the   books. 

Symptoms. — This  disease  begins  with  chilliness  and  headache,  and  exacer- 
bations and  remissions  occur  each  day.  In  severe  cases  the  temperature 
during  certain  hours  reaches  104°  or  105°,  and  the  exacerbation  may  be 
accompanied  by  delirium  or  stupor.  The  severe  headache,  restlessness,  and 
jactitation  show  that  the  nervous  system  is  profoundly  involved  in  certain 
cases.  There  may  be  distinct  remissions  in  the  beginning,  and  afterward,  for 
a  few  days,  the  fever  be  pretty  uniform,  when  it  again  remits  or  ceases.  The 
tongue  is  covered  with  a  light  fur.  Thirst,  loss  of  appetite,  a  tendency  to 
constipation,  and  scanty,  high-colored  urine  containing  urates,  are  common 
symptoms. 

l)iAGNOSis ;  Prognosis. — Typhoid  fever  usually  comes  on  more  grad- 
ually than  remittent  fever,  and  is  not  attended  by  so  great  a  daily  variation 
in  temperature.  It  is  of  more  importance  to  make  the  differential  diagnosis 
between  remittent  fever  and  the  acute  local  diseases,  especially  meningitis 
and  pneumonitis  ;  but  a  careful  examination  of  the  .signs  and  symptoms,  which 
will  be  considered  hereafter  in  our  remarks  on  the  local  diseases,  will  enable 
us  to  make  the  diagnosis.  The  prognosis  is  favorable  with  prompt  and  appro- 
priate treatment. 

Treatment. — Prompt  treatment  by  one  of  the  salts  of  quinine  is  required. 
Formerly  it  was  thought  advisable  to  employ  first  laxative  and  diaphoretic 
remedies,  in  the  belief  that  quinine,  if  administered  immediately,  might  cause 
cerebral  congestion.  But  since  the  bromides  and  antipyrine  came  into  use 
no  treatment  preparatory  to  the  use  of  quinine  is  required,  unless  a  sin- 
gle laxative  dose  in  the  beginning,  as  by  calomel  or  the  magnesium  citrate. 
Alternate  doses  of  quinine  and  bromide  of  potassium,  at  intervals  of  two 
hours,  will  in  a  few  days  control  the  fever.     The  bromide  will  prevent  any 


456  TYPHOID  FEVER. 

ill  effects  of  the  quinine  in  producing  cerebral  congestion,  which  was  formerly 
feared.  In  cases  attended  by  marked  pyrexia,  jactitation,  and  delirium  anti- 
pyrine  should  be  added  to  the  bromide. 


CHAPTER    III. 
TYPHOID  FEVER. 

Typhus  and  typhoid  fevers  occur  in  children,  but  the  former  is  mild  and 
infrequent,  rarely  occurring  except  when  adults  of  the  same  household  are 
affected.  It  requires  little  treatment  besides  good  nursing.  Typhoid  fever, 
on  the  other  hand,  is  not  infrequent  in  children,  and,  as  it  presents  certain 
peculiarities  prior  to  the  age  of  puberty,  it  is  proper  to  describe  it  in  this  con- 
nection. This  disease  is  much  less  common  in  infancy  than  in  childhood, 
and  in  the  first  half  of  infancy  is  believed  to  be  rare.  Still,  there  can  be  no 
doubt  that  many  cases  in  the  first  years  of  life  are  not  diagnosticated,  being 
mistaken  for  subacute  and  protracted  entero-colitis.  It  is  probably  more 
common  under  the  age  of  six  years  than  is  usually  supposed,  although  the 
younger  the  child  below  this  age  the  less  frequent  does  it  appear  to  be,  while 
above  the  age  of  six  years  it  is  more  and  more  frequent  until  puberty.  In  the 
statistics  of  Cadet  de  Gassicourt,  embracing  276  children,  3  were  at  the  age  of 
two  years,  7  at  the  age  of  three  years,  8  at  four  years,  13  at  five  years,  and 
the  number  gradually  increased  in  successive  years  until  there  were  32,  41, 
and  42  cases  at  the  ages  of  twelve,  thirteen,  and  fourteen  years.  Farnham 
has  reported  a  case  occurring  in  a  girl  of  three  years  whose  father  was  at  the 
time  convalescing  from  the  fever.  She  complained  of  feeling  tired,  and  was 
listless,  but  fretful.  Her  surface  was  hot  and  face  flushed  in  the  latter  part 
of  the  day.  Her  temperature  on  the  seventh  day  reached  104.8°,  when  she 
was  put  to  bed.  The  fever  ceased  on  the  sixteenth  day,  after  which  the 
temperature  was  subnormal  for  ten  days. 

Causation. — Klebs  in  1881  announced  that  he  had  discovered  a  bacillus 
in  cases  of  typhoid  fever,  which  he  believed  to  be  the  cause  of  the  disease, 
and  which  he  designated  the  bacillus  typhosus.  Each  bacillus  contained  a 
spore  in  its  interior,  and  often  one  at  its  extremity  from  which  new  bacilli 
developed.^  About  the  same  time  Eberth  also  discovered  the  bacillus  in  the 
intestinal  mucous  membrane,  the  mesenteric  glands,  and  spleen  in  typhoid 
fever,  and  ascertained  that  it  differed  from  other  bacteria  in  the  staining. 
In  17  cases  these  bacilli  were  found  in  6,  and  not  found  in  11.'^ 

Gaffby  announced  the  results  of  his  observations  and  experiments  with 
the  bacillus  typhosus.  He  succeeded  in  cultivating  it  in  various  substances. 
Upon  the  surface  of  potato,  sterilized  by  steam,  it  grows  abundantly,  forming 
rods  0.2//.  thick  and  0.6/j.  to  0.8//  in  length.  The  rods  have  active  move- 
ment and  are  aerobic. 

The  bacillus  typhosus  is  constantly  found  at  an  early  stage  of  typhoid 
fever  in  the  spleen,  mesenteric  glands,  Peyer's  patches,  and  the  solitary 
follicles.  Occasionally  it  has  been  discovered  in  the  lungs,  liver,  and  kidneys, 
and  rarely  in  the  blood.  When  the  symptoms  pertaining  to  the  fever  begin 
to  abate,  the  bacillus  also  begins  to  disappear,  so  that  in  the  fourth  week  it 
sometimes  cannot  be  discovered,  and  is  usually  less  abundant  than  in  the  first 
and  second  weeks  ;  but  it  may  be  present  after  the  fourth  week.     The  bacilli 

1  Phila.  Med.  Times,  Dec.  3,  1881.  ^  Brit.  Med.  Jour.,  Nov.  26,  1881. 


CAUSATION. 


457 


occur  in   colonies  or   irregular  masses.     The   figure  represents  the  bacilli  as 
observed  in  the  spleen. 

The  bacillus  typhosus  has  nut  been  discovered  in  any  other  disease  than 
typhoid  fever,  although  search  has  been  made  for  it.  Friinkel  and  Sim- 
monds  inoculated   rabbits  .with  it.     They  were  sick  in   consequence,  and   in 


Fig.  29. 


those  that  died  the  spleen,  the  solitary  follicles,  Peyerian  patches,  and  certain 
lymphatic  glands  were  found  tumefied.  For  the  reasons  stated,  pathologists 
for  the  most  part  agree  that  this  bacillus  is  the  cause  of  typhoid  fever,  but 
from  the  fact  that  no  bacilli,  or  but  few,  are  found  in  the  blood,  it  is  not 
improbable  that  the  fever  and  other  prominent  symptoms  of  the  disease  may 
be  largely  due  to  ptomaines  which  the  bacilli  produce. 

The  bacillus  typhosus  is  very  tenacious  of  life.  Prudden  found  that  it 
could  be  cultivated  after  it  had  been  frozen  in  ice  one  hundred  and  three  days  ; 
also  after  it  had  been  subjected  to  a  heat  of  132.8°,  and  again  when  it  had  been 
alternately  frozen  and  thawed.^  Vidal  and  Chantemesse,  by  capillary  punc- 
tures of  the  spleen  during  the  life  of  the  patient,  obtained  the  bacillus,  with 
which  they  inoculated  mice  and  guinea-pigs,  and  subsequently  discovered  this 
organism  in  their  lungs  and  abdominal  organs.  They  also  found  it  in  the 
placenta  of  a  typhoid  patient  who  aborted  at  the  fourth  month. - 

Vaughan  and  Xovy  obtained  cultures  of  the  typhoid  bacillus  from  the 
water  used  by  a  considerable  number  of  typhoid-fever  patients,  and  the 
syrupy  extract  containing  the  bacillus  and  the  ptomaines  produced  by  it, 
injected  under  the  skin  of  cats,  caused  2°  to  4.5°  of  rise  in  temperature. 
They  have  formulated  the  following  definition  of  the  disease:  '"An  infectious 
disease  arises  when  a  specific  pathogenic  micro-organism,  having  gained  admit- 
tance to  the  body,  and  having  found  the  conditions  favorable,  grows  and 
multiplies,  and  in  so  doing  elaborates  a  chemical  poison  which  induces  its 
characteristic  effects."  ^ 

The  discovery  of  the  bacillus  typhosus,  and  of  its  causal  relation  to 
typhoid  fever,  affords  important  aid  to  our  knowledge  of  the  manner  in 
which   typhoid  fever  is   produced.      The   theory  advocated   by   Murchison, 

1  N.  Y.  Med.  Eec,  1887.  2  Loncl.  Lane,  1887. 

^  Ptomaines  and  Leucomaines,  1888. 


458  TYPHOID  FEVER. 

that  this  disease  may  originate  de  vovo  by  exposure  to  filthy  accumulations 
of  any  kind,  is  now  known  to  be  false.  Only  such  substances  can  commu- 
nicate the  disease  as  contain  the  specific  bacillus,  and  it  is  obviously  neces- 
sary that  this  bacillus  should  in  some  manner  enter  the  system,  so  as  to  infect 
the  individual.  Exhalations  from  the  most  fifthy  accumulations,  and  even 
inoculation  with  the  most  fetid  material,  will  not  cause  typhoid  fever  unless 
the  bacillus  typhosus  be  present.  But  the  remarkable  vitality  of  this  organ- 
ism, and  its  power  of  propagation  in  certain  substances  in  common  use,  as 
water  and  milk,  give  rise  to  epidemics  in  localities  where  it  happens  to  be 
introduced. 

Typhoid  fever  is  seldom,  and  perhaps  not  at  all,  contracted  by  inhaling 
the  breath  of  a  patient  or  exhalations  from  his  surface,  but  his  urinary  and 
fecal  excreta  contain  the  bacillus  in  abundance  and  are  the  most  common 
source  of  infection.  Many  instances  are  on  record  of  epidemics  caused  by 
the  use  of  water  for  culinary  or  drinking  purposes  which  had  been  in  some 
manner  polluted  by  the  excreta  of  typhoid  patients.  One  of  the  earliest 
recorded  instances  of  this  kind  was  observed  by  the  late  Prof.  Austin  Flint 
in  1843.  In  a  village  in  Western  New  York  a  traveller  with  typhoid  fever 
was  cared  for  at  the  inn,  and  his  excreta  were  deposited  near  the  well  which 
supplied  the  whole  village  except  one  family.  The  stranger  died,  and  within 
a  month  typhoid  fever  occurred  in  all  the  families  of  the  village  except  the 
one  that  obtained  water  from  a  different  well.  At  Pierrefonds  23  persons  occu- 
pied adjacent  houses.  The  water  which  they  used  was  obtained  from  shallow 
wells  into  which  it  had  percolated  through  a  porous  soil  from  a  neighboring 
stream.  This  stream  received  the  drainage  of  two  cesspools,  one  being  thirty 
and  the  other  sixty-five  feet  from  the  well,  and  the  well  was  on  lower  ground 
than  the  cesspools.  In  August  and  September,  20  of  the  23  persons  were 
attacked  with  typhoid  fever,  and  in  one  of  the  houses  4  died.  The  water  sup- 
plying this  house  was  examined  by  Chantemesse  in  October,  and  was  found  to 
contain  the  bacillus  of  typhoid  fever  in  abundance.  A  month  subsequently 
none  could  be  found.  Vienna,  Angouleme,  Cincinnati,  and  Bordeaux  may  be 
mentioned  among  the  places  where  the  occurrence  of  typhoid  fever  has  been 
traced  to  pollution  of  the  drinking  water.  In  1888  a  severe  epidemic  of 
typhoid  fever  occurred  at  Iron  Mountain,  Michigan,  and  in  the  drinking 
water  employed  in  families  that  had  suffered  from  the  disease  Vaughan 
and  Novy  found  the  typhoid  bacillus.  Therefore,  sufficient  observations 
have  been  made  to  show  that  many  epidemics  of  typhoid  fever  have  been 
caused,  and  are  still  caused,  by  the  use  of  polluted  drinking  water  which  con- 
tained the  specific  bacillus,  and  that  when  epidemics  arise  from  this  cause  it 
apparently  gains  admittance  into  the  system  through  the  digestive  apparatus. 
In  1871,  Ballard,  health  officer  of  Islington,  called  attention  to  the  fact  that 
the  use  of  infected  milk  sometimes  causes  typhoid  fever.  He  had  investi- 
gated an  outbreak  of  the  disease  which  was  apparently  produced  by  rinsing 
milk-cans  with  water  which  was  polluted  by  direct  communication  of  the  tank 
with  drains.  Since  then  a  considerable  number  of  epidemics  have  been  traced 
to  the  use  of  infected  milk.  The  milk  in  most  of  the  investigated  cases  was 
contaminated  by  polluted  water  employed  in  rinsing  the  cans  or  added  to  the 
milk  for  the  purpose  of  diluting  it.  Milk  may  also  receive  the  typhoid  bacil- 
lus from  ice  which  contains  this  organism  and  is  employed  for  the  purpose 
of  reducing  the  temperature  or  for  dilution.  Seitz,  Wolfhtigel,  and  Reidel 
have  shown  that  the  typhoid  bacillus  grows  freely  in  milk.  Vaughan  mixed 
water  containing  the  typhoid  bacillus  with  milk,  and  subsequently  was  able 
to  obtain  from  the  milk  a  poisonous  extract  due  to  the  growth  and  activity 
of  the  bacillus  (31ed.  News,  Jan.  28,  1888).  Therefore  the  milk-supply 
should  also  be  investigated  on  the  occurrence  of  an  epidemic. 


ANATOMICAL  CHARACTERS.  459 

But  typhoid  fever  is  probably  coninmnicated  by  the  inhalation  of  air 
which  contains  the  typhoid  bacillus,  although,  as  we  have  seen,  the  disease  is 
not  likely  to  be  contracted  by  the  attendants  of  typhoid  patients  if  there  be 
prompt  and  efficient  disinfection  of  the  excreta.  In  New  York  City  many 
observations  show  that  the  filthy  flowing  streams  in  the  sewers  are  infected 
with  the  typhoid  bacillus,  and  cases  occur  in  which  the  fever  seems  to  be 
due  to  the  escape  of  the  sewer  gas  into  the  houses.  Thus,  in  my  practice, 
in  a  house  whose  plumbing  was  supposed  to  be  faultless  three  children  who, 
so  far  as  known,  had  not  been  exposed  outside,  sickened  with  typhoid  fever. 
A  thorough  examination  finally  revealed  the  escape  of  sewer  gas  into  the  cel- 
hir  in  a  strong  current.  The  inference  is  that  in  such  instances  the  tainted 
air  conveys  the  bacillus  to  the  lungs,  and  this  organism  enters  the  system 
through  this  oi'gan.  But  it  is  true  that  the  bacillus  in  such  instances  may  be 
deposited  from  the  air  in  the  food  or  drink,  or  in  the  mouth  or  fauces,  and  be 
swallowed,  so  that  the  systemic  infection  may  occur  through  the  digestive 
system.  But  it  suffices,  so  far  as  the  employment  of  preventive  measures  is 
concerned,  to  know  that  an  atmosphei'e  infected  by  exhalations  from  filthy 
sources  may  communicate  typhoid  fever  without  the  actual  presence  of  a 
typhoid  patient.  Between  1873  and  1885,  one  hundred  and  forty-six  cases  of 
typhoid  fever  occurred  in  one  of  two  barracks  occupied  by  the  German  artil- 
lery, while  cases  did  not  occur  in  the  other  barrack,  although  the  water  and 
food  used  in  the  two  were  the  same.  Finally,  suspicion  fell  upon  the  bed- 
linen  and  clothing,  and  the  discovery  was  made  that  recent  patients  had  worn 
the  clothes  of  men  previously  attacked,  and  even  stains  of  dried  fecal 
matter  were  found  in  their  pants.  Saturation  of  the  infected  articles  and 
the  barrack  with  chlorine  gas  followed  by  dry  heat  was  now  employed,  and 
no  more  cases  occurred  (^3Ied.  Press  and  Circ,  March  28,  1888).  There- 
fore the  typhoid  bacillus  gains  admittance  into  the  system  not  only  by  the 
use  of  infected  drinking  water,  milk,  and  solid  food,  but  also  by  the  inhala- 
tion of  an  infected  atmosphere. 

Anatomical  Characters. — Since  typhoid  fever  is  a  constitutional  dis- 
ease, we  would  expect  to  find  early  and  important  changes  in  the  blood.  No 
alteration,  however,  has  been  discovered  in  this  fluid  peculiar  to  typhoid 
fever.  The  amount  of  fibrin  is  diminished,  as  in  most  of  the  essential  fevers, 
and  its  coagulation  is  feeble,  forming,  when  the  blood  stands,  soft,  small,  and 
dark  clots.  When  the  fever  has  continued  for  some  time  a  state  of  anaemia 
more  or  less  decided  supervenes  in  which  the  amount  of  albumen  and  blood- 
corpuscles  is  diminished.  Although  there  are  often  decided  symptoms  refer- 
able to  the  nervous  system,  no  constant  changes  have  been  discovered  in  the 
brain  or  spinal  cord.  The  changes  observed  in  them  when  death  has  occurred 
in  the  course  of  typhoid  fever  have  been  for  the  most  part  due  to  other 
causes.  It  is  diffei'ent  with  the  respiratory  system.  After  the  first  week  of 
typhoid  fever  mild  bronchitis  is  almost  as  constant  as  inflammation  of  the 
fauces  in  scarlet  fever,  and  accordingly  we  find  in  fatal  cases  redness  and 
thickening  of  the  bronchial  mucous  membrane,  which  is  covered  with  a  viscid 
and  ordinarily  scanty  secretion.  Hypostatic  congestion  of  the  lungs,  with 
more  or  less  oedema,  and  in  severe  and  enfeebled  cases  hypostatic  pneumo- 
nia, are  not  uncommon.  In  the  bronchitis  and  state  of  feebleness  we  have 
the  causes  of  pulmonary  collapse,  and  this  lesion  is  not  infrequent  over 
limited  portions  of  the  lungs,  especially  if  the  bronchitis  aff"ect  the  smaller 
tubes. 

The  lesions  occurring  in  the  digestive  system  are  important.  The  pharynx 
is  normal  or  slightly  aff'eeted.  The  mucous  membrane  of  the  oesophagus 
and  stomach  is  sometimes  normal  or  nearly  so,  and  in  other  cases  hyperjtmic. 
It  is  said  that  ulcers  have  been  occasionally  observed  in  the  cardiac  end  of 


460  TYPHOID  FEVER. 

the  oesophagus.  The  mucous  membrane  of  the  small  intestine  is  more  or 
less  injected,  and  at  an  early  period,  even  by  the  second  or  third  day,  the 
patches  of  Peyer,  solitary  glands,  and  at  the  same  time  the  mesenteric, 
begin  to  enlarge.  I  have  made  microscopic  examination  of  these  glands  in 
typhoid  fever  of  the  adult,  and  have  found  a  considerable  increase  of  the 
small  round  granular  cells  of  which  they  are  composed.  It  appears,  there- 
fore, that  the  enlargement  is  due  mainly  to  hyperplasia  of  the  cellular  ele- 
ments of  the  glands,  though  there  is  probably  infiltration  to  a  certain  extent 
of  inflammatory  products  between  the  cells.  The  mucous  membrane  over 
the  glands  undergoes  inflammatory  thickening  and  softening.  In  the  adult 
sloughing  of  this  membrane  is  frequent,  with  the  disintegration  of  the  glands 
and  their  elimination  into  the  intestines,  producing  ulcers,  small  and  circular, 
corresponding  with  the  site  of  the  solitary  glands,  large  and  oval  or  irregular, 
corresponding  with  the  site  of  Peyer's  patches.  Disintegration  of  these 
glands  and  the  formation  of  ulcers  are  less  frequent  in  children  than  in 
adults.  In  the  adult  who  recovers  the  mesenteric  glands  and  the  solitary  and 
agminate  which  are  not  destroyed  return  to  their  normal  state  by  fatty  degen- 
eration, liquefaction,  and  absorption  of  the  redundant  cells.  In  the  child  this 
is  the  common  result,  instead  of  sloughing  and  disintegration,  as  regards  both 
the  solitary  and  agminate  glands,  and  uniform  result  as  regards  the  mesen- 
teric, and  I  may  add  bronchial  glands,  which  are  also  in  a  state  of  hyperplasia. 
The  absence  of  ulcei'ation  or  its  slight  extent  afibrds  explanation  of  the  fact 
that  intestinal  perforation  is  very  I'are  in  children.  The  inflammatory  changes 
described  above  pertain  chiefly  to  the  ileum.  The  duodenum  and  jejunum 
present  their  normal  appearance  or  are  moderately  hyperaemic  in  places  and 
their  follicles  swollen. 

The  spleen  gradually  enlarges,  often  to  twice  the  normal  size,  has  a  dark- 
red  color,  and  is  softened.  Enlargement  of  the  spleen  possesses  great  diag- 
nostic value  in  those  cases  in  which  the  diagnosis  is  obscure.  For  while  very 
similar  intestinal  lesions  may  occur  in  chronic  entero-colitis,  the  coexistence 
of  these  lesions  with  the  splenic  enlargement  and  softening  shows  the  con- 
stitutional nature  of  the  malady.  The  liver  usually  presents  its  normal 
appearance,  or  it  may  be  pale  in  consequence  of  the  anaemia,  or,  on  the  other 
hand,  it  may  be  hyperfemic.  Microscopic  examination  sometimes  reveals  a 
granular  state  of  the  hepatic  cells  with  indistinct  nuclei. 

In  cases  which  are  severe  and  which  present  a  decidedly  adynamic  type 
the  muscles  become  soft  and  flabby,  the  action  of  the  heart  is  feeble,  and 
more  or  less  passive  congestion  of  the  viscera  results.  In  such  cases  con- 
gestion of  the  kidneys  and  albuminuria  are  not  infrequent.  Parenchymatous 
degeneration  of  the  kidneys  occasionally  occurs,  the  epithelium  becoming 
granular,  the  cells  indistinct,  and  their  nuclei  invisible.  Liebermeister  states 
that  he  has  frequently  noted  the  absence  of  albuminuria  during  the  fever 
when  the  autopsy  showed  marked  degenerative  changes  in  the  kidneys. 
Inflammation  of  the  endocardium  and  pericardium  is  rare,  but  the  myo- 
cardium exhibits  structural  changes  in  severe  cases.  Atrophy  and  fatty 
degeneration  of  its  muscular  fibres  sometimes  occur,  which  may  lead  to  the 
formation  of  clots  in  the  cavities  of  the  heart,  and  consequent  emboli  in 
other  organs.  Hoff'mann  demonstrated  the  occurrence  of  fatty  degenera- 
tion of  the  minute  arteries  in  various  organs  in  prolonged  cases  of  typhoid 
fever,  and  degenerative  changes  have  also  been  observed  in  the  voluntary 
muscles. 

Pathology. — Recent  investigations  relating  to  the  acute  infectious  dis- 
eases of  childhood  render  it  probable  that  as  regards  most,  if  not  all,  of  them 
systemic  infection  occurs  through  ptomaines  or  poisonous  chemical  agents 
which  are   produced   by  the   action  of  the   microbes  which  are  the  specific 


SYMPTOMS.  461 

principles.  This  is  believed  to  be  true  as  regards  typhoid  fever.  In  1885, 
Brieger  obtained  a  ptomaine  from  cultures  of  the  typhoid  bacillus  which,  inocu- 
lated in  guinea-pigs,  caused  salivation,  hurried  breathing,  dilated  pupils,  diar- 
rhoea, paralysis,  and  death  within  one  to  two  days.'  From  such  observa- 
tions and  experiments  the  theory  has  arisen  that  the  symptoms  which  cha- 
racterize typhoid  fever  are  mainly  due,  not  directly  to  the  action  of  the 
bacillus,  but  to  a  ptomaine  or  ptomaines  created  by  the  bacillus  and 
absorbed  into  the  system.  This  theory  also  receives  support  from  the 
observations  and  experiments  of  Hoifa,  Sirotirvin,  Beaumer  and  Peiper, 
and  others. 

Incubative  Period. — As  in  scarlet  fever  and  diphtheria,  the  incubative 
period  in  typhoid  fever  varies.  In  three  cases  detailed  by  Griesinger  the 
fever  began  twenty-four  hours  after  exposure.  In  a  school  at  Clapham,  20 
out  of  22  boys  sickened,  according  to  Murchison,  within  four  days  after 
exposure.  Authenticated  cases  of  a  longer  incubative  period  are  on  record, 
so  that  Murchison  believed  that  it  is  commonly  about  two  weeks,  and 
William  Budd  that  it  is  in  most  instances  from  ten  to  fourteen  days,  but 
cases  have  occurred  in  which  it  seemed  to  be  as  long  as  twenty-eight 
days.^ 

Symptoms. — Typhoid  fever  has  a  prodromic  stage  of  a  few  days,  some- 
times of  a  week  or  more,  in  which  the  child  appears  languid,  indisposed  to 
play,  and  has  little  appetite,  but  complains  of  no  pain  unless  occasional 
slight  headache,  and  has  no  symptoms  which  would  lead  the  friends,  or  even 
physicians,  to  suspect  the  nature  of  the  disease  which  impends.  By  and 
by  a  slight  fever  occurs. 

In  exceptional  instances  typhoid  fever  begins  with  a  chill,  followed  by 
pronounced  fever.  It  occurred  in  3  of  the  14  cases  observed  by  Dr.  Jacobi 
in  Bellevue  Hospital.  This  was  a  larger  proportion  of  cases  with  such  com- 
mencement than  I  observed  in  the  epidemic  of  1882  or  have  since  observed, 
but  the  cases  in  Bellevue  seem  to  have  been  unusually  severe,  since  5  of  the 
14  died. 

The  fever,  which  gradually  becomes  more  pronounced,  remits,  but  does 
not  cease  in  the  morning,  and  it  has  evening  exacerbations.  After  the  first 
week  of  fever  the  remissions  are  less  marked,  but  the  fever  is  not  uniform 
at  any  period  in  its  course.  Hence  some  of  the  writers  on  diseases  of  children 
continue  to  designate  typhoid  fever  of  children  remittent  fever,  fully  aware 
of  its  identity  with  typhoid  fever  of  the  adult.  As  the  case  advances  the 
appetite  fails,  all  solid  food  being  refused,  and  liquid  food  being  taken  more 
from  thirst  than  hunger.  The  tongue  in  the  first  week,  and  in  some  patients 
throughout  the  course  of  the  disease,  is  covered  with  a  light  moist  fur,  while 
in  others  having  a  graver  type  of  the  fever  the  tongue  after  the  first  week  is 
dry  and  brown.  During  the  prodromic  period  and  in  the  first  week  the 
bowels  act  regularly  or  are  slightly  relaxed,  and  they  are  readil}^  affected  by 
purgative  medicines.  After  the  fii'st  week  there  is  in  some  children  a  tend- 
ency to  diarrhoea,  which  requires  now  and  then  the  use  of  astringents,  the 
stools  being  watery  and  brown  or  dark  yellow.  Diarrhoea  is  less  frequent  in 
children  than  in  adults,  and  in  some  children  it  does  not  occur  during  the 
entire  sickness.  The  abdominal  walls  are  seldom  retracted,  but  prominent, 
especially  after  the  first  week,  in  consequence  of  meteorism,  which  is  present 
in  children  as  well  as  adults.  Sometimes  there  is  appai'ent  tenderness  when 
pressure  is  made  over  the  right  iliac  region,  but  this  must  not  be  confounded 
with  hypersesthesia,  which  is  common  in  the  commencement  of  febrile  diseases 

'  L.  Brieger,  Ueber  Ptoma'ine,  Berlin,  188-5-86. 

^  See  article  "  Typhoid  Fever,"  American  System  of  Practical  Medicine ;  Philada.,  18S5, 
Lea  Bros. 


462  TYPHOID  FEVER. 

in  children,  and  which  is  observed  especially  upon  the  abdomen,  chest,  and 
inner  part  of  the  thighs. 

The  respiration  in  the  first  week  is  slightly  accelerated,  as  it  is  in  all 
febrile  diseases.  In  the  second  week,  and  subsequently  when  bronchitis  is 
developed,  the  respiration  is  ordinarily  more  accelerated,  though  not  in  a 
marked  degree,  unless  in  those  exceptional  instances  in  which  there  is  an 
abundant  collection  of  mucus  in  the  smaller  bronchial  tubes.  A  cough  is 
often  present,  dependent  on  the  bronchitis,  and  varying  in  character  accord- 
ing to  the  degree  and  stage  of  the  inflammation.  In  the  first  days  of  the 
fever  it  is  infrequent  or  lacking ;  at  a  later  stage  it  is  more  frequent  and  not 
so  dry,  though  in  cases  of  ordinary  severity  the  amount  of  expectoration  is 
inconsiderable.  Hypostatic  congestion,  oedema,  hypostatic  pneumonia,  spleni- 
zation  or  thickening  of  the  alveolar  walls,  and  collapse,  which  not  infre- 
quently occur  in  the  advanced  disease,  increase  more  or  less  the  frequency 
of  the  respiration  and  the  cough  and  modify  the  physical  signs. 

The  pulse  in  the  first  week,  in  ordinary  cases,  is  from  100  to  110  or  115. 
It  gradually  becomes  more  accelerated,  numbering  in  the  second  week  123  or 
more ;  in  grave  cases  even  160.  The  more  frequent  the  pulse,  the  greater 
the  danger  and  more  unfavorable  the  prognosis.  During  the  exacerbations 
the  number  of  pulsations  per  minute  is  fifteen  or  twenty  more  than  in  the 
remissions.  The  change  in  temperature  corresponds  with  that  of  the  pulse, 
being  from  1°  to  2°  higher  in  the  exacerbation  than  remission.  The  extremes 
of  temperature  in  cases  of  ordinary  severity  are  about  101°  to  104°.  A  tem- 
perature above  105°  shows  a  grave,  perhaps  a  fatal,  type  of  the  disease  or 
else  a  serious  complication. 

There  is  great  variation  as  regards  the  symptoms  referable  to  the  nervous 
system.  Headache  is  common  in  the  prodromic  and  initial  stages,  after  which 
it  ceases.  A  few  are  delirious  even  from  an  early  period,  screaming  loudly 
or  muttering  incoherently,  but  the  majority  are  quiet,  having,  indeed,  a 
degree  of  mental  dulness,  but  being  able  to  appreciate  questions  when 
aroused  and  answering  correctly.  Subsultus  tendinum  and  carphologia, 
which  some  exhibit,  show  that  there  is  profound  disturbance  of  the  nervous 
system.  Epistaxis  occurs  occasionally  in  the  first  week,  as  in  the  adult,  but  is 
usually  slight. 

The  rose-colored  eruption  appears  in  children  as  well  as  adults  between 
the  sixth  and  twelfth  days,  but  is  more  frequently  absent  in  the  former  than 
the  latter  ;  sometimes  the  number  of  spots  is  less  than  half  a  dozen.  Sudamina 
are  common  in  the  second  and  third  weeks,  and  perspirations  may  occur  at  any 
time  in  the  course  of  the  fever,  but  without  amelioration  of  symptoms.  More 
or  less  deafness  is  common,  being  in  most  instances  a  purely  nervous  symp- 
tom, without,  therefore,  any  structural  change  in  the  ear,  but  it  is  possible,. 
as  has  been  suggested  by  certain  writers,  that  it  sometimes  results  from 
inflammatory  thickening  of  the  Eustachian  tube  or  external  meatus,  or  from 
a  weakened  and  flabby  state  of  the  muscles  of  the  ear. 

Duration. — As  in  diphtheria,  so  in  typhoid  fever,  the  duration  varies 
greatly  in  difi'erent  cases.  Mild  forms  of  the  disease  terminate  within  one 
week,  but  cases  of  a  severe  type  may  continue  several  weeks.  Henoch  states- 
that  the  duration  of  80  cases  which  he  observed  were  as  follows :  from  seven 
to  ten  days,  11  ;  from  ten  to  fifteen  days,  26;  from  fifteen  to  twenty  days,. 
16 ;  from  twenty  to  thirty  days,  21  ;  and  from  thirty  to  forty-nine  days,  6 
cases.  The  limits  in  the  duration  were  therefore  seven  days  in  the  shortest 
and  mildest  cases,  and  forty -nine  days  in  those  that  were  the  most  protracted. 
In  the  cases  of  short  duration  the  diagnosis  was  rendered  clear  by  the  roseola, 
enlargement  of  the  spleen,  and  diarrhoea.  When  the  disease  begins  to  abate, 
there  is  frequently  in  the  morning  a  complete  apyrexia  and  a  return  of  the 


COMPLICATIONS.  463 

fever  in  the  latter  part  of  tlie  day.  Tliis  period  of  an  intermittent  fever 
usually  varies  from  two  to  five  days.  Forchhcimer,  who  observed  a  severe 
epidemic  of  typhoid  fever  in  Cincinnati,  says  that  this  disea.se  in  children 
sometimes  terminates  in  six  days  (^Colutn/jus  Med.  Jour.,  1888).  In  a  discus- 
sion relating  to  typhoid  fever  at  a  recent  session  of  the  New  York  Medical 
Association,  Dr.  K.  G.  Janeway  also  stated  that  this  disease  sometimes  termi- 
nates within  ten  days.  In  cases  continuing  three  or  four  weeks  the  patient 
becomes  progressively  more  emaciated  and  feeble,  and  in  a  severe  form  of 
the  disease  his  condition  seems  very  unpromising  to  one  not  familiar  with  the 
clinical  history  of  the  fever.  Pale,  emaciated,  and  feeble,  probably  pas.sing 
his  evacuations  in  bed,  and  taking  little  notice  of  objects  around  him,  he 
presents  at  the  close  of  the  third  week  or  in  the  fourth  an  appearance  of 
helplessness,  notwithstanding  the  best  nursing  and  the  constant  employment 
of  sustaining  measures,  which  is  truly  discouraging. 

Relapiits — Second  Attacks. — Rilliet  and  Barthez  called  attention  to  the 
fact  that  relapses  sometimes  occur,  although  they  observed  only  3  such 
cases  in  ni  patients.  Henoch  witnessed  21  relapses  in  137  cases,  the  relapses 
occurring  after  severe  and  after  mild  cases.  The  majority  of  the  cases  in 
which  relapse  occurred  were,  however,  mild.  As  a  rule,  the  relapse  occurred 
between  the  third  and  fifth  weeks,  and  after  a  complete  apyrexia  of  three  to 
ten  days.  In  one  case  even  eighteen  days  of  apyrexia  had  occurred  when 
the  fever  was  renewed.  In  some  cases  the  relapse  took  place  during  the 
decline  of  the  fever,  when  there  was  a  morning  intermission  and  an  evening 
fever,  the  fever  again  becoming  continuous.  Eichhorst,  in  examining  the 
records  of  666  cases  occurring  in  Zurich,  ascertained  that  second  attacks 
occurred  in  28  persons,  or  in  4.2  per  cent,  of  the  cases.  He  has  observed 
cases  of  a  third  and  even  of  a  fourth  attack,  so  that,  as  in  diphtheria,  a  first 
or  even  a  second  attack  does  not  destroy  the  susceptibility  to  the  disease. 

Complications. — The  chief  complications  of  typhoid  fever  are  broncho- 
pneumonia, already  sufficiently  described,  enteritis,  intestinal  hemorrhage, 
peritonitis,  otitis,  parotiditis,  and  muguet.  In  one  instance  I  lost  a  patient 
about  ten  years  old,  in  whom  the  fever  had  nearly  terminated,  by  the  sudden 
accession  of  croup.  There  is,  as  we  have  seen,  in  ordinary  cases  more  or  less 
inflammation  of  the  mucous  membrane  of  the  air-passages  and  of  the  intes- 
tines, especially  in  the  vicinity  of  the  patches  of  Peyer.  It  is  easy  to  under- 
stand how,  under  circumstances  which  may  arise  in  the  fever  favorable  to 
the  development  of  mucous  inflammations,  the  bronchitis  and  enteritis  may 
so  increase  as  to  constitute  complications.  They  are  the  most  frequent  of 
the  serious  complications. 

Feeble  action  of  the  heart,  common  in  severe  cases  of  typhoid  fever,  and 
which  after  the  second  week  is  partly  attributable  to  granulo-fatty  degenera- 
tion of  the  muscular  fibres  of  the  heart,  which  is  frequent  in  grave  forms  of 
the  infectious  diseases,  obviously  favors  the  occurrence  of  bronchial  and  pul- 
monary congestion.  Hence  the  proneness  in  these  cases  of  the  inflammation 
to  extend  downward  from  the  larger  to  the  smaller  bronchial  tubes  and  to 
the  lungs,  so  that  broncho-pneumonia  becomes  an  occasional  very  grave  com- 
plication. 

In  the  child  as  well  as  adult  with  this  disease  the  mucous  membrane  of 
the  lower  part  of  the  ileum  in  the  vicinity  of  Peyer's  patches  is  frequently 
thickened  and  hyperaemic — a  true  intestinal  catarrh.  We  can  readily  under- 
stand how  under  certain  circumstances  this  may  become  aggravated  so  as  to 
constitute  an  intestinal  inflammation  of  considerable  extent  and  gravity,  a 
severe  entero-colitis,  so  that  the  local  symptoms  predominate  over  the  consti- 
tutional and  aggravate  the  latter. 

In  the  adult,  as  is  well  known,  the  Peyerian  and  solitary  glands,  becom- 


464  TYPHOID  FEVER. 

ing  more  and  more  prominent  by  proliferation  of  the  cellular  elements 
(the  lymphoid  cells),  begin  to  ulcerate  in  the  second  week,  and  slough  in  the 
third,  forming  the  typhoid  ulcer,  which  is  slow  in  healing  and  aids  in 
keeping  up  the  diarrhoeal  state.  Such  destructive  or  necrotic  inflammation 
is  rare  in  young  children,  but  it  may  occur  in  those  of   a  more  advanced 

Intestinal  hemorrhage  is  therefore  an  occasional  accident.  Hillier  met 
4  cases  in  30  of  the  fever.  It  indicates  the  presence  of  ulcers  upon  the  sur- 
face of  the  intestines.  The  younger  the  child  the  less  the  liability  to  it. 
Some  in  whom  it  has  occurred  recover,  but  others  die.  A  girl  of  nine  years 
complained  of  severe  abdominal  pain  on  the  seventeenth  day  of  the  fever, 
which  was  followed  by  syncope  and  death.  At  the  autopsy  one  of  Peyer's 
patches  was  found  deeply  ulcerated,  and  at  the  bottom  of  the  ulcer  was  a 
perforation  through  which  blood  had  escaped  into  the  peritoneal  cavity. 

Intestinal  perforation  is  more  rare  in  children  than  in  adults,  as  might  be 
inferred  from  the  statement  already  made  that  intestinal  ulceration  is  less 
frequent  and  extensive  in  them.  Statistics  show  that  perforation  in  children 
occurs  only  once  in  232  cases.  Therefore,  as  perforation  is  the  common  cause 
of  peritonitis  in  this  disease,  this  inflammation  is  a  rare  complication.  Peri- 
tonitis may,  however,  occur  in  typhoid  fever  without  perforation.  In  one 
such  case  (an  adult)  in  the  fever  wards  attached  to  Charity  Hospital  local 
peritonitis  with  fibrinous  exudation  occurred  opposite  two  ulcerated  patches 
of  Peyer,  the  ulcers  extending  nearly  to  the  peritoneum,  but  not  perforating. 
The  lesions  observed  in  this  case  throw  light  on  those  cases  of  peritonitis 
complicating  typhoid  fever  which  recover,  the  cause  of  which  has  received  a 
diff'erent  explanation. 

In  advanced  and  greatly  debilitated  cases  thrush  sometimes  appears  in  the 
interior  of  the  mouth  and  upon  the  fauces.  It  is  always  an  unfavorable 
prognostic  symptom  in  children  suffering  from  chronic  or  protracted  disease. 
Parotiditis  is  also  a  rare  complication.  Otitis,  commencing  with  pain  and 
producing  a  discharge  which  may  continue  for  weeks,  is  not  rare,  though 
less  frequent  than  in  scarlet  fever.  The  otitis  is  commonly  external,  but  it 
may  in  scrofulous  subjects  extend  to  the  middle  ear. 

Diagnosis. — This  is  more  difficult  in  children  than  in  adults,  and  the 
younger  the  child  the  greater  the  difficulty.  In  infants  protracted  entero- 
colitis, with  fever  and  a  dry  furred  tongue,  cannot  in  certain  cases  be 
positively  diagnosticated  from  typhoid  fever  by  the  symptoms  and  clinical 
history.  Typhoid  fever  is  believed,  however,  to  be  rare  at  this  age,  for  an 
infant  nourished  at  the  breast  is  very  seldom  exposed  to  the  cause  of  the 
disease.  When,  however,  as  now  and  then  happens,  a  young  child  presents 
the  symptoms  characteristic  of  protracted  subacute  entero-colitis  or  typhoid 
fever,  and  older  members  of  the  household  have  the  fever,  it  is  highly 
probable  that  the  case  is  one  of  the  latter  disease,  and  it  should  be  treated 
accordingly. 

Even  in  older  children  typhoid  fever  is  frequently  mistaken  for  simple 
subacute  enteritis  or  entero-colitis,  or  vice  versa.  The  following  facts  aid  in 
the  differential  diagnosis  :  In  typhoid  fever  there  is  a  total  loss  of  appetite, 
while  in  the  subacute  intestinal  inflammation  food  is  not  entirely  refused. 
Diarrhoea  commences  early  in  the  inflammation,  while  in  the  fever  it  is  not 
ordinarily  till  after  the  lapse  of  a  few  days.  Abdominal  tenderness  in  the 
fever  is  not  appreciable  or  is  located  in  the  right  iliac  region  ;  in  the  other 
disease  it  is  general  over  the  abdomen  or  located  in  the  umbilical  region. 
In  typhoid  fever  there  is  bronchitis  with  a  cough,  which  is  absent  in  the 
inflammation.  In  typhoid  fever  there  are  certain  other  symptoms,  more 
or  fewer  of  which  are  present  in  most  cases,  and  which  do  not  occur  in  the 


TREA  TMENT.  465 

intestinal  diseases,  except  as  a  coincidence ;  for  example,  headache,  epistaxis, 
stupor,  delirium,  and  perhaps  the  rose-colored  spots.  The  evening  rise  of 
temperature  and  enlargement  of  the  spleen  are  also  important  diagnostic 
symptoms.  When  it  is  very  important  to  make  a  positive  diagnosis,  cultures 
may  be  made  from  blood  drawn  from  the  spleen,  from  the  sediment  of  albu- 
minous urine,  or  from  the  feces,  and  if  the  disease  be  typhoid  fever  the 
specific  bacillus  will  be  found. 

Typhoid  fever  may  be  mistaken  for  meningitis  during  the  first  week,  but 
in  meningitis  there  is  more  constipation,  irritability  of  stomach,  and  less  ele- 
vation of  temperature.  Moreover,  in  meningitis  at  a  comparatively  early 
stage  we  are  able  to  detect  patches  of  congestion  of  the  features  coming  and 
disappearing  suddenly,  and  slight  inequality  of  the  pupils  or  their  oscilla- 
tion when  the  light  is  uniform — signs  which  are  lacking  in  typhoid  fever. 
In  a  doubtful  case  the  ophthalmoscope  might  be  employed,  which  in  menin- 
gitis discloses  congestion  of  the  vessels  of  the  retina,  cedema,  etc. — anatomi- 
cal changes  which  do  not  pertain  to  typhoid  fever. 

The  differential  diagnosis  of  typhoid  fever  and  acute  tuberculosis  may  be 
made  by  attention  to  the  following  points :  In  tuberculosis  there  is  cough, 
with  some  acceleration  of  respiration  from  the  first,  without  epistaxis,  stupor, 
or  other  nervous  symptoms,  and  without  the  abdominal  symptoms  which  are 
so  prominent  in  the  fever.  The  occurrence  of  typical  cases  in  the  same 
house  or  in  those  who  have  been  similarly  exposed  has  in  certain  instances 
enabled  me  to  make  a  clear  diagnosis. 

In  localities  where  diseases  due  to  marsh  miasm  occur,  the  remittent  fever 
arising  from  this  cause  and  typhoid  fever  bear  considerable  resemblance  to 
each  other.  The  two,  indeed,  may  coexist — a  fact  observed  during  the  late 
Civil  War,  so  that  cases  in  which  this  coexistence  occurred  were  designated 
typho-malarial.  In  malarial  remittent  fever  the  commencement  is  more 
abrupt,  the  vomiting  and  headache  more  severe,  and  the  remissions  more 
marked  than  in  typhoid  fever.  Moreover,  quinine  exerts  a  decided  control- 
ling effect  in  the  fever  due  to  marsh  miasm,  while  its  effect  in  typhoid  fever 
is  much  less  pronounced. 

Prognosis. — A  much  larger  percentage  of  children  recover  than  of  adults. 
Although  there  be  great  emaciation  with  loss  of  strength,  recovery  may  be 
confidently  predicted,  provided  that  no  serious  complication  occur.  Grave 
symptoms,  as  high  fever,  delirium,  severe  diarrhoea,  an  unusually  rapid  and 
feeble  pulse,  have  a  bad  import.  If  from  any  cause  the  system  is  in  a 
marked  degree  debilitated  when  the  fever  begins,  the  prognosis  is  much  less 
favorable  than  in  those  who  are  robust.  Thus  the  presence  of  hereditary 
syphilis,  of  tuberculosis,  of  severe  scrofula,  or  of  bronchial  or  intestinal 
catarrh  when  typhoid  fever  begins,  greatly  increases  the  danger.  But  in 
fatal  cases  which  I  have  met  the  unfavorable  result  occurred,  as  a  rule,  from 
the  complications  rather  than  directly  from  the  malady.  Of  the  compli- 
cations, the  most  serious  are  intestinal  ulceration,  giving  rise  to  hemor- 
rhage, or  even  perforation,  and  consequent  peritonitis,  diphtheria,  pneu- 
monia, nephritis,  pleuritis  with  serous  or  purulent  effusion,  meningitis,  and 
granulo-fatty  degeneration  of  the  myocardium.  Complications  like  these 
largely  increase  the  mortality  of  typhoid  fever.  The  condition  in  which 
severe  typhoid  fever  leaves  a  patient  is  favorable  for  the  development  of 
tubercles,  and  now  and  then  they  occur,  disappointing  our  expectations  and 
prediction  of  recover3^  The  possibility  of  a  relapse  should  be  borne  in 
mind,  so  that  the  patient  should  remain  in  bed,  free  from  excitement  and 
with  plain  but  nutritious  and  easily  digested  diet,  until  convalescence  is  well 
advanced. 

Treatment. — Typhoid  fever,  like  typhus,  cannot  be  abridged  by  treat- 
30 


466  TYPHOID  FEVER. 

ment,  and  tlie  indication  is  to  sustain  the  vital  powers,  diminist  the  intensity 
of  the  fever,  and  arrest  if  possible  any  untoward  symptom  or  complication. 
Quinia,  so  useful  in  malarial  diseases,  may  be  administered  in  small  doses 
for  its  tonic  effect  and  as  an  aid  in  promoting  digestion.  It  is  commonly  and 
properly  prescribed  in  some  convenient  vehicle  for  this  purpose,  but  it  does 
not  antagonize  the  typhoid  as  it  does  the  malarial  poison.  Perturbating 
medicines,  and  especially  cathartics,  should  be  given  with  caution.  The 
tendency  to  intestinal  ulceration  and  hemorrhage  and  the  anaemic  nature 
of  the  fever  require  abstinence  from  or  cautious  use  of  such  agents.  A 
temperature  remaining  under  103°  usually  involves  little  danger.  If  it 
remain  above  103°  morning  and  evening,  antipyretic  measures  should  be 
employed.  I  therefore  order  the  nurse  to  bathe  frequently  the  forehead, 
face,  hands,  arms,  neck,  and  sometimes  the  chest,  with  cold  water,  to  which 
it  is  proper  to  add  alcohol  or  some  spirituous  lotion.  A  cloth  wrung  out  of 
ice-water  or  an  ice-bag  should  be  applied  over  the  head,  and  the  hands  may 
be  allowed  to  lie  a  considerable  time  in  a  washbowl  containing  the  lotion, 
which  is  always  grateful  to  the  patient.  The  water  treatment  thus  applied 
will  usually  reduce  the  temperature  one,  two,  or  three  degrees  within  a  few 
hours.  Cold  general  baths  are  not  so  well  tolerated  by  children  as  by  adults. 
Collapse  has  sometimes  followed  their  use,  and,  on  the  other  hand,  benefit 
has  apparently  in  some  cases  accrued  from  their  employment  when  the  tem- 
perature was  above  104°.  The  bath,  if  used,  should  be  at  a  temperature  of 
about  88°,  and  the  patient  should  not  be  immersed  in  it  longer  than  five  to 
eight  minutes  (Henoch).  It  seems  preferable,  however,  in  most  cases  of  high 
temperature,  to  endeavor  to  reduce  it  by  cold  sponging  or  cold  compresses. 
A  compress  frequently  wrung  out  of  ice-water  or  containing  broken  ice  mixed 
with  bran,  or  a  rubber  ice-bag  applied  over  the  head  and  another  over  the 
abdomen,  or  Leiter's  coils  applied  over  the  same  parts  as  the  compress,  grad- 
ually abstract  the  heat,  and  with  more  safety  to  the  patient  than  the  use  of 
the  cold  bath.  Ice  applications  should  be  discontinued  if  the  temperature 
fall  to  103°  or  if  the  patient  complain  of  chilliness.  Even  an  afternoon  tem- 
perature of  104°  does  not  require  ice  applications  or  any  active  antipyretic, 
provided  there  is  a  decided  morning  remission.  Moderate  doses  of  quinine 
and  general  sustaining  remedies  suffice  for  such  cases. 

Of  the  internal  antipyretics,  sodium  salicylate,  antipyrine,  phenacetin, 
acetanilide,  and  quinine  have  been  chiefly  employed.  The  sodium  salicylate 
is  likely  to  retard  digestion,  and  it  sometimes  causes  albuminuria.  Its  use, 
therefore,  cannot  be  recommended.  Antipyrine  effectually  reduces  the  tempera- 
ture, but  is  depressing.  It  may  be  given,  especially  in  the  early  stages  of  typhoid 
fever,  in  doses  of  two  to  five  grains  according  to  the  age,  along  with  an  alco- 
holic stimulant,  with  a  good  result.  Some  physicians  recommend  the  use  of 
phenacetin  instead  of  antipyrine,  as  being  equally  effectual  and  less  depress- 
ing. It  may  be  given  in  about  half  the  dose  of  antipyrine.  Acetanilide  in 
one-fourth  the  dose  of  antipyrine  also  reduces  the  fever,  but  it  is  also  depress- 
ing, and  it  does  not,  so  far  as  I  am  aware,  possess  any  advantages  over  anti- 
pyrine. In  the  majority  of  cases  the  reduction  of  temperature  is  best  effected 
by  cold-water  bathing,  or  cold  compresses  and  the  internal  use  of  quinine. 
Quinine  in  moderate  doses  as  a  tonic  appears  to  be  useful  during  the  entire 
course  of  the  fever,  but  in  cases  of  a  temperature  dangerously  high  antipy- 
rine, acetanilide,  or  phenacetin  is  now  preferred  by  good  observers  to  the  use 
of  large  doses  of  quinine,  which  were  formerly  employed  (Von  Ziemssen). 

The  fact  that  in  a  large  proportion  of  cases  the  typhoid  bacillus  enters 
the  system  in  the  ingesta,  and  effects  a  lodgment  upon  the  gastro-intcstinal 
surface,  suggests  the  query  whether  the  early  use  of  antiseptics  administered 
by  the  mouth  might  not  be  destructive  to  the  bacillus,  and  thus  in  a  measure 


TREATMENT.  467 

destroy  the  cause  of  the  disease.  The  remedy  wliich  has  tlius  far  been  used 
for  this  purpose,  and  whicli  is  supposed  by  some  to  exert  a  specific  action 
upon  tlie  disease,  apart  from  its  purgative  or  elimiiuitive  effect,  is  calomel. 
Its  mode  of  action  is  not  fully  understood.  It  is  supposed  by  some  to  be  in 
part  changed  into  the  bichloride  in  the  stomach  and  intestines.  Von  Ziem.s- 
sen  in  treating  adults  administers  early  in  the  attack  three  72-grain  doses  of 
calomel  at  intervals  of  two  hours,  and  obtains  by  so  doing  a  consideraVjle 
reduction  of  temperature  during  the  following  twelve  hours.  Liebermeister 
claims  that  the  use  of  calomel  diminishes  the  intensity  of  the  disease,  and 
Wunderlich  even  believed  at  one  time  that  it  might  abort  the  fever.  On  the 
other  hand,  Weil,  Griesinger,  and  Baumler  assert,  from  their  observations 
and  statistics,  that  the  mortality  is  not  diminished  nor  is  the  number  of  aborted 
cases  increased  by  the  use  of  calomel,  and  that  it  is  only  useful  as  a  mild, 
non-irritating  evacuant.  Wilson  says:  "Attempts  to  fix  the  hypothetical 
specific  action  by  long-continued  calomel  treatment,  and  to  force  a  true  abor- 
tive calomel  treatment,  have  at  different  times  failed,  as  has  also  the  subli- 
mate treatment  of  typhoid  fever,"  The  use  of  calomel  should  probably  be 
restricted  to  one  or  a  few  doses  at  the  commencement  of  the  attack. 

Since  it  is  impossible  to  arrest  typhoid  fever  or  abridge  its  duration  by 
any  therapeutic  measures  of  which  we  are  cognizant,  the  indication  is  to  sus- 
tain the  vital  powers  and  alleviate,  so  far  as  possible,  the  symptoms.  Qui- 
nine is  not  only  employed  in  large  doses  to  reduce  the  fever,  but  it  is  often 
prescribed  in  small  doses  during  the  subsequent  progress  of  the  disease,  in  the 
belief  that  it  may  exert  some  tonic  effect.  It  does  not  appear,  however,  to 
exert  any  marked  controlling  effect  upon  the  symptoms.  Iodine,  iodide  of 
potassium,  and  carbolic  acid  have  also  been  employed  internally,  but  their 
efficacy  is  doubtful,  but  Liebermeister  states  that  the  iodide  of  potassium 
employed  in  two  hundred  cases,  although  it  did  not  appreciably  ameliorate 
the  symptoms,  apparently  diminished  the  mortality. 

The  mineral  acids  have  also  their  advocates,  and  statistics  appear  to  show 
benefit  from  their  use.  The  late  Prof.  Austin  Flint  treated  78  patients  with 
the  acids  with  a  death-rate  of  10.25  per  cent,  and  70  patients  without  the 
acids  with  a  death-rate  of  20  per  cent.,  the  treatment  otherwise  of  the  two 
classes  being  alike.  The  mineral  acid  which,  in  my  opinion,  is  most  useful  is 
the  muriatic,  since  it  aids  digestion,  which  is  greatly  impaired  by  the  fever, 
and  since  the  digestive  ferments  in  this  disease  are  apparently  secreted  in 
insufficient  quantity.  I  usually  prescribe  this  acid  with  pepsin,  as  in  the 
following  formula : 

R.  Pepsini  puri,  in  lamellis,  3j  ; 

Acidi  muriat.  dilut.,  ^ij ; 

Syr.  simplic,  .\j ; 

Aquae,  giij.     Misce. 

Give  one  teaspoonful  in  water  every  two  hours  to  a  child  of  ten  years.  The 
wine  of  pepsin  of  the  National  formulary  may  also  be  employed,  but  each 
teaspoonful  contains  only  about  one  minim  of  the  dilute  muriatic  acid,  so 
that  the  quantity  of  the  acid  might  be  increased. 

In  all  but  the  mildest  cases  alcoholic  stimulants  are  required,  especially 
after  the  first  week.  In  the  first  week  they  may  be  withheld  in  ordinary 
cases,  but  in  attacks  of  a  severe  type  and  attended  by  early  prostration  they 
may  be  required  at  or  soon  after  the  commencement  of  the  fever.  The  indi- 
cations for  their  use  are  feeble  pulse  with  faint  systolic  sound  and  marked 
nervous  symptoms,  as  subsultus  tendinum,  stupor,  and  delirium.  In  the 
prostration  consequent  on  high  fever  and  protracted  and  obstinate  diarrhoea 


468  TYPHOID  FEVER. 

the  use  of  alcohol  is  important  as  a  cardiac  stimulant.  Still,  such  large  and 
frequent  doses  of  the  alcoholic  compounds  are  not  needed  as  are  useful  in 
diphtheria.  The  object  in  employing  them  is  to  sustain  the  flagging  pulse 
and  promote  digestion  and  assimilation.  The  preferable  mode  of  employing 
alcoholic  stimulants  is  in  the  form  of  milk  punch  or  wine  whey. 

Wakefulness,  which  is  sometimes  an  unpleasant  symptom,  and  which  may 
occur  with,  and  is  perhaps  largely  due  to,  the  headache,  may  be  relieved  by 
a  powder  of  phenacetin  and  bromide  of  potassium  or  sodium,  two  to  five 
grains  of  the  former  and  double  or  treble  its  amount  of  the  bromide.  The 
new  remedy,  sulphonal,  triturated  and  given  in  sweetened  water  or  milk, 
will  also  relieve  the  insomnia,  and  in  some  instances  it  appears  to  be  pref- 
erable to  the  other  agents  which  have  been  employed  for  the  purpose  of 
procuring  sleep.  An  opiate,  as  Dover's  powder,  is  also  useful  in  relieving 
wakefulness,  and  should  be  prescribed  if  the  patient  at  the  same  time  have 
diarrhoea.  Three  grains  may  be  given  to  a  child  of  eight  years.  For  head- 
ache, whether  accompanied  by  wakefulness  or  not,  I  know  no  better  remedy 
than  phenacetin  in  combination  with  the  bromide  of  potassium  or  sodium,  as 
given  above.  At  the  same  time,  cool  lotions  should  be  applied  to  the  head. 
The  same  remedies  which  are  appropriate  for  the  insomnia  are  also  useful  for 
the  delirium  which  occasionally  occurs  in  cases  of  a  grave  type.  The  con- 
stant application  of  cold  to  the  head  and  an  increase  in  the  stimulation  may 
also  be  required. 

We  have  stated  elsewhere  that  diarrhoea  is  less  common  in  the  typhoid 
fever  of  children  than  in  that  of  adults,  but  it  sometimes  occurs,  and  should 
be  promptly  checked.  The  subnitrate  of  bismuth  in  rather  large  and  fre- 
quent doses,  along  with  an  opiate  and  vegetable  astringent,  will  usually  con- 
trol the  diarrhoea,  and  the  same  remedies  should  be  employed  in  intestinal 
hemorrhage.  Recently  in  my  practice  in  the  case  of  a  boy  of  about  fifteen 
years  near  the  close  of  the  second  week  of  typhoid  fever,  so  large  a  flow  of 
blood  occurred  from  the  intestines  that  the  condition  of  the  patient  was  very 
critical.  But  the  loss  of  blood  was  quickly  checked  by  large  doses  of  sub- 
nitrate  of  bismuth  and  teaspoonful  doses  of  equal  parts  of  the  camphorated 
tincture  of  opium  and  tincture  of  catechu,  and  the  patient  recovered.  The 
constipation  which  is  sometimes  present  in  typhoid  fever,  and  more  frequently 
in  children  than  in  adults,  may  be  relieved  by  an  enema  of  water,  half  a  pint 
containing  one  or  two  teaspoonfuls  of  glycerin. 

The  distension  of  the  stomach  and  intestines  with  flatus  is  sometimes  so 
great  that  it  requires  treatment.  It  may  cause  a  sensation  of  fulness  and 
prevent  the  descent  of  the  diaphragm  in  respiration,  and  it  increases  the  dan- 
ger of  perforation  if  a  deep  intestinal  ulcer  exist.  External  pressure  and 
manipulation  should  not  be  employed  under  such  circumstances,  since  they 
might  cause  rupture,  nor  should  the  hypodermic  needle  be  used.  Jacobi  has 
witnessed  a  fatal  peritonitis  produced  by  the  escape  of  fecal  matter  through 
the  punctures  caused  by  the  needle  (^Arch.  of  Pediatrics,  Dec,  1888).  The 
proper  remedy  for  the  flatus  is  either  turpentine  or  the  aniseed  cordial  of  the 
National  Formulary. 

Sustaining  measures  are  of  the  highest  importance.  Typhoid  fever  ceases 
after  some  days  or  weeks  with  or  without  medicinal  treatment,  and  the  patient 
recovers  if  the  strength  be  adequately  supported.  Hence  the  food  should  be 
sufiicient  in  quantity,  of  the  most  nutritious  kind,  and  easily  digested  and 
assimilated.  It  must  be  liquid,  since  the  repugnance  to  food  and  the  mental 
state  of  the  patient  render  it  impossible  to  feed  him  with  solids  unless  in  the 
mildest  cases.  Milk  sterilized  by  heat  or  peptonized,  the  meat  broths,  and 
gruels  with  milk  must  be  the  food  chiefly  employed.  Since  the  digestive 
ferments  are  apparently  secreted  in  small  quantity  during  the  fever  and  diges- 


TREATMENT.  469 

tion  is  feebly  performed,  it  is  well  to  employ  predigested  food  when  the  dis- 
ease is  unusually  severe  and  the  temperature  very  high.  Peptonized  milk 
and  the  beef  peptones  of  the  shops  are  useful  under  such  circumstances. 
Milk  with  some  farinaceous  food  long  boiled,  as  barley  flour,  should  in  most 
instances  be  employed  as  the  principal  article  of  diet.  The  mistake  is  some- 
times made  by  anxious  friends  of  giving  the  nutriment  too  frequently,  even 
every  half  hour.  As  in  health,  so  in  this  disease,  the  digestive  function 
requires  intervals  of  rest,  so  that,  as  a  rule,  the  food  should  not  be  given 
oftencr  than  every  two  hours,  and  then  in  sufficient  quantity.  A  dose  of 
pepsin  before  each  feeding,  employed  in  the  formula  recommended  above, 
has  been  useful  in  critical  cases  in  my  practice.  So  important  is  the  diet  in 
typhoid  fever  that  the  physician  neglects  an  important  duty  if  he  do  not  give 
ae  full  and  explicit  directions  in  regard  to  the  feeding  as  he  does  in  refer- 
ence to  the  use  of  medicines.  The  room  occupied  by  the  patient  should  be 
large  and  well  ventilated.  Statistics  show  that  the  result  is  far  better  if  there 
be  a  plentiful  supply  of  pure  fresh  air  than  in  closed  and  ill-ventilated  apart- 
ments ;  so  that  in  some  of  the  hospitals  patients  are  treated  in  canvas  tents 
upon  the  hospital  grounds  when  the  weather  is  suitable.  Nearly  forty  years 
ago  an  emigrant-ship  arrived  at  Perth  Amboy,  N.  J.,  with  more  than  300 
passengers,  82  of  whom  were  sick  with  fever,  and  several  had  died  at  sea. 
There  being  no  hospital  in  the  town,  the  fever  patients,  12  of  whom  were 
insensible,  were  placed  in  hastily-constructed  wooden  shanties  with  sail  roofs. 
To  add  to  their  discomfort,  a  violent  thunder-storm  occurred  which  drenched 
the  interior  of  the  shanties,  and  yet  with  simple  medicinal  treatment  and  the 
use  of  buttermilk  and  animal  broths  only  1  of  the  82  patients  died.  Four 
sailors  who  sickened  with  the  fever  after  the  arrival  of  the  vessel  were  taken 
to  a  dwelling-house,  and  two  of  them  died.  These  facts,  which  were  related 
to  the  New  York  Academy  of  Medicine  at  the  June  meeting  in  1853  by  the 
late  Dr.  John  H.  Griscom,  and  were  published  in  the  Transactions  of  the 
Academy  for  that  year,  strongly  impressed  the  profession  of  New  York  with 
the  importance  of  fresh  air  in  the  treatment  of  typhus  and  typhoid  fevers, 
and  the  knowledge  thus  obtained  has  no  doubt  been  instrumental  in  saving 
many  lives.  But  in  the  treatment  of  children  the  sudden  reduction  of  tem- 
perature and  currents  of  cold  air  should  be  avoided,  for  by  taking  cold  the 
bronchial  catarrh  which  is  ordinarily  present  in  a  mild  form  might  be  aggra- 
vated, or  a  croup  or  pneumonia  might  be  developed. 

Von  Ziemssen  states  that  in  severe  cases  attended  by  feeble  heart-action 
the  patient  should  not  be  allowed  to  move  without  assistance  or  get  out  of 
bed,  for  sudden  heart-failure  and  death  "  frequently  result  from  a  neglect  of 
this  rule  "  {Annual  of  Med.  Sci,  vol.  i,,  1888).  The  occurrence  of  bed-sores 
should  be  guarded  against  by  change  of  position  and  the  use  of  a  soft  mat- 
tress or  water-bag.  In  severe  cases  attended  by  much  prostration  the  patient 
should  not  be  allowed  to  leave  the  bed  until  some  days  after  the  fever  has 
ceased  and  the  strength  is  in  a  measure  restored. 

ProjjJif/laxi's. — The  duty  of  the  physician  does  not  cease  with  the  care  of 
the  patient.  He  should  employ  efficient  measures  to  prevent  the  propagation 
of  the  disease.  Especial  attention  should  be  given  to  the  disinfection  of  the 
excreta.  This  may  be  accomplished  by  adding  six  ounces  of  chloride  of 
lime  to  one  gallon  of  water,  and  mixing  one  quart  of  this  solution  with  each 
fecal  evacuation  and  a  less  quantity  with  each  urinary  discharge.  Crude 
carbolic  acid  (one  part  to  ten  or  fifteen  of  water),  sulphate  of  copper  (one 
part  to  twenty  of  water),  or,  best  of  all,  corrosive  sublimate  (one  part  to  two 
hundred  to  four  hundred  of  water)  may  be  employed  for  the  same  purpose. 
The  disinfected  discharge  should  be  allowed  to  stand  a  few  moments  before 
it  is  emptied  into  the  water-closet,  and  the  closet  should  be  thoroughly  flushed 


470  CEREBROSPINAL  FEVER. 

out.  In  country  practice  great  care  must  be  taken  that  the  discharges  be  not 
emptied  in  such  a  place  that  they  can  by  any  possibility  percolate  into  the 
well  which  supplies  the  drinking  water  to  the  families  or  neighbors.  A  pound 
or  more  of  corrosive  sublimate  in  solution  should  be  sprinkled  in  the  vault, 
and  chloride  of  lime  should  be  dusted  over  the  contents.  The  milk  used  in 
the  family  should  be  sterilized  by  steaming  two  hours  at  a  temperature  of  180° 
to  190°,  or  by  boiling,  and  the  drinking  water  should  be  boiled  or  distilled. 
Care  should  be  taken  to  disinfect  promptly  the  clothing  worn  by  the  patient 
and  the  bedding.  This  may  be  accomplished  by  placing  them  immediately 
when  removed  in  boiling  water  or  by  immersing  them  in  a  solution  of  corro- 
sive sublimate  (one  part  to  one  thousand),  or  carbolic  acid  (one  part  to  fifty), 
or  sulphate  of  copper  or  chloride  of  lime  (one  part  to  one  hundred). 


CHAPTER   IV. 

CEREBEO-SPINAL  FEVEE. 

Definition. — Probably  a  microbic  disease.  It  is  manifested  chiefly  by 
the  occurrence  of  cerebro-spinal  meningitis.  Its  prominent  symptoms  are 
such  as  meningitis  gives  rise  to — to  wit,  fever,  headache,  tonic  contraction 
of  the  muscles  of  the  nucha,  hypersesthesia,  and  neuralgic  pains  in' the  trunk 
and  extremities.  It  is  non-contagious  or  contagious  in  a  very  low  degree, 
and,  as  with  most  of  the  microbic  diseases,  its  victims  are  chiefly  the  young. 
It  is  ordinarily  a  primary  disease,  but  it  sometimes  occurs  as  a  complication 
of  other  acute  as  well  as  chronic  maladies.  It  begins  abruptly  or  without  a 
premonitory  stage,  and  it  is  often  speedily  fatal  from  the  intense  hyperaemia 
of  the  nervous  centres  or  the  severity  of  the  cerebro-spinal  meningitis.  In 
other  cases,  after  weeks  or  months  of  suffering  and  progressive  loss  of  flesh 
and  strength,  death  occurs  in  a  state  of  extreme  prostration.  In  those  who 
recover  convalescence  is  protracted  and  slow. 

This  disease  has  been  designated  by  diff"erent  terms  in  diff"erent  countries, 
as  spotted  fever,  cerebro-spinal  fever,  malignant  purpuric  fever,  typhus  petech- 
ialis,  typhus  syncopalis,  and  febris  nigra,  expressive  of  its  constitutional 
nature.  Those  who  employ  such  terms  regard  it  as  a  general  or  systemic 
disease,  with  the  meningitis  as  its  local  manifestation,  just  as  pharyngitis 
is  a  local  manifestation  of  scarlet  fever  or  bronchitis  of  measles  or  pertussis. 
This  opinion  of  its  nature  receives  sti'ong  support  from  the  clinical  fact  that 
in  severe  forms  of  the  disease  extravasations  of  blood  occur  early  under  the 
skin,  indicating  a  profoundly  altered  state  of  the  blood  and  systemic  infec- 
tion. The  disease  has  also  been  designated  by  terms  expressive  of  its  local 
nature,  as  epidemic  meningitis,  epidemic  cerebro-spinal  meningitis,  typhoid 
meningitis,  malignant  meningitis.  We  will  treat  hereafter  of  the  nature  of 
this  malady,  and  endeavor  to  justify  the  opinion  which  has  led  to  the  use  of 
terms  that  indicate  its  constitutional  character. 

History. — Whether  cerebro-spinal  fever  occurred  previously  to  the  pres- 
ent century  is  uncertain.  If  it  did  it  was  confounded  with  other  diseases. 
Vieussens  in  1805  was  apparently  the  first  who  wrote  a  clear  and  unmistak- 
able description  of  it,  designating  it  "  a  malignant  non-contagious  fever."  He 
described  an  epidemic  of  it  which  appeared  in  G-eneva,  Switzerland,  in  a 
family  of  3  children,  of  whom  2  died  in  twenty-four  hours.  Two  weeks 
later  4  children  in  another  family  died  of  it,  after  an  illness  of  less  than  a 


HISTORY.  471 

day,  and  a  young  man  in  another  house  died  with  similar  symptoms  after  an 
equally  brief  illness,  his  surface  havinfi;  a  deeply  congested  or  violet  appear- 
ance. Iti  these  and  suhse(|uent  cases  the  attack  began  in  the  latter  part  of 
the  day  or  at  night,  and  was  attended  by  vomiting,  violent  headache,  convul- 
sions, dysphagia,  petechi;\3,  and  tonic  contraction  of  the  posterior  muscles  of 
the  neck  and  trunk,  producing  retraction  of  the  head  and  opisthotonos. 
Thirty-three  lost  their  lives  during  this  epidemic,  after  a  sickness  varying 
•from  twelve  hours  to  five  days.  Within  the  next  two  years  epidemics  of 
cerebro-spinal  fever  occurred  in  Bavaria,  Holland,  Germany,  and  at  about 
the  same  time  or  soon  after  in  parts  of  England. 

The  first  American  cases  of  the  disease,  so  far  as  is  now  known,  were  at 
Medfield,  Massachusetts,  in  180G.  From  1806  to  1816  occasional  outbreaks 
of  it  occurred  in  England,  France,  and  America  in  several  localities.  It 
appeared  in  both  Canada  and  the  United  States.  From  1816  to  1828,  so  far 
as  is  now  known,  only  two  epidemics  of  it  occurred,  and  they  were  limited  to 
small  areas  and  were  of  brief  duration.  The  one  was  at  Middletown,  Con- 
necticut, and  the  other  at  Vesoul,  France.  In  1828  it  occurred  in  Trumbull 
county,  Ohio,  in  1830  at  Sunderland,  England,  and  in  1833  at  Naples.  After 
the  Naples  epidemic  a  respite  from  the  disease  appears  to  have  occurred,  in 
both  the  Eastern  and  Western  Hemispheres,  until  1837.  In  that  year  it 
appeared  in  the  South  of  France,  in  and  around  Bayonne,  and  gradually 
extended  to  isolated  localities  over  almost  the  whole  of  France.  It  occurred  at 
this  time  among  troops  in  their  barracks  as  well  as  civilians,  and  in  some  local- 
ities of  the  troops  affected  from  50  to  75  per  cent.  died.  Even  Versailles  and 
Paris  did  not  escape.  During  the  twelve  years  from  1837  to  1849.  France 
suffered  far  more  than  any  other  country  from  this  disease.  It  was  espe- 
cially common  and  fatal  among  the  soldiers  in  many  localities,  and  at  some 
of  the  military  stations  in  France  several  successive  epidemics  occurred.  In 
the  decade  from  1839  to  1849  cerebro-spinal  fever  extended  to  Naples,  the 
Romagna,  Sicily,  Gibraltar,  Algeria,  and  various  places  in  Denmark,  England, 
and  Ireland. 

In  1842  the  United  States  was  again  visited  by  cerebro-spinal  fever  in 
localities  at  a  distance  from  the  seaboard,  and  therefore,  apparently,  not  by 
communication  from  Europe.  In  1842-43  it  occurred  in  Kentucky,  Tennessee, 
Alabama.  Illinois,  Mississippi,  and  Arkansas.  From  1840  to  1850  it  visited 
Montgomery  in  Alabama,  Beaver  county  in  Pennsylvania,  Cayuga  county  in 
New  York,  and  New  Orleans  in  Louisiana.  Between  1850  and  1854  there 
is  no  record  of  its  occurrence  in  either  hemisphere,  but  from  1854  to  1860 
it  ravaged  the  Scandinavian  peninsula  and  caused  more  than  four  thousand 
deaths. 

Since  1860  certain  localities  in  nearly  every  civilized  country  have  been 
severely  visited  by  this  disease.  In  all  these  countries  it  is  justly  regarded 
as  one  of  the  most  fatal  and  important  of  the  epidemic  maladies. 

An  interesting  fact  in  regard  to  these  many  epidemics  on  both  continents, 
which  have  been  reported  by  competent  observers,  is  that  they  have  occurred 
in  isolated  localities  far  apart  and  without  the  least  evidence  of  transportation. 
Cerebro-spinal  fever  has  not,  so  far  as  I  am  aware,  in  any  instance  extended 
from  one  locality  to  an  adjacent  one  in  the  manner  of  contagious  diseases. 
The  cause  of  the  malady  has  evidently  arisen  or  been  created  in  the  places 
where  the  cases  have  occurred,  and  is  not  susceptible  of  transportation  so  as 
to  produce  the  disease  elsewhere.  Cerebro-spinal  fever  resembles  in  this 
respect  the  diseases  due  to  marsh  miasm. 

But  since  1860  this  disease  has  appeared  in  this  country  in  another  phase. 
It  has  become  or  is  being  established — or,  to  use  the  phrase  commonly 
employed  in  medical  literature,  naturalized — in  the  cities  of  the  United  States. 


472  CEREBROSPINAL  FEVER. 

For  some  years  not  a  week  has  passed  without  the  report  of  deaths  from  this 
cause  in  New  York,  Philadelphia,  Jersey  City,  and  Chicago.  It  is  probably 
already  permanently  established  in  Cincinnati,  St.  Louis,  Minneapolis,  New- 
ark, and  San  Francisco,  since  deaths  from  it  have  been  reported  it  these  cities 
during  many  consecutive  weeks. 

In  New  York  City  prior  to  1866  only  4  deaths  occurred  from  what  was 
perhaps  cerebro-spinal  fever,  since  in  1838  2  deaths  were  reported  from 
so-called  spotted  fever,  1  in  1850  and  1  in  1861.  What  was  the  nature  of, 
this  spotted  fever  is  now  a  matter  of  conjecture.  In  1866,  18  patients  died 
of  cerebro-spinal  fever  within  the  city  limits,  and  not  a  year  has  passed  since, 
and  in  the  last  few  years  not  a  week,  without  deaths  from  it.  From  1866  to 
1872  the  annual  deaths  from  this  disease  in  New  York  varied  from  18  to  48. 
Commencing  in  December,  1871,  and  continuing  during  the  first  half  of 
1872,  a  severe  epidemic  occurred,  producing  a  large  mortality.  Many  who 
recovered  permanently  lost  their  hearing  and  some  their  sight  from  the  attack. 
In  this  epidemic  the  physicians  of  New  York  were  fully  aroused  to  the 
importance  of  the  disease  which  was  causing  so  much  suffering,  and  which 
attacked  the  lower  animals,  especially  the  jaded  horses  of  the  city  car-  and 
stage-lines,  not  a  few  of  them  dropping  down  in  harness,  so  suddenly  did  the 
attacks  occur.  In  1872,  782  deaths,  chiefly  of  children,  resulted  from 
cerebro-spinal  fever  within  the  city  limits.  This  epidemic  appeared  to  pro- 
duce a  greater  dissemination  of  the  disease  and  more  firmly  established  it  in 
the  city,  for  since  then  the  annual  deaths  from  it  have  varied  between  97  in 
1878  and  461  in  1881.  In  Philadelphia  cerebro-spinal  fever  began  in  1863, 
causing  49  deaths  in  that  year,  and  it  has  never  been  absent  from  that  city 
since.  Prof.  Stille  states  that  between  1863  and  1882  it  has  caused  2049 
deaths  within  the  city  limits.  In  Philadelphia,  as  in  New  York,  it  has  for 
some  years  produced  a  nearly  uniform  weekly  mortality.  The  prevalence  of 
cerebro-spinal  fever  in  the  United  States  and  its  probable  importance  in  the 
future  may  be  inferred  from  the  fact  that  it  has  recently  occurred  also  in 
Cincinnati,  Minneapolis,  Denver,  Norfolk,  Boston,  Worcester,  New  Haven, 
x\lbany,  Syracuse,  Auburn,  Milwaukee,  Wilmington,  Detroit,  Baltimore, 
Charleston,  Toledo,  Mobile,  Salt  Lake,  Grand  Rapids,  Providence,  Chatta- 
nooga, Hartford,  New  Orleans,  Fall  River,  Richmond,  Knoxville,  and 
Nashville. 

Etiology. — That  this  disease  is  produced  by  a  micro-organism  is  gener- 
ally believed.  Dr.  A.  Frankel  and  other  European  microscopists  have  care- 
fully examined  the  bacteria  found  in  the  blood  and  tissues  of  those  affected 
by  it.  At  a  meeting  of  the  Berlin  Medical  Society,  held  February  12,  1883, 
Herr  Leyden  showed  under  the  microscope  specimens  of  micrococci  found 
in  a  case  of  cerebro-spinal  fever.  They  had  an  oval  shape,  were  mostly  in 
pairs,  and  were  faintly  tremulous.  They  resembled  those  found  in  pneu- 
monia and  erysipelas,  but  Leyden  did  not  think  them  identical.  At  the 
same  meeting  Herr  Baginsky  related  cases  which  seemed  to  show  that  in 
some  instances  the  cause  of  cerebro-spinal  fever  and  that  of  pneumonia  might 
be  identical.^ 

Dr.  V.  0.  Pushkareff,  connected  with  one  of  the  barrack-infirmaries  of 
St.  Petersburg,  states  that  in  five  cases  of  croupous  pneumonia  in  which 
cerebro-spinal  meningitis  occurred  as  a  complication  he  discovered  in  the  pus 
taken  from  the  cerebral  meninges  swarms  of  micrococci  whose  appearance 
under  the  microscope  seemed  identical  with  that  of  Friedlander's  pneumococ- 
cus.  They  were  either  isolated  or  in  groups  of  two,  seldom  in  four,  having 
distinct  capsules,  and  they  were  absent  from  the  fluid  taken  from  the  men- 
inges in  simple  pneumonia.  Pushkareff  was  able  to  cultivate  the  micrococ- 
^  Deutsch.  med.  Wochensckr.,  April  4,  1883. 


ETIOLOGY.  473 

cus  taken  from  the  meningeal  pus,  and  the  cultivated  microbes,  like  their 
parents,  presented  an  appearance  identical  with  that  of  the  pneumococcus.' 
Moreover,  Eberth,  in  a  case  of  meningitis  following  pneumonia,  believes  that 
he  found  the  same  micrococcus  in  the  lungs  and  in  the  liquid  exuded  froni 
the  inflamed  pia  mater.  Frilnkel  also  states  that  he  obtained  from  the  puru- 
lent exudation  in  the  pia  mater,  in  a  case  of  meningitis  occurring  with  pneu- 
monia, a  microbe  resembling  that  in  the  pneumonic  exudation.^ 

From  the  investigations  of  so  many  competent  microscopists,  therefore, 
it  appears  that  the  microbe  found  in  the  exudate  of  the  meninges  in  cerebro- 
spinal fever,  and  which  is  supposed  to  sustain  a  causal  relation  to  this  disease, 
bears  a  close  resemblance  in  form  to  the  pneumococcus,  if  it  be  not  identical 
with  it.  But  we  would  infer,  from  the  fact  that  croupous  pneumonia  is  so 
universal  a  disease  occurring  in  localities  where  there  is  no  cerebro-spinal 
fever,  that  the  cause  of  the  two  must  be  different,  or,  if  there  be  a  form  of 
croupous  pneumonia  which  is  produced  by  the  same  microbe  as  that  of 
cerebro-spinal  fever,  the  pneumonia  which  is  universal  must  have  a  different 
origin.  The  microbic  causation  of  cerebro-spinal  fever  needs  further  inves- 
tigation, which  it  will  doubtless  receive,  before  positive  statements  can  be 
made. 

Among  the  conditions  which  are  favorable  for  the  occurrence  of  cerebro- 
spinal fever,  and  may  therefore  be  regarded  as  predisposing  to  it,  we  may 
mention  the  winter  season.  Statistics  collected  in  Europe  and  the  United 
States  show  that  while  166  epidemics  occurred  in  the  six  months  commencing 
with  December,  only  50  were  in  the  remaining  six  months  of  the  year.  Ac- 
cording to  the  statistics  of  Prof  Hirsch,  which  were  collected  mainly  from 
Central  Europe,  57  epidemics  were  in  winter  or  in  winter  and  spring,  11  in 
spring,  5  between  spring  and  autumn,  4  commenced  in  autumn  and  extended 
into  winter  or  into  winter  and  the  ensuing  spring,  and  6  lasted  the  entire 
year.  I  suspect  that  the  opinion  expressed  by  Prof  Hirsch  is  correct,  that 
the  excess  of  epidemics  in  the  winter  months  is  due  mainly  to  the  greater 
crowding  and  less  ventilation  in  the  domiciles  during  the  cold  than  during 
the  warm  months,  especially  among  European  peasantry.  In  New  York 
Citv,  where  the  state  of  the  domiciles  is  about  the  same  the  year  round, 
the  season  appears  to  exert  little  influence  on  the  prevalence  of  the 
disease. 

The  fact  has  repeatedly  been  observed  that  antihygienic  conditions  increase 
the  liability  to  cerebro-spinal  fever.  Soldiers  in  barracks  and  the  poor  in  tene- 
ment-houses suffer  most  severely  when  the  epidemic  is  prevailing.  In  New 
York  City  the  fact  is  often  remarked  that  multiple  cases  occur  for  the  most 
part  where  obvious  insanitary  conditions  exist,  as  in  apartments  which  are 
unusually  crowded  and  filthy  or  in  tenement-houses  around  which  refuse  mat- 
ter has  collected  or  which  have  defective  drainage.  The  interesting  chart 
prepared  under  the  direction  of  Dr.  Moreau  Morris  for  the  Health  Board 
shows  that  comparatively  few  cases  occurred  in  the  epidemic  of  1872  in  those 
portions  of  the  city  where  the  sanitary  conditions  were  good.  Antihygienic 
conditions  probably  predispose  to  cerebro-spinal  fever  in  the  same  way  that 
they  do  to  other  grave  epidemic  disease,  as,  for  example,  to  Asiatic  cholera, 
whose  ravages  are  chiefly  where  hygienic  requirements  are  most  neglected. 
We  will  presently  relate  striking  examples  which  show  how  foul  air  increases 
the  number  and  malignancy  of  cases.  Insanitary  conditions  not  only  ener- 
vate the  system  and  render  it  more  liable  to  contract  any  prevailing  dis- 
ease, but  probably  promote  the  development  and  activity  of  the  specific 
principle. 

'  Ejen.  klin.  Gazefa,  April  21,  1885. 

^  Deutsch.  nied.  Wochenschr.,  Nov.  13,  1886. 


474  CEBEBBO-SPINAL   FEVEB. 


Is  Cerbbro-Spinal  Fever  Contagious? 

It  is  the  almost  unanimous  opinion  of  those  who  are  most  competent  to 
judge  from  their  observations  that  it  is  either  not  contagious  or  is  contagious 
in  a  very  slight  degree.  It  is  certain  that  the  vast  majority  of  cases  occur 
vrithout  the  possibility  of  personal  communication.  Thus,  in  the  commence- 
ment of  an  epidemic  the  first  patients  are  afiected  here  and  there  at  a  dis- 
tance from  each  other,  often  miles  apart,  and  throughout  an  epidemic  usually 
only  one  is  seized  in  a  family.  Children  may  be  around  the  bedside  of  the 
patient,  passing  in  and  out  of  the  room  without  restriction,  and  yet  we  can 
confidently  predict  that  none  of  them  will  contract  the  malady  if  there  be 
proper  ventilation  and  cleanliness  and  none  of  the  conditions  of  insalubrity 
exist  within  or  around  the  domicile.  Moreover,  when  multiple  cases  occur 
in  a  family  the  disease  begins  at  such  irregular  intervals  in  the  different 
patients  that  there  can  be  little  doubt  in  most  instances  that  it  is  not  com- 
municated from  one  to  the  other,  but,  like  the  fevers  from  marsh  miasm,  is 
produced  by  exposure  to  the  same  morbific  cause,  existing  outside  the  indi- 
viduals, but  within  or  around  the  premises.  Thus,  in  the  Brown  family 
treated  by  the  late  Dr.  John  Gr.  SewelP  of  New  York,  the  first  child  sick- 
ened January  30th,  and  subsequently  the  remaining  five  children  at  intervals 
respectively  of  five,  seven,  eleven,  twenty-five,  and  forty-five  days.  That  so 
many  were  afi'ected  in  one  family  was  attributed  by  the  doctor  to  the  filthy 
state  of  the  house  and  the  bad  plumbing,  which  allowed  the  free  escape  of 
sewer-gas.  In  my  own  practice,  in  the  family  which  sufi"ered  the  most 
severely  of  all,  four  patients  were  seized  in  succession,  and  yet  I  could  see 
no  evidence  of  contagiousness.  The  family  occupied  a  small  plot  of  ground, 
not  more  than  thirty  feet  by  one  hundred,  and  their  occupation  was  to  pre- 
pare for  the  meat-market  what  is  known  as  head-cheese.  They  lived  on  the 
second  floor  of  the  two-story  wooden  house  in  which  the  work  was  carried 
on.  At  the  time  of  the  sickness  the  shop  contained  four  hundred  heads  of 
animals  from  which  the  meat  for  the  cheese  was  obtained,  and  it  was  evident 
that  decaying  animal  matter  was  present.  The  occupation  and  surroundings 
of  this  family  afl'orded  sufficient  explanation  of  the  fact  that  so  many  were 
attacked.  Two  workmen  contracted  the  disease  within  about  one  week  of 
each  other,  and  were  removed  from  the  house.  On  January  26th,  four 
weeks  after  the  commencement  of  the  malady  in  the  workman  who  was  first 
attacked,  one  child  sickened  with  it,  and  died  on  February  1st.  Fifteen 
days  subsequently  (February  16th)  a  second  child  was  attacked,  and,  after 
a  tedious  sickness,  finally  recovered.  The  long  and  irregular  intervals 
between  these  cases  indicate  that  the  disease  was  not  contracted  by  one 
from  the  other.  The  important  factor  in  causing  so  severe  an  outbreak 
of  cerebro-spinal  fever  in  this  family  was  probably  the  miasm  produced  by 
such  an  occupation  in  the  house  where  the  family  resided,  with  neglect  of 
ventilation  and  cleanliness. 

But  the  strongest  evidence  that  cerebro-spinal  fever  is  either  noncon- 
tagious or  very  feebly  contagious  is  afforded  by  the  fact  that  a  large  majority 
of  the  cases  occur  singly  in  families,  although  there  is  no  isolation  of  the 
patients.  The  following  are  the  statistics  relating  to  this  point  in  the  cases 
which  I  have  observed  since  cerebro-spinal  fever  commenced  in  New  York, 
in  1871:  Single  cases  occurred  in  seventy  families  ;  dual  cases  occurred  in 
nine  families ;  three  cases  occurred  in  one  family,  and  four  cases  in  one 
family.  Intercourse  with  the  sick-room  was  unrestricted  in  all  these  fami- 
lies, so  that  children  frequently  went  out  and  in,  and  sometimes  assisted  in 
the  nursing. 

1  Medical  Record,  July,  1872. 


IS  CEREBROSPINAL  FEVER  CONTAGIOUS*  475 

The  most  striking  example  of  apparent  contagiousness  which  has  come 
to  my  knowledge  was  related  by  Hirsch,  and  is  quoted  by  Von  Ziemssen. 
A  young  man  sickened  with  cerebro-spinal  fever  on  February  8th.  The 
woman  who  nursed  him  returned  to  her  home  in  a  neighboring  village,  and 
there  died  of  the  same  disease  on  February  26th.  To  her  funeral  mourners 
came  from  a  neighboring  township,  and  after  their  return  home  three  of  them 
died  with  the  same  disease — one  within  twenty-four  hours,  another  on  March 
4th,  and  a  third  on  the  7th. 

In  one  instance  only  in  my  practice  did  the  facts  point  to  contagiousness. 
A  boy  of  twelve  years  died  of  cerebro-spinal  fever,  and  was  buried  on  Satur- 
day or  Sunday.  On  ^Monday  the  mother  washed  the  linen  and  bedclothes  of 
the  boy,  which  had  accumulated  and  were  in  a  very  filthy  state.  Two  days 
subsequently  she  was  attacked,  and  her  infant  soon  afterward,  both  perishing. 
The  state  of  the  bedding  and  apartments  in  this  house,  as  seen  by  myself, 
was  such  as  would  be  likely  to  concentrate  and  intensify  the  poison,  render- 
ing it  peculiarly  active,  for  they  were  very  dirty,  and  the  mother,  exhausted 
by  her  long  and  incessant  watching  and  lack  of  sleep,  and  depressed  by  grief, 
rendered  her  system  more  liable  to  the  disease  by  her  self-imposed  duties  on 
the  day  after  the  funeral.  One  in  her  state  of  mind  and  body,  standing  for 
a  considerable  part  of  a  day  over  the  bedclothes  and  bedding  of  her  child 
soiled  by  the  excreta,  would  certainly  be  in  a  condition  to  contract  the  disease 
if  it  were  contagious  in  any,  even  in  the  lowest,  degree.  In  the  present  state 
of  our  knowledge,  therefore,  upon  this  important  subject  the  evidence  leads 
us  to  believe  that  with  proper  ventilation  and  cleanliness  and  the  suppression 
of  antihygienic  conditions  in  an  infected  domicile  those  who  are  in  a  good 
state  of  body  and  mind  will  not  contract  the  disease,  but  in  the  opposite  con- 
ditions it  is  not  improbable  that  the  poison  may  be  so  intensified,  and  the  sys- 
tem rendered  so  liable  to  receive  the  prevailing  malady  through  impairment 
of  the  general  health  and  diminished  resisting  power,  that  cerebro-spinal 
fever  may,  though  rarely,  be  communicated  either  by  the  breath  of  the  patient 
or  by  exhalations  from  his  surface  or  from  soiled  clothing. 

The  occurrence  of  cerebro-spinal  fever  in  certain  of  the  lower  animals  is 
a  very  interesting  fact,  especially  as  the  question  is  sometimes  asked  whether 
it  may  not  be  communicated  from  them  to  man.  In  the  epidemic  of  1811  in 
Vermont,  according  to  Dr.  Gallop,  even  the  foxes  seemed  to  be  afi'ected,  so 
that  they  were  killed  in  numbers  near  the  dwellings  of  the  inhabitants. 
Cerebro-spinal  fever,  previously  unknown  in  New  York  City,  began,  as  stated 
above,  in  1871,  among  the  horses  in  the  large  stables  of  the  city  car-  and 
stage-lines,  disabling  many  and  proving  very  fatal,  while  among  the  people 
the  epidemic  did  not  properly  commence  till  January,  1872,  although  a  few 
isolated  cases  occurred  in  December  of  1871.  No  evidence  exists,  so  far  as 
I  am  aware,  that  the  disease  was  in  any  instance  communicated  by  these 
animals  to  man.  Those  who  had  charge  of  the  infected  horses,  as  the  veter- 
inary surgeons  and  stable-men,  did  not  contract  the  malady,  certainly  not 
more  frequently  than  others  who  were  not  so  exposed.  Although  we  may 
admit  slight  contagiousness,  there  has  probably  been  no  well-established 
example  of  the  transmission  of  cerebro-spinal  fever  from  animals  to  man. 
If  transmission  ever  does  occur,  it  is  so  rare  that  practically  no  account  need 
be  made  of  it. 

In  some  instances  we  are  able  to  discover  an  exciting  cause.  An  indi- 
vidual whose  system  is  affected  by  the  epidemic  influence  may  perhaps  escape 
by  a  quiet  and  regular  mode  of  life,  but  if  there  be  any  unusual  excitement 
or  if  the  normal  functional  activity  of  the  system  be  sei'iously  disturbed,  an 
outbreak  of  the  malady  may  occur.  Among  the  exciting  causes  we  may 
mention  overwork  and  lack  of  sleep,  fatigue,  mental  excitement,  depressing 


476  CEREBROSPINAL  FEVER. 

emotions,  prolonged  abstinence  from  food  followed  by  over-eating,  and  the 
use  of  indigestible  and  improper  food.  Thus,  in  once  instance  among  my 
cases  a  delicate  young  woman,  at  the  head  of  one  of  the  departments  in  a 
well-known  Broadway  store,  was  anxious  and  excited  and  her  energies  over- 
taxed at  the  annual  reopening.  Within  a  day  or  two  subsequently  the  disease 
began.  Another  patient,  a  boy,  was  seized  after  a  day  of  unusual  excitement 
and  exposure,  having  in  the  mean  time  bathed  in  the  Hudson  when  the 
weather  was  quite  cool.  Those  children  have  seemed  to  me  especially  liable 
to  be  attacked  who  were  subjected  to  the  severe  discipline  of  the  public 
schools,  returning  home  fatigued  and  hungry,  and  eating  heartily  at  a  late 
hour.  In  one  instance  which  I  observed  a  school-girl  ten  years  of  age 
returned  from  school  excited  and  crying  because  she  had  failed  in  her  exami- 
tion  and  had  not  been  promoted.  In  the  evening,  after  she  had  closely  studied 
her  lessons,  the  fever  began  with  violent  headache. 

Dr.  Frothingham  ^  writes  as  follows  of  the  brigade  in  which  cerebro-spinal 
fever  occurred  in  the  Army  of  the  Potomac  :  "  Under  General  Butterfield,  a 
stern  disciplinarian,  ....  the  men  were  drilled  to  the  full  extent  of  their 
powers,  often  to  exhaustion.  I  did  not  at  the  time  recognize  this  as  the 
cause  of  the  disease  in  question,  but  I  learnt  that  in  the  present  epidemic  in 
Pennsylvania  the  attack  generally  follows  unusual  exertion  and  exposure  to 
cold." 

Many  observers  have  noticed  that  bodily  fatigue  and  mental  depression 
and  excitement  are  important  factors  in  causing  an  attack  of  cerebro-spinal 
fever  when  this  disease  is  epidemic.  Dr.  Gallop,  in  his  history  of  cerebro- 
spinal fever  as  it  occurred  during  the  war  of  1812,  directs  attention  to  the 
severity  of  the  cases  among  the  troops  under  General  Dearborn,  who  were 
fatigued  by  marches  and  greatly  dispirited  on  account  of  a  repulse  which 
they  had  sustained  from  the  British.  In  one  case  which  occurred  in  my 
practice  a  boy,  six  years  and  eleven  months  of  age,  was  punished  at  school 
and  came  home  with  cheeks  flushed  from  excitement,  the  excitement  con- 
tinuing during  the  ensuing  night.  On  the  following  day  cerebro-spinal  fever 
began  with  vomiting  and  chilliness,  the  attack  ending  fatally  on  the  seven- 
teenth day.  In  another  case,  which  was  related  to  me  by  the  mother  and 
the  physician,  the  patient,  a  bright  girl  twelve  years  of  age,  of  nervous  tem- 
perament and  forward  in  her  studies,  had  been  much  excited  in  competing 
for  a  prize  in  athletic  exercises.  In  the  evening  of  the  same  day  a  violent 
thunder-storm  occurred,  and  after  a  severe  clap  she  started  from  bed  pallid 
and  excited,  and  expressed  the  belief  that  she  had  been  struck  by  lightning. 
The  disease  began  immediately  after  this,  and  terminated  fatally  on  the  fifth 
day. 

Secondary  Cerebbo-Spinal  Fever. 

Fagge^  says :  "  Several  observers  have  found  that  during  or  just  after  an 
epidemic  of  cerebro-spinal  fever  meningitis  has  presented  itself  with  unusual 
frequency  as  a  complication  of  other  acute  diseases."  He  mentions  croupous 
pneumonia,  pleurisy,  acute  tonsillitis,  and  scarlatinal  nephritis  as  the  diseases 
upon  which  it  is  very  liable  thus  to  supervene.  In  this  respect  cerebro-spinal 
fever  resembles  diphtheria  and  erysipelas,  which  we  know  are.  very  liable  to 
occur  in  those  who  are  suffering  from  other  diseases. 

A  striking  example  of  cerebro-spinal  fever  occurring  as  a  complication 
was  recently  seen  by  me  in  consultation.  A  child  of  about  ten  years  with 
typical  typhoid  fever  had  rea,;hed  about  the  twelfth  day  of  a  mild  form  of 

'  American  Medical  Times,  April  30,  1864. 
^  Practice  of  Medicine,  vol.  i.  p.  614. 


SECONDARY  CEREBROSPINAL  FEVER. 


477 


the  disease.  The  initial  headache  had  ceased,  there  was  no  delirium,  the 
temperature  was  but  moderately  elevated,  and  no  doubt  had  arisen  in  the 
mind  of  the  experienced  physician  in  attendance  that  the  disease,  which 
presented  the  characteristic  signs,  would  terminate  favorably  after  the  usual 
time.  Suddenly  violent  headache  occurred,  the  temperature  rose  to  103°  or 
104°  F.,  and  in  a  few  days  fatal  coma  terminated  the  case.  Another  disease 
in  which  T  have  seen  cerebro-spinal  fever  occur  as  a  complication  is  gastro- 
intestinal catarrh. 

Sex. — It  is  stated  by  certain  writers  that  more  males  are  affected  than 
females.  The  statistics  of  hospitals  and  camps  show  this,  for  men  subject 
to  lives  of  hardship  are  especially  liable  to  be  attacked  ;  but  in  family  prac- 
tice, in  which  a  large  proportion  of  the  patients  are  children,  the  number  of 
males  and  females  is  about  equal.  Thus,  in  105  cases  occurring  chiefly  in 
my  practice,  but  a  few  of  them  in  the  practice  of  two  other  physicians  of 
this  city,  I  find  that  59  were  males  and  46  females  :  91  of  these  were  children. 
In  New  York  City,  during  the  epidemic  of  1872,  905  cases  of  cerebro-spinal 
fever  were  reported  to  the  Board  of  Health  between  January  1  and  Novem- 
ber 1,  and  of  these  484  were  males  and  421  females.  Dr.  Sanderson's 
statistics  of  the  epidemic  in  the  provinces  around  the  Vistula,  the  cases 
being  chiefly  children,  give  also  but  a  slight  excess  of  males.  Probably,  there- 
fore, in  the  same  conditions  and  occupations  of  life  the  sexes  are  equally 
liable  to  contract  this  malady,  and  the  excess  of  males  is  due  to  the  fact  that 
they  lead  a  more  irregular  life  and  are  more  subject  to  privations  and 
exposures.  That  soldiers  on  duty  in  barracks  have  been  attacked  while 
families  in  the  vicinity  escape,  thus  increa.sing  the  proportion  of  male  cases, 
must  be  due  to  irregularities,  hardships,  and  perhaps  the  lack  of  sanitary 
regulations  in  their  mode  of  life. 

Age. — My  observations  lead  me  to  think  that  the  younger  the  patient 
the  more  frequently  is  cerebro-spinal  fever  overlooked  and  some  other  disease 
diagnosticated.  Nevertheless,  all  published  statistics,  so  far  as  I  am  able  to 
ascertain,  show  that  a  large  proportion  of  cases  occur  under  the  age  of  five 
years,  and  that  a  larger  proportion  of  fatal  cases  are  in  the  first  year  of  life 
than  in  any  other  year.  Thus,  in  New  York  City  the  ages  of  those  who  died 
from  this  disease  in  1883  were  as  follows  : 


Under  1  year 57 

From    1  to    2  years 31 

From    2  to    3     " 22 

From    3  to    4     " 12 

From    4  to    5     "      9 

From    5  to  10     "      37 

From  10  to  15     " 18 

From  15  to  20     " 15 


From  20  to  25  years 7 

From  25  to  30     "      3 

From  30  to  35     "      4 

From  35  to  40     "      3 

From  40  to  45     "      1 

From  45  to  50     "      2 

From  50  to  60     '•      1 

Over  60  years 1 


The  following  are  the  statistics  of  the  New  York   Health  Board  relating  to 
the  ages  of  the  cases  during  the  epidemic  of  1872: 


Under  1  year 125 

From   1  to    5  years 336 

From   5  to  10     "        204 

From  10  to  15     "        106 


From  15  to  20  years 54 

From  20  to  30     "        79 

Over  30  years 71 

Total 975 


In  the  cases  which  occurred  in  my  own  practice,  and  in  a  few  cases  in  the 
practice  of  other  physicians  added  to  mine,  I  find  that  the  ages  were  as 
follows : 


478 


CEREBROSPINAL  FEVER. 


Under  1  year 16 

From   1  to    3  years 27 

From   3  to    5      "       25 

From   o  to  10      "       20 


From  10  to  15  years 10 

Over  15  years 15 

Total 113 


In  my  practice,  therefore,  three-fourths  of  the  cases  have  been  under  the 
age  of  ten  years  ;  and  the  statistics  of  epidemics  in  other  localities  correspond 
with  mine  in  giving  a  large  excess  of  cases  in  childhood.  Thus,  Dr.  Sander- 
son, in  examining  the  records  of  deaths  in  one  epidemic,  ascertained  that  218 
had  perished  under  the  age  of  fourteen  years,  and  only  17  above  that  age ; 
and  although  this  does  not  show  the  exact  ratio  of  children  to  adults  in  the 
entire  number  of  cases,  it  is  evident  that  the  children  were  greatly  in  excess. 

The  more  advanced  the  age  after  the  tenth  year,  the  less  the  liability  to 
this  malady,  so  that  very  few  who  have  passed  the  thirty-fifth  year  are 
attacked,  and  old  age  possesses  nearly  an  immunity.  In  New  York  City,  in 
which,  as  T^e  have  seen,  cerebro-spinal  fever  has  been  occurring  since  1871, 
only  two  cases  have  come  to  my  knowledge  which  had  passed  the  fortieth 
year.  The  age  of  one  was  forty-seven,  and  of  the  other  sixty-three  years. 
But  nearly  every  year  the  statistics  of  the  Health  Board  show  that  one  or 
two  old  people  have  died  of  this  disease. 

Not  a  few  cases  occur  in  this  city  in  infants  of  the  age  of  three  or  four 
months.  An  infant  of  four  months  died  of  cerebro-spinal  fever  in  the  New 
York  Infant  Asylum,  the  nature  of  the  disease  not  being  known  until  it  was 
revealed  by  the  autopsy. 

Symptoms. — During  the  prevalence  of  cerebro-spinal  fever  cases  now  and 
then  occur  in  which  the  symptoms  are  mild  and  transient  and  the  health  is 
soon  fully  restored.  It  seems  proper  to  regard  some,  at  least,  of  these  as 
genuine  but  aborted  forms  of  the  disease.  The  following  cases  which  occur- 
red in  my  practice  may  be  cited  as  examples  : 

A  boy  eight  years  of  age,  previously  well,  was  taken  with  headache  and 
vomiting,  attended  by  moderate  fever,  on  April  2,  1872.  The  evacuations 
were  regular,  and  no  local  cause  of  the  attack  could  be  discovered.  On  the 
following  day  the  symptoms  continued,  except  the  vomiting,  but  he  seemed 
somewhat  better.  On  April  4th  the  fever  was  more  pronounced,  and  in  the 
afternoon  he  was  drowsy  and  had  a  slight  convulsion.  The  forward  move- 
ment of  the  head  was  apparently  somewhat  restrained.  On  the  6th  the 
symptoms  had  begun  to  abate,  and  in  about  one  week  from  the  commence- 
ment of  the  attack  his  health  was  fully  restored. 

A  boy  aged  six  was  well  till  the  second  week  in  May,  1872,  when  he 
became  feverish  and  complained  of  headache.  At  my  first  visit,  on  May 
14th,  he  still  had  headache,  with  a  pulse  of  112.  The  pupils  were  sensitive 
to  light,  but  the  right  pupil  was  larger  than  the  left.  The  bromide  and  iodide 
of  potassium  were  prescribed,  with  moderate  counter-irritation  behind  the 
ears.  The  headache  and  fever  in  a  few  days  abated,  the  equality  of  the 
pupils  was  restored,  and  within  a  little  more  than  one  week  from  the  com- 
mencement of  the  disease  he  fully  recovered. 

These  cases  occurred  when  the  epidemic  of  1872  was  at  its  height ;  but 
if  the  symptoms  are  so  mild  and  the  duration  of  the  disease  short  as  in  these 
two  cases,  the  diagnosis  must  sometimes  be  doubtful.  Observei's  in  different 
epidemics  report  similar  cases,  and  as  the  symptoms,  so  far  as  they  appeared 
in  my  patients,  seemed  charcteristic,  I  have  not  hesitated  to  regard  them  as 
genuine  but  aborted  cases.  On  such  patients  the  epidemic  influence  acts  so> 
feebly  or  their  ability  to  resist  it  is  so  great  that  they  escape  with  a  short  and 
trivial  ailment. 

Occasionally  also  during  the  progress  of  an   epidemic  we  meet  patients 


MODE  OF  COMMENCEMENT.  479 

who  present  more  or  fewer  of  the  characteristic  symptoms,  but  in  so  mild  a 
form  that  they  are  never  seriously  sick  and  never  entirely  lose  their  appetite, 
but  the  disease,  instead  of  aborting,  continues  about  the  usual  time. 

Thus,  on  January  4,  1873,  I  was  called  to  a  girl  aged  thirteen  who  had 
been  seized  with  headache,  Ibllowcd  by  vomiting,  in  the  last  week  in  Decem- 
ber. During  a  period  of  six  to  eight  weeks,  or  till  nearly  March  1st,  she  had 
the  following  symptoms :  daily  paroxysmal  headache,  often  most  severe  in 
the  forenoon ;  neuralgic  pain  in  the  left  hypochondrium,  and  sometimes  in 
the  epigastric  region  ;  pulse  and  temperature  sometimes  nearly  normal,  and 
at  other  times  accelerated  and  elevated,  both  with  daily  variations  ;  inequality 
of  the  pupils,  the  right  being  larger  than  the  left  during  a  portion  of  the 
sickness.  The  patient  was  never  so  ill  as  to  keep  the  bed,  usually  sitting 
quietly  during  the  day  in  a  chair  or  reclining  on  a  Igunge,  and  she  never 
fully  lost  her  appetite.  Quinine  had  no  appreciable  effect  on  the  fever  or 
paroxysms  of  pain. 

There  can,  in  my  opinion,  be  little  doubt  that  this  girl  was  affected  by  the 
epidemic,  but  so  mildly  that  there  was,  for  a  considerable  time,  much  uncer- 
tainty in  the  diagnosis. 

Cases  like  these,  in  which  the  disease  is  so  feebly  developed  that  the 
patient  is  never  seriously  sick,  though  unimportant  pathologically,  must  be 
recognized  in  a  treatise  on  cerebro-spinal  fever. 

Mode  of  Commencement. — Cerebro-spinal  fever  rarely  begins  in  the 
forenoon  after  a  night  of  quiet  and  sound  sleep.  In  the  cases  which  I 
observed  in  the  severe  and  fatal  epidemic  of  1872,  and  in  the  36  cases  of 
which  I  have  records  observed  since  1872,  the  commencement  was  almost 
without  exception  between  midday  and  midnight.  The  fact  that  this  disease 
does  not  commence  after  the  repose  of  night  till  several  hours  of  the  day 
have  passed  shows  the  propriety  and  need  of  enjoining  a  quiet  and  regular 
mode  of  life,  free  from  excitement  and  with  sufficient  hours  of  sleep,  dur- 
ing the  time  in  which  the  epidemic  is  prevailing. 

The  commencement  is  usually  without  premonitory  stage  and  sudden 
— unlike,  therefore,  the  beginning  of  other  forms  of  meningitis,  which  come 
on  gradually  and  are  preceded  by  symptoms  which,  if  rightly  interpreted, 
direct  attention  to  the  cerebro-spinal  system.  Exceptionally  certain  premo- 
nitions occur  for  a  few  hours  or  days  before  the  advent  of  the  disease,  such 
as  languor,  chilliness,  etc.  3Iild  cases  more  frequently  begin  gradually  and 
with  certain  premonitions  than  severe  cases.  The  ordinary  mode  of  com- 
mencement is  as  follows  :  The  patient  is  seized  with  vomiting,  headache,  and 
perhaps  a  chill  or  chilliness,  so  that  there  is  a  sudden  change  from  perfect 
health  to  a  state  of  serious  sickness.  Rigor  or  chilliness  is  a  common  initial 
symptom,  especially  in  adult  patients.  One  patient,  an  adult  female,  had 
three  or  four  chills  of  considerable  severity  in  the  commencement  of  the 
attack.  Children  often  have  clonic  convulsions  in  place  of  the  chill  or  imme- 
diately after  it,  partial  or  general,  slight  or  severe.  Stupor  more  or  less  pro- 
found, or  less  frequently  delirium,  succeeds.  In  the  gravest  cases  semi-coma 
occurs  within  the  first  few  hours,  in  which  patients  are  with  difiiculty  aroused, 
or  profound  coma,  which,  in  spite  of  prompt  and  appropriate  treatment,  is 
speedily  fatal.  Those  thus  stricken  down  by  the  violent  onset  of  the  disease 
if  aroused  to  consciousness  complain  of  severe  headache,  with  or  without  or 
alternating  with  equally  severe  neuralgic  pains  in  some  part  of  the  trunk  or  in 
one  of  the  extremities.  The  pain  frequently  shifts  from  one  part  to  another. 
Among  the  eai'ly  symptoms  of  cerebro-spinal  fever  are  those  which  pertain 
to  the  eye.  The  pupils  are  dilated  or  less  frequently  contracted,  and  they 
respond  feebly  or  not  at  all  to  light  if  the  attack  be  severe  or  dangerous ; 
often  they  oscillate,  and  occasionally  one  is  larger  than  the  other.     Vomiting 


480  CEREBROSPINAL  FEVER. 

with  little  apparent  nausea,  and  often  projectile,  is  common  in  the  commence- 
ment of  cerebro-spinal  fever.  It  occurred  as  an  early  symptom  in  51  of 
56  cases  observed  by  Dr.  Sanderson.  In  97  cases  occurring  in  New  York, 
most  of  them  observed  by  myself,  but  a  few  of  them  related  to  me  by  the 
late  Dr.  John  Gr.  Sewall,  vomiting  occurred  as  an  early  symptom  in  68  cases. 
Its  absence  on  the  first  day  was  recorded  in  only  3  cases,  while  in  the  remain- 
ing 27  patients  the  records  of  the  first  day  make  no  mention  of  its  presence 
or  absence.  It  was  probably  present  in  most  of  these  27  cases  as  one  of  the 
first  symptoms. 

Since  the  epidemic  of  1872,  in  examining  patients,  now  numbering  thirty- 
six,  as  has  been  already  stated,  I  have  made  careful  inquiry  in  regard  to  the 
mode  of  commencement,  and  with  only  two  or  three  exceptions  either  the 
previous  health  had  been  good,  or,  if  symptoms  of  ill-health  antedated  the 
cerebro-spinal  fever,  they  were  due  to  some  ailment  entirely  distinct  from  this 
disease.  In  a  boy  four  and  a  half  years  of  age,  living  in  Broadway,  it  was 
stated  to  me  that  the  cerebro-spinal  fever  came  on  gradually  with  pains  in  the 
head  and  elsewhere  :  this  case  was  mild  throughout  and  the  patient  was  never 
in  imminent  danger.  In  nearly  all  the  cases,  if  the  patients  were  at  home  and 
under  observation,  the  exact  moment  of  the  beginning  of  the  disease  could 
be  stated.  Thus,  a  man  aged  twenty-eight  returned  from  his  work  at  mid- 
day, April  23,  1883,  in  good  health  and  cheerful,  ate  a  hearty  meal  at  twelve 
M.,  and  at  one  P.  M.  had  a  chill,  with  intense  headache  and  severe  vomiting. 
Minute  red  points  appeared  on  his  face  after  vomiting,  from  capillary  extrav- 
asations. In  this  case  the  interesting  fact  was  observed  of  a  cessation  of 
the  symptoms,  so  that  on  the  24th  and  25th,  being  free  from  pain,  he  went 
to  Brooklyn.  On  the  26th,  however,  the  symptoms  returned.  He  had  pains 
in  the  head,  back,  and  extremities,  and  was  seriously  sick.  Occasional  remis- 
sions, so  that  very  grave  symptoms  become  mild  for  a  time  and  then  return 
in  full  severity,  as  well  as  distinct  intermissions,  as  in  this  case,  have  been  fre- 
quently noticed  by  observers  in  different  epidemics.  A  little  girl,  previously 
entirely  well,  was  slightly  punished  on  June  11,  1882 ;  immediately  she 
vomited  and  seemed  quite  sick ;  by  kind  nursing  on  the  part  of  the  mother 
she  became  better,  so  that  on  the  12th  she  had  some  appetite  and  went  out. 
On  the  13th  cerebro-spinal  fever  began,  with  a  temperature  of  103°  F.,  and 
its  course  was  tedious.  A  robust  girl,  aged  thirteen,  vivacious  and  cheer- 
ful, went  as  usual  in  the  morning  to  one  of  the  public  schools  entirely  well. 
Before  the  school  was  dismissed  she  returned  home  crying  on  account  of 
dizziness  and  violent  pain  in  the  top  of  her  head,  in  her  knees,  and  in  the 
calves  of  the  legs.  The  case  was  attended  by  Prof.  Alonzo  Clark,  Prof. 
Knapp,  and  myself,  and  was  fatal  after  four  and  a  half  weeks.  A  boy  aged 
ten  returned  from  another  public  school  in  a  similar  manner,  having  gone 
to  it  in  the  morning  in  apparently  perfect  health. 

We  may  therefore  summarize  as  follows  the  symptoms  which  commonly 
attend  the  commencement  of  cerebro-spinal  fever :  violent  pain  in  some  part 
of  the  head,  and  sometimes  also  in  the  trunk  or  limbs,  vomiting,  a  chill  or 
chilliness,  clonic  convulsions,  dizziness,  dilated,  sluggish,  or  altered  pupils, 
fever  of  greater  or  less  intensity  according  to  the  severity  of  the  attack,  heat 
of  head,  and  in  most  patients  heat  of  the  surface  generally.  If  the  disease 
be  of  a  severe  and  dangerous  type,  these  symptoms  are  frequently  followed 
within  a  few  hours  by  delirium,  semi-coma,  or  coma. 

Nervous  System. — Since  in  cerebro-spinal  fever  extensive  and  severe 
inflammation  of  the  cerebral  and  spinal  meninges  occurs,  with  more  or  less 
congestion  of  the  brain  and  spinal  cord — lesions  which  we  will  consider  here- 
after— we  should  expect  that  this  disease  would  be  attended  by  severe  and 
dangerous  symptoms,  inasmuch  as  the  cerebro-spinal  axis  exerts  such  a  con- 


MODE  OF  COMMENCEMENT.  481 

trolling  influence  upon  the  functions  of  the  body.  Also  we  should  expect 
that  the  symptoms  would  vary  according  to  the  portion  of  the  meninges 
which  happens  to  be  most  severely  inflamed.  There  is,  indeed,  variation  in 
symptoms  according  to  the  extent  and  intensity  of  the  meningitis  and  the 
degree  in  which  the  cerebro-spinal  axis  is  congested  or  implicated,  but  certain 
symptoms  occur  in  all  or  nearly  all  cases,  and  as  they  are  characteristic  they 
render  diagnosis  easy. 

Pain,  already  described  as  an  initial  symptom,  continues  during  the  acute 
period  of  the  malady.  It  is  ordinarily  severe,  eliciting  moans  from  the 
sufi'erer,  but  its  intensity  varies  in  different  patients.  Its  most  frequent  seat 
is  the  head,  and  the  location  of  the  cephalalgia  varies  in  diff'erent  patients  and 
in  the  same  patient  at  diff'erent  times.  One  refers  it  to  the  top  of  the  head, 
another  to  the  occiput,  and  another  to  the  frontal  region,  and  the  same  patient 
at  diff'erent  times  may  complain  of  all  these  parts.  The  pain  is  described  as 
sharp,  lancinating,  or  boring.  It  is  also  common  in  the  neck,  especially  in 
the  nucha,  the  epigastrium,  the  umbilical  and  lumbar  regions,  along  the  spine 
(rachialgia),  and  in  the  extremities,  where  it  shifts  from  one  part  to  another. 
It  is  more  common  and  persistent  in  the  head  and  along  the  spine  than  else- 
where. The  patient,  if  old  enough  to  speak  and  not  delirious  or  too  stupid, 
often  exclaims,  "  Oh  my  head  !"  from  the  intensity  of  his  suff'ering,  but  after 
some  moments  complains  equally  of  pain  in  some  other  part,  while  perhaps 
the  headache  has  ceased  or  is  milder.  In  a  few  instances  the  headache  is 
absent  or  is  slight  and  transient,  while  the  pain  is  severe  elsewhere.  After 
some  days  the  pain  begins  to  abate,  and  by  the  close  of  the  second  week  is 
much  less  pronounced  than  previously.  Vertigo  occurs  with  the  headache, 
so  that  the  patient  reels  in  attempting  to  stand  or  walk.  I  have  stated  above 
that  vertigo  may  be  a  prominent  initial  symptom,  as  in  the  girl  of  thirteen 
years  who  suddenly  became  sick  in  the  public  school  which  she  was  attend- 
ing, and  reached  her  home  with  difficulty  on  account  of  the  headache  and 
dizziness.  Contributing  to  the  unsteadiness  of  the  muscular  movements  is  a 
notable  loss  of  flesh  and  strength,  which  occurs  early  and  increases. 

The  state  of  the  patient's  mind  is  interesting.  It  is  well  expressed  in 
ordinary  cases  by  the  term  apathy  or  indifference,  and  between  this  mental 
state  and  coma  on  the  one  hand  and  acute  delirium  on  the  other  there  is 
every  grade  of  mental  disturbance.  Some  patients  seem  totally  unconscious 
of  the  words  or  presence  of  those  around  them,  when  it  subsequently 
appears  that  they  understood  what  was  said  or  done.  Delirium  is  not  infre- 
quent, especially  in  the  older  children  and  in  adults.  Its  form  is  various, 
most  frequently  quiet  or  passive,  but  occasionally  maniacal,  so  that  forcible 
restraint  is  required.  It  sometimes  resembles  intoxication  or  hysteria,  or  it 
may  appear  as  a  simple  delusion  in  regard  to  certain  subjects.  Thus,  one 
of  ray  patients,  a  boy  of  five  yeai's,  appeared  for  the  most  part  rational, 
protruding  his  tongue  when  requested,  and  ordinarily  answering  questions 
correctly ;  but  he  constantly  mistook  his  mother — who  was  always  at  his 
bedside — for  another  person.  Severe  active  delirium  is  commonly  pi-eceded 
by  intense  headache.  In  favorable  cases  the  delirium  is  usually  short,  but 
in  the  unfavorable  it  often  continues  with  little  abatement  till  coma  super- 
venes. 

On  account  of  the  pain  and  the  disordered  state  of  the  mind  patients 
seldom  remain  quiet  in  bed,  unless  they  are  comatose  or  the  disease  be  mild 
or  so  far  advanced  that  muscular  movements  are  difficult  from  weakness. 
In  severe  cases  they  ai'e  ordinarily  quiet  for  a  few  moments,  as  if  slumbering, 
and  then,  aroused  by  the  pain,  they  roll  or  toss  from  one  part  of  the  bed  to 
another.  One  of  my  patients,  a  boy  of  five  years,  repeatedly  made  the  entire 
circuit  of  the  bed  during  the  spells  of  restlessness.  In  mild  cases  or  cases 
31 


482  CEREBROSPINAL  FEVER. 

attended  by  less  headache  or  mental  disturbance  patients  are  quiet,  usually 
with  their  eyes  closed  unless  when  disturbed. 

Hyperaesthesia  of  the  surface  is  another  common  symptom.  Few  patients, 
not  comatose,  are  free  from  it  during  the  first  weeks,  and  it  materially  increases 
the  sufiering.  Friction  upon  the  surface,  and  even  slight  pressure  with  the 
fingers  upon  certain  parts,  extort  cries.  Gently  separating  the  eyelids  for  the 
purpose  of  inspecting  the  eyes,  and  moving  the  limbs  or  changing  the  position 
of  the  head,  evidently  increase  the  suffering  and  are  resisted.  I  have  some- 
times heard  such  expressions  of  suffering  from  slowly  introducing  the  ther- 
mometer into  the  rectum  that  I  was  led  to  believe  that  the  anal  and  perhaps 
rectal  surfaces  were  hypersensitive.  The  hypersesthesia  has  diagnostic  value, 
for  there  is  no  disease  with  which  cerebro-spinal  fever  is  likely  to  be  con- 
founded in  which  it  is  so  great.  It  is  due  to  the  spinal  meningitis,  and  is 
appreciable  even  in  a  state  of  semi-coma.  The  headache  and  hyperaesthesia 
fluctuate  greatly  in  the  course  of  the  disease,  and  the  former  sometimes  recurs 
at  times,  especially  from  mental  excitement  or  from  an  afflux  of  blood  to  the 
brain  from  physical  exertion,  for  months  after  the  health  is  otherwise  fully 
restored. 

Some  contraction  of  certain  muscles  or  groups  of  muscles  is  present  in 
all  typical  cases.  In  a  small  proportion  of  patients  it  is  absent  or  is  not  a 
prominent  symptom — to  wit,  in  those  in  whom  the  encephalon  is  mainly 
involved,  the  spinal  cord  and  meninges  being  but  slightly  affected  or  not  at 
all.  This  contraction  is  most  marked  in  the  muscles  of  the  nucha,  causing 
retraction  of  the  head,  but  it  is  also  common  in  the  posterior  muscles  of  the 
trunk,  causing  opisthotonos,  and  in  less  degree  in  those  of  the  abdomen  and 
lower  extremities,  and  hence  the  flexed  position  of  the  thighs  and  legs,  in 
which  patients  obtain  most  relief.  The  muscular  contraction  is  not  an  initial 
symptom.  I  have  ordinarily  first  observed  it  about  the  close  of  the  second 
day,  but  sometimes  as  early  as  the  close  of  the  first  day,  and  in  other 
instances  not  till  the  close  of  the  third  day.  Attempts  to  overcome  the 
rigidity,  as  by  bringing  forward  the  head,  are  very  painful  and  cause  the 
patient  to  resist.  In  young  children  having  a  mild  form  of  the  fever,  with 
little  retraction  of  the  head,  the  rigidity  is  sometimes  not  easily  detected. 
I  have  been  able  in  such  cases  to  satisfy  myself  and  the  friends  of  its 
presence  by  placing  the  child  in  an  upright  position,  as  on  the  lap  of  the 
mother,  and  observing  the  difiiculty  with  which  the  head  is  brought  forward 
on  presenting  to  the  patient  a  tumberful  of  cold  water,  which  is  craved  on 
account  of  the  thirst.  The  usual  position  of  the  patient  in  bed  in  a  typical 
or  marked  case  is  with  the  head  thrown  back,  the  thighs  and  legs  flexed,  with 
or  without  forward  arching  of  the  spine.  The  muscular  contraction  and 
rigidity  continue  from  three  to  five  weeks,  more  or  less,  and  abate  gradually ; 
occasionally  they  continue  much  longer.  Through  the  kindness  of  Dr.  Henry 
Griswold  I  was  allowed  to  see  an  infant  of  seven  months  in  the  tenth  week 
of  the  disease.  It  was  still  very  fretful,  and  exhibited  decided  prominence 
of  the  anterior  fontanel,  probably  from  intracranial  serous  effusion,  and  marked 
rigidity  of  the  muscles  of  the  nucha,  with  retraction  of  the  head. 

Paralysis  is  another  occasional  symptom,  but  complete  paralysis  of  any 
muscle  or  group  of  muscles  is  less  frequent  than  one  would  suppose  from 
the  nature  of  the  malady.  It  may  occur  early,  but  is  sometimes  a  late 
symptom.  It  may  be  limited  to  one  or  two  of  the  limbs,  as  the  legs  or  an 
arm  and  a  leg.  or  it  may  be  more  general.  In  a  case  occurring  in  Roosevelt 
Hospital  and  published  in  the  New  York  Medical  Record  for  October  10, 
1878,  the  patient,  a  boy  of  ten  years,  was  unable  to  move  his  legs  one  hour 
after  the  commencement  of  the  disease.  This  sudden  development  of  para- 
plegia in  the  commencement  of  cerebro-spinal  fever  resembled  that  of  infan- 


MODE  OF  COMMENCEMENT. 


483 


tile  paralysis,  and  was  probably  due  to  the  same  cause — to  wit,  active 
inflammatory  congestion  of'  the  anterior  cornua  of  the  spinal  column.  The 
sudden  and  complete  loss  of  speech  which  occurs  in  certain  cases,  when  con- 
sciousness is  retained  and  the  vocal  organs  are  in  their  normal  state,  seems 
to  be  due  to  the  fact  that  .the  portion  of  the  brain  which  controls  the  func- 
tion of  speech  is  acutely  congested  or  is  the  seat  of  effusion.  Thus,  in 
June,  1882,  a  girl  of  three  years  whom  I  attended  lost  her  speech  on  the 
second  day  of  cerebro-spinal  fever,  and  she  was  unable  to  articulate  even 
the  simplest  word  for  two  and  a  half  months.  Finally,  she  began  to  utter 
slowly  and  with  difficulty  the  easiest  monosyllables ;  and  after  the  lapse  of 
more  than  a  year  her  speech  was  slow  and  lisping,  her  hands  were  tremulous 
and  unsteady,  she  was  easily  fatigued,  and  cried  often  from  oversensitiveness. 
During  the  long  period  of  speechlessness  she  daily  made  eff"orts  to  talk,  but 
without  uttering  a  sound.  Strabismus,  to  which  we  will  allude  hereafter  in 
treating  of  the  eye,  is  a  common  symptom,  either  transient  or  protracted, 
due  to  paralysis  of  certain  of  the  motor  muscles  of  the  eye. 

Paralysis  of  more  or  fewer  muscles  has  been  noticed  and  recorded  by 
many  observers  in  this  country  and  in  Europe.  Dr.  Law  observed  a  patient 
in  the  epidemic  of  1865  in  Dublin  who  could  move  neither  arms  nor  legs, 
and  Wunderlich  saw  one  who  had  paralysis  of  both  lower  extremities  and 
of  a  considerable  part  of  the  trunk.  As  this  symptom  is  due  to  the 
inflammatory  process  of  the  cerebro-spinal  axis,  it  usually  disappears  in  a 
few  weeks  as  the  inflammation  abates  and  absorption  of  the  inflammatory 
products  occurs  ;  but  it  may  be  more  protracted.  In  Wunderlich's  case 
there  was  only  partial  recovery  from  the  paralysis  after  the  lapse  of  five 
months. 

Clonic  convulsions  have  already  been  alluded  to  among  the  early  symp- 
toms  of  the   attack.       They  indicate  a  grave  form   of  the  disease,  and  are 

Fig.  30. 


not  infrequent  in  young  children,  in  whom  they  appear  to  occur  in  place 
of  the  chill  which  is  common  in  those  of  a  more  advanced  age.  The 
eclamptic  attack  may  be  short  and  not  repeated,  or  it  may  be  protracted,  or 
return  again  and  again  when  the  medicines  which  control  it  are  suspended. 
Under  such  circumstances  it  is  likely  to  end  in  profound  coma,  and  is,  of 
course,  a  symptom  of  great  gravity.  Thus,  an  infant  of  seven  months  had 
unilateral  eclamptic  attacks  daily  during  the  first  week  of  the  attack.  The 
mother  informed  me  that  the  convulsions  seldom  lasted  longer  than  three 
minutes,   and    that    the    intervals    between    them    were    short.       The    child 


484  CEREBROSPINAL  FEVER. 

recovered  with  loss  of  sight  from  the  cerebro-spinal  fever,  but  still  after  the 
lapse  of  a  year,  when  I  examined  him,  had  symptoms  which  were  apparent- 
ly due  to  hydrocephalus.  Another  infant  of  eleven  months  had  clonic  con- 
vulsions nearly  constantly  during  the  first  twenty-four  hours,  but  with 
occasional  brief  intermissions.  On  the  following  day  he  was  in  profound 
coma  and  apparently  dying,  with  a  temperature  of  105°  F.  To  my  aston- 
ishment, he  gradually  emerged  from  the  state  of  unconsciousness,  and  after  a 
week  was  able  to  sit  in  his  cradle  long  enough  to  take  drinks. 

Occasionally  eclampsia  does  not  occur  in  the  first  days,  but  in  the  second 
or  third  week,  when  it  is  usually  accompanied  by  an  increase  of  other  symp- 
toms, due  to  a  recrudescence  of  the  disease.  A  female  infant  aged  eleven 
months,  treated  by  me  in  1882,  had  been  sick  one  week  when,  during  an 
increase  in  the  febrile  movement,  she  had  one  eclamptic  seizure.  Her  recov- 
ery, though  slow,  was  complete.  A  boy  aged  eleven  and  a  half  years,  whose 
attack  began  with  a  chill,  violent  headache,  and  fever,  and  whom  I  visited 
frequently,  died  on  the  fourth  day.  Clonic  convulsions  did  not  occur  in  his 
case  until  within  twenty-four  hours  of  his  death,  when  he  had  six  seizures, 
which  ended  in  coma. 

Though  adult  patients  are  much  less  liable  to  eclampsia  than  children, 
they  are  not  entirely  exempt.  A  male  patient  aged  twenty-eight  years, 
whom  I  saw  in  consultation,  had  a  single  clonic  convulsion  lasting  ten  to 
fifteen  minutes  on  the  third  day  of  his  illness.  In  five  weeks  he  had  fully 
recovered,  except  that  his  headache  returned  upon  any  excitement.  Even 
drinking  a  cup  of  beer  caused  it.  Clonic  convulsions  are,  however,  much  less 
common  than  the  tonic  muscular  contraction  and  rigidity  already  alluded  to. 
This  occurs  to  a  greater  or  less  extent  in  nearly  all  cases,  and  is  a  symptom 
of  diagnostic  value,  the  rigidity  often  extending  to  the  muscles  of  the  extrem- 
ities. Thus,  in  a  child  aged  three  years  who  had  no  eclampsia  the  tonic  con- 
traction of  the  muscles  of  the  extremities  did  not  relax  till  after  the  twelfth  day. 

Choreic  or  choreiform  movements  are  occasionally  observed.  I  do  not 
refer  to  the  tremulousness  which  sometimes  occurs  from  weakness  or  as  a 
premonition  of  eclampsia,  but  to  a  movement  which  has  the  character  of 
true  chorea.  An  infant  aged  ten  months  began  to  have  choreic  movements 
during  the  acute  stage  of  the  disease,  most  marked  in  the  upper  extremities 
and  ceasing  in  sleep.  They  continued  during  the  remainder  of  the  life  of  the 
child,  death  occurring  ten  months  subsequently  from  diphtheria.  Rarely  a 
choreiform  movement  of  the  eyes  is  also  observed — a  lateral  movement  from 
right  to  left  and  from  left  to  right.  I  have  seen  from  recollection  two  such 
cases. 

Drowsiness,  already  spoken  of,  is  a  common  symptom,  and  it  exists  in  all 
grades  from  slight  stupor  to  profound  coma.  In  some  patients  it  is  present 
from  the  first  hour,  while  in  others  it  occurs  after  a  period  of  restlessness  or 
delirium  or  it  alternates  with  it.  Stupor  more  or  less  profound  is  common 
after  the  attack  of  eclampsia  or  the  chill.  That  it  is  a  frequent  symptom  in 
severe  cases  receives  ready  explanation  from  the  state  of  the  brain  and  its 
meninges,  for  the  exudation  which  occurs  upon  the  surface  of  the  brain  and 
the  serous  efi"usion  within  the  ventricles  are  sufficient  to  cause  it  by  compress- 
ing the  cerebral  substance.  It  is  surprising  in  some  cases  how  profound  the 
stupor  may  be — a  state,  indeed,  of  coma,  and  yet  the  patient  gradually 
emerges  from  it  and  recovers.  In  the  epidemic  of  1872,  in  New  York 
City,  when  the  malady  was  new  with  us,  many  physicians  predicted  cer- 
tain death,  and  employed  remedies  without  expectation  of  any  benefit 
on  account  of  the  apparently  hopeless  state  of  patients,  who  seemed  to 
be  in  profound  coma,  and  yet  not  a  few  of  them  gradually  and  fully 
recovered. 


MODE  OF  COMMENCEMENT.  485 

Di'ijcsfive  Si/stem. — Vomiting,  which  is  the  most  prominent  symptom  refer- 
able to  the  digestive  system,  has  ah-eady  been  mentioned.  Occurring  early  in 
the  disease,  it  may  cease  in  a  few  hours  or  not  till  after  several  days,  and  often 
it  returns  during  the  periods  of  recrudescence  which  are  common  in  the  prog- 
ress of  the  fever.  It  occurs  with  little  effort  and  without  previous  nausea  or 
with  little  nausea,  as  is  usual  when  it  has  a  cerebral  origin.  It  does  not  differ 
as  a  symptom  from  the  vomiting  which  is  so  common  in  other  forms  of  men- 
ingitis. The  substance  vomited  consists  of  the  ingesta  and  the  secretions,  as 
mucus  and  bile.  Having  a  similar  origin  is  a  sensation  of  faintness  or  depres- 
sion, referred  to  the  epigastrium. 

The  appetite  is  usually  impaired  or  lost  during  the  active  period  of  the 
attack,  and  it  is  not  fully  restored  till  convalescence  is  well  advanced. 
Occasionally  considerable  nutriment  is  taken,  and  with  apparent  reli.sh,  as 
by  one  of  my  patients,  twenty-eight  years  of  age,  who  always  had  some 
appetite.  Ordinarily,  on  account  of  repeated  vomitings,  constant  febrile 
movements,  impaired  appetite  and  digestion,  patients  progressively  lose 
flesh  and  strength,  so  that  in  protracted  cases  emaciation  is  always  a 
prominent  symptom,  and  is  often  extreme.  Much  emaciation  and  loss  of 
strength,  which  attend  many  cases  after  the  lapse  of  several  weeks,  greatly 
diminish  the  chances  of  a  favorable  termination.  Thirst,  already  referred  to, 
and  constipation  are  common  in  this  as  in  other  forms  of  meningitis,  but 
retraction  of  the  abdomen  is  not  a  notable  symptom,  except  in  protracted  and 
greatly-wasted  cases.  The  diarrhoja  which  is  occasionally  present  in  cerebro- 
spinal fever  in  the  summer  months  must  be  regarded  as  a  distinct  disease 
and  a  complication.  The  tongue  and  the  buccal  and  faucial  surfaces  present 
nothing  unusual  in  their  appearance.  It  is  seldom,  even  in  the  most  pro- 
tracted and  emaciated  cases,  that  the  sordes  and  dry  and  brownish  fur  occur 
which  are  so  common  in  typhus  and  typhoid  fevers.  The  tongue  is  usually 
moist  and  but  slightly  furred. 

I  have  seen  in  consultation  two  patients  that  perished  early  with  inability 
to  swallow  as  the  prominent  symptom,  attended  in  both  by  an  abundant  secre- 
tion upon  the  faucial  surface,  without  any  redness,  swelling,  or  other  evidence 
of  inflammation.  The  early  death  of  these  young  children,  whose  ages  were 
ten  months  and  two  years,  rendered  the  diagnosis  less  certain  than  in  most 
other  patients,  but  the  attending  physician  as  well  as  myself  diagnosticated 
cerebro-spinal  fever  with  suddenly  developed  paralysis  of  the  muscles  of 
deglutition,  so  that  no  nutriment  could  be  taken.  If  our  understanding  of 
these  interesting  cases  is  correct,  the  paralysis  was  caused  by  lesion  of  that 
portion  of  the  medulla  oblongata  which  controls  the  function  of  deglutition, 
or  else  by  injury  of  the  intracranial  portions  of  the  nerves  which  supply  the 
muscles  concerned  in  this  act.     The  following  were  the  cases  in  question  : 

0 ,  male,  two  years  of  age,  became  feverish  and  dull,  but  without 

vomiting,  on  October  22,  1882;  axillary  temperature,  102°  F.  On  the  fol- 
lowing day  inability  to  swallow  occurred,  and  the  muscles  of  deglutition 
appeared  totally  inactive.  Death  occurred  on  the  third  day,  suddenly  and 
apparently  easily,  as  if  from  arrested  function  of  important  nerves,  especially 
the  pneumogastric.  The  abundant  secretion  of  thin  mucus  or  transudation 
of  serum  covering  the  faucial  surface,  and  reaccumulating  as  soon  as  removed 
without  any  notable  change  in  the  appearance  of  the  fauces,  was  remarkable. 
The  physician  in  attendance,  who  for  more  than  thirty  years  had  had  a  large 
city  practice,  had  seen  no  similar  case,  nor  had  I  at  the  time. 

Soon  afterward  the  second  case  occurred.  An  infant  of  ten  months,  with- 
out cough  or  embarrassment  of  respiration  or  faucial  redness  or  swelling,  lost 
the  power  of  deglutition  soon  after  the  commencement  of  the  supposed  cere- 
bro-spinal fever,  so  that  in  the  attempts  to  swallow  the  drinks  entered  the 


486  CEREBROSPINAL  FEVER. 

larynx,  and  the  secretion  or  exudation  was  abundant,  as  in  the  other  case. 
Death  occurred  in  forty-eight  hours.  The  rectal  temperature  was  only  101°  F. 
In  another  case,  which  was  ultimately  fatal  and  in  which  the  diagnosis  of 
cerebro-spinal  fever  was  certain,  a  robust  girl,  aged  twelve,  suddenly  lost  the 
power  of  deglutition  at  one  time  during  her  sickness,  although  she  was 
entirely  conscious  and  repeatedly  endeavored  to  swallow.  The  ability  to 
swallow  returned  in  a  few  days. 

Puke. — This  is  usually  accelerated,  and  the  more  severe  and  danger- 
ous the  attack  the  more  rapid  is  the  heart's  action,  except  occasionally  in  the 
comatose  state,  when,  probably  in  consequence  of  compression  of  the  brain 
from  an  abundant  exudation,  the  pulse  may  be  subnormal.  Thus,  in  one  of 
my  patients,  an  adult,  the  pulse  fell  to  40  per  minute,  and  in  two  others  to 
between  60  and  70  per  minute.  With  the  exception  of  these  three,  the  pulse 
in  all  cases  which  I  have  observed,  so  far  as  1  recollect,  has  varied  from  the 
normal  number  of  beats  per  minute  to  such  frequency  that  it  was  difficult  to 
count  it.  As  death  draws  near  the  pulse  ordinarily  becomes  more  frequent 
and  feeble.  Intermissions  in  the  pulse  do  not  seem  to  be  as  common  as  in 
other  forms  of  meningitis,  but  marked  variations  in  its  frequency  during 
different  hours  of  the  day  and  on  consecutive  days  constitute  a  conspicuous 
symptom.  Thus,  in  a  case  which  was  fatal  in  the  fifth  week  consecutive 
enumerations  of  the  pulse  in  the  acute  stage  were  as  follows :  128,  120,  88, 
130,  84,  112. 

Temperature. — Some  of  the  older  writers  before  the  days  of  clinical  ther- 
mometry stated  that  the  temperature  is  not  increased.  North  remarked  as 
follows :  "  Cases  occur,  it  is  true,  in  which  the  temperature  is  increased  above 
the  natural  standard,  but  these  are  rare ;"  and  Foot  and  Gallop  make  similar 
statements.  Some  recent  writers  have  held  the  same  opinion.  Thus,  Lidell 
wrote  as  follows  in  a  treatise  bearing  the  date  of  1873 :  "  Febrile  symptoms 
do  not  necessarily  belong  to  epidemic  cerebro-spinal  meningitis  as  a  substan- 
tive disease,  for  it  may,  and  not  unfrequently  does,  occur  without  exhibiting 
any  such  symptoms."  We  should  naturally  expect  that  meningitis,  accom- 
panied as  it  is  by  active  congestion  of  the  brain  and  spinal  cord,  would  pro- 
duce more  or  less  fever,  and  in  eighty  six  cases  which  I  examined  by  the 
thermometer  I  found  elevation  of  temperature  in  every  case  during  the  acute 
stage,  except  in  the  beginning  of  the  attack  in  two  instances.  In  a  young 
man  aged  twenty-eight  years  who  had  severe  headache  and  seemed  seriously 
sick  the  thermometer  under  the  tongue  showed  no  rise  of  temperature  on  the 
first  and  second  days,  but  on  the  third  day  it  was  at  100°  F.,  and  it  remained 
elevated  till  his  death  on  the  thirteenth  day.  The  second  case  was  that  of  a 
young  woman  whom  I  saw  in  consultation,  and  who  at  the  time  of  my  visit 
had  fever,  but  had  had  none  previously,  according  to  the  statement  of  the 
attending  physician. 

In  the  87  cases  which  I  examined  the  heat  of  the  surface  occasionally 
did  not  seem  above  normal  to  the  touch,  and  now  and  then  the  thermometer, 
applied  in  the  axilla  or  groin,  did  not  indicate  fever,  but  the  rectal  temper- 
ature was  always  elevated  above  that  of  health  after  the  disease  was  fully 
established.  The  temperature  fluctuated  from  day  to  day  and  in  different 
hours  of  the  same  day,  but  there  was  no  exception  to  the  rule  that  it  was 
above  the  normal  during  the  active  stage  of  the  malady  after  the  first 
few  days.  Sometimes  the  elevation  of  temperature  was  slight,  as  in  a  female 
patient  forty-seven  years  of  age,  in  whom  the  thermometer  showed  no  eleva- 
tion of  temperature  when  it  was  placed  in  the  mouth  and  axilla,  but  on 
introducing  it  into  the  rectum  it  rose  to  to  992°  F.  In  the  case  of  a  young 
lady  attended  by  me  in  1890,  having  a  very  asthenic  and  fatal  form  of 
cerebro-spinal  fever,   accompanied  by  great  prostration,  a    brown    and   dry 


MODE  OF  COMMENCEMENT.  487 

ton<fue,   and   delirium,   the   temperature    under   the   tongue   was    subnormal 
during  the  first  two  or  three  days,  but  was  afterward  above  normal. 

The  highest  temperature  which  I  have  thus  far  observed  was  107-|°  F., 
in  a  child  aged  two  years.  This  was  in  the  commencement  of  the  attack. 
Subse(juently  it  fell  a  little,  but  rose  again  on  the  third  day  to  107°,  when 
she  died.  In  two  other  cases  the  temperature  was  106°  F.  on  the  first  day, 
and  it  did  not  afterward  reach  so  high  an  elevation.  One  of  these  died  on 
the  ninth  day,  and  the  other  in  the  ninth  week.  The  next  highest  temperature 
was  105i°.F.,  also  on  the  first  day,  in  an  infant  aged  eight  months,  who  died 
on  the  ninth  day.  The  first  and  last  of  these  cases  occurred  in  an  old  wooden 
tenement-house  in  the  suburbs  of  the  city  and  upon  an  elevated  outcropping 
of  rock.  The  highest  temperature  in  any  case  in  New  York  City  which  has 
come  to  my  notice  was  observed  in  a  male  patient  aged  twenty-eight  years 
who  had  active  delirium,  and  died  on  the  fifth  day  in  Roosevelt  Hospital. 
The  temperature  on  the  last  day,  taken  four  times,  was  as  follows :  1022°, 
106:1°,  and,  when  the  pulse  had  become  imperceptible,  109°  and  1071°  F. 
Wundcrlich  has  recorded  a  temperature  of  110°  F.  in  one  or  two  cases,  but  so 
great  an  elevation  must  be  very  rare,  and  is  of  course  prognostic  of  an  unfa- 
vorable ending. 

The  external  temperature  undergoes  still  greater  fluctuations  than  the 
internal,  rising  above  and  falling  below  the  normal  standard  several  times  in 
the  course  of  the  same  day.  Similar  fluctuations  occur  in  other  forms  of 
meningitis,  but  they  are,  according  to  my  experience,  less  pronounced  than 
in  cerebro-spinal  fever,  especially  as  I  observed  them  in  the  epidemic  of 
1872.  Perhaps  since  that  epidemic  they  have  been  less  marked  in  the  cases 
occurring  in  this  city.  The  more  grave  the  attack  in  tho.se  not  comatose  the 
greater  these  variations.  The  following  is  a  common  example  of  these  sudden 
thermometric  changes,  occurring  in  a  child  of  two  years.  The  internal  tem- 
perature varied  from  101°  to  1044°  F.  as  the  exti-emes,  while  that  of  the 
fingers  and  hands  at  the  first  examination  was  90 0°,  at  the  second  90°,  at  the 
third  103°.  and  at  the  fourth  83°.  Hence  at  the  third  examination  the  tem- 
perature of  the  exti'emities  had  risen  13°,  so  as  nearly  to  equal  that  of  the 
blood,  and  at  the  fourth  examination  it  had  fallen  20°.  The  patient  recov- 
ered. These  great  and  sudden  variations  in  the  pulse  and  the  internal  and 
external  temperature  have  considerable  diagnostic  value  in  obscure  and 
doubtful  cases. 

Respirator}/  Si/sfem. — This  system  is  not  notably  involved  in  ordinary 
cases.  Intermittent,  sighing,  or  irregular  respiration  appears  to  be  less 
frequent  than  in  tubercular  meningitis,  but  it  does  occur.  In  most  patients 
the  respiration  is  quiet,  but  somewhat  accelerated,  and  without  any  marked 
disturbance  in  its  rhythm.  In  thirty-one  observations  in  children  who  had 
no  complication,  I  found  the  average  respirations  42  per  minute,  while  the 
average  pulse  was  137.  Therefore  the  respiration,  as  compared  with  the 
pulse,  was  proportionately  more  frequent  than  in  health,  due  perhaps  to  the 
fact  that  certain  muscles  concerned  in  respiration,  as  the  abdominal,  are  em- 
barrassed in  their  movements  by  tonic  contraction. 

Various  observers  in  diff"erent  epidemics  have  recorded  an  unusual  preva- 
lence of  croupous  pneumonia  occurring  simultaneously  with  cerebro-spinal 
fever.  Bascome  in  his  history  of  epidemics  stated  that  "  epidemic  encephal- 
itis and  malignant  pneumonias  prevailed  in  Germany  in  the  sixteenth  cen- 
tury "  (Webber).  Webber  in  his  prize  essay  describes  a  variety  of  cerebro- 
spinal fever  which  he  designates  pneumonic,  in  which  the  cerebro-spinal  axis 
is  involved  but  slightly  or  not  at  all,  and  the  brunt  of  the  disease  falls  upon 
the  respiratory  organs.  According  to  him,  in  certain  epidemics  the  pneu- 
monic form  has  been  common  and  in  others  infrequent.     This  fact  is  interest- 


488  CEREBROSPINAL  FEVER. 

ing  taken  in  connection  with  the  examination  of  the  microbes  of  croupous 
pneumonia  and  cerebro-spinal  fever,  as  detailed  in  our  remarks  under  the 
head  of  etiology. 

Cuianeou?,  Surface. — The  features  may  be  pallid,  of  normal  appearance, 
or  flushed  in  the  first  days  of  the  disease,  but  in  advanced  cases  they  are 
pallid,  as  is  the  skin  generally.  A  circumscribed  patch  of  deep  congestion 
often  appears,  as  in  sporadic  meningitis,  upon  some  part  of  them,  as  the 
forehead,  cheek,  or  an  ear,  and  after  a  short  time  disappears.  The  hyper- 
gemic  streak,  the  tache  cerebrale  of  Trousseau,  produced  by  drawing  the  fin- 
ger firmly  across  the  surface,  also  appears  as  in  other  forms  of  meningitis  if 
the  temperature  of  the  surface  be  not  too  much  reduced. 

The  following  are  the  abnormal  appearances  of  the  skin  most  frequently 
observed:  1.  Papilliform  elevations,  the  so-called  goose-skin,  due  to  contrac- 
tions of  the  muscular  fibres  of  the  corium.  This  is  not  uncommon  in  the 
first  weeks.  2.  A  dusky  mottling,  also  common  in  the  first  and  second 
weeks  in  grave  cases,  and  most  marked  when  the  temperature  is  reduced. 
3.  Numerous  minute  red  points  over  a  large  part  of  the  surface,  bluish  spots 
a,  few  lines  in  diameter,  due  to  extravasation  of  blood  under  the  cuticle^ 
resembling  bruises  in  appearance,  and  large  patches  of  the  same  color  an 
inch  or  more  in  diameter,  less  common  than  the  others,  of  irregular  shape  as 
well  as  size,  and  usually  not  more  than  two  or  three  upon  a  patient.  These 
last  resemble  bruises,  and  they  may  sometimes  be  such,  received  during  the 
times  of  restlessness ;  but  ordinarily  extravasations  of  this  kind  result 
entirely  from  the  altered  state  of  the  blood.  In  New  York  in  the  epidemic 
of  1872  they  were  common,  but  since  this  epidemic,  in  the  thirty-six  cases 
which  I  have  observed,  I  have  rarely  seen  either  the  reddish  points  or  the 
extravasations  of  blood.  They  were  probably  common  in  the  epidemics  in 
the  first  part  of  this  century  in  this  country,  since  the  disease  was  desig- 
nated by  the  name  "  spotted  fever ''  by  the  American  physicians  who  wrote 
upon  it  at  that  time.  That  they  are  unusual  in  the  European  epidemics  at 
the  present  time  we  infer  from  the  fact  that  Von  Ziemssen  expresses  sur- 
prise that  the  disease  should  ever  have  been  designated  in  America  by  such 
a  title.  4.  Herpes.  This  is  common.  It  sometimes  occurs  as  early  as  the 
second  or  third  day,  but  in  other  instances  not  till  toward  the  close  of  the 
first  week  or  in  the  second.  The  number  of  herpetic  eruptions  varies  from 
six  or  eight  to  clusters  as  large  as  or  larger  than  the  hand.  This  cutaneous 
disease  evidently  has  a  nervous  origin,  its  vesicles  occurring  in  most 
instances  on  those  parts  of  the  surface  which  are  supplied  by  branches  of 
the  fifth  pair  of  nerves.  Its  most  common  seat  is  upon  the  lips,  but  occa- 
sionally it  appears  upon  the  cheek,  upon  and  around  the  ears,  and  upon  the 
scalp.  Erythema  and  roseola,  both  transient  skin  eruptions,  occasionally 
appear,  and  in  one  instance  in  my  practice  erysipelas  occurred.  During  the 
first  days  the  skin  is  frequently  dry  ;  afterward  perspirations  are  not  unusual, 
and  free  perspirations  sometimes  occur,  especially  about  the  head,  face,  and  neck. 

Urinary  Organs. — In  other  forms  of  meningitis  it  is  well  known  that  the 
quantity  of  urine  excreted  is  usually  diminished,  but  in  this  disease  it  is 
normal,  and  it  may  be  more  than  normal.  Polyuria  has  been  noticed  in  dif- 
ferent cases  by  various  observers.  Mosler  observed  a  boy  aged  seven  years 
who  had  an  excessive  secretion  of  urine,  which  dated  back  to  an  attack  of 
cerebro-spinal  fever  in  his  third  year.  The  polyuria  is  probably  due  to 
injury  of  the  nervous  centre,  since  physiological  experiment  has  demon- 
strated that  irritation  of  the  central  end  of  the  vagus,  of  certain  parts  of  the 
cerebellum,  and  of  the  walls  of  the  fourth  ventricle  sometimes  produces  this 
efi"ect.  The  urine  occasionally  contains  a  moderate  amount  of  albumen,  and 
in  exceptional  instances  cylindrical  casts  and  blood-corpuscles. 


MODE  OF  COMMENCEMENT.  4S9 

Arthritic  inflammation,  apparently  of  a  rlieumatic  character,  has  been 
occasionally  observed.  It  is  conunonly  slight,  producing  merely  an  oedema- 
tous  appearance  around  one  or  more  joints.  Thus  in  one  case  which  came 
under  my  notice,  and  wliich  was  subsecjuently  fatal,  the  parents,  who  were 
poor,  and  were  therefore  without  medical  advice  till  the  case  was  somewhat 
advanced,  had  already  diagnosticated  rheumatism  on  account  of  the  puffiness 
which  they  had  noticed  around  one  of  the  wrists. 

The  Special  Senses. — Taste  and  smell  are  rarely  affected,  so  far  as  is 
known,  but  it  is  possible  that  they  are  sometimes  perverted,  or  even  tempo- 
rarily lost,  during  the  time  of  greatest  stupor.  In  one  case  which  I  saw  the 
sense  of  smell  was  entirely  lost  in  one  nostril,  and  I  do  not  know  whether  it 
was  ever  fully  restored. 

The  affections  of  the  eye  and  ear  are  important  and  of  frequent  occurrence. 
Strabismus  is  common.  It  may  occur  at  any  period  of  the  fever,  continuing 
a  few  hours  or  several  days,  and  it  may  appear  and  disappear  several  times 
before  convalescence  is  established :  occasionally  it  continues  several  weeks. 
after  which  the  parallelism  of  the  eyes  is  gradually  and  fully  restored.  In 
other  instances  it  is  permanent. 

Changes  in  the  pupils  are  among  the  first  and  most  noticeable  of  the 
initial  symptoms,  as  I  have  already  stated  in  describing  the  mode  of  com- 
mencement. These  are  dilatation,  less  frequently  contraction,  oscillation, 
inequality  of  size,  feeble  response  to  light,  etc.  Most  patients  present  one 
or  more  of  these  abnormalities  of  the  pupils,  and  they  continue  during  the 
first  and  second  weeks,  and  gradually  abate  if  the  course  of  the  disease  be 
favorable.  Inflammatory  hyperasmia  of  the  conjunctiva  often  occurs.  It 
begins  early,  and  now  and  then  the  conjunctivitis  is  so  intense  that  consider- 
able tumefaction  of  the  lids  results,  with  a  free  muco-purulent  secretion.  The 
false  diagnosis  has  indeed  been  made  of  purulent  ophthalmia  in  cases  in  which 
this  affection  of  the  lids  was  early  and  severe.  But  such  intense  inflamma- 
tion is  quite  exceptional.  More  frequently  there  is  a  uniform  diffused  redness 
of  the  conjunctiva,  not  so  dusky  as  in  typhus,  and  the  injected  vessels  cannot 
be  so  readily  distinguished  as  in  that  disease. 

In  certain  cases  almost  the  whole  eye  (all,  indeed,  of  the  important  con- 
stituents) becomes  inflamed ;  the  media  grow  cloudy,  the  iris  discolored,  and 
the  pupils  uneven  and  filled  up  with  fibrinous  exudation.  The  deep  struc- 
tures of  the  eye  cannot,  therefore,  be  readily  explored  by  the  ophthalmo- 
scope, but  they  are  observed  to  be  adherent  to  each  other  and  covered  by 
inflammatoi'y  exudation.  They  present  a  dusky-red  or  even  a  dark  color 
when  the  inflammation  is  recent.  Exceptionally  the  cornea  ulcerates  and 
the  eye  bursts,  with  the  loss  of  more  or  less  of  the  liquids  and  shrinking 
of  the  eye.  "  But  ordinarily  no  ulceration  occurs,  and  as  the  patient  con- 
valesces the  oedema  of  the  lids,  the  hyperaemia  of  the  conjunctiva,  the  cloud- 
iness of  the  cornea  and  of  the  humors  gradually  abate  and  the  exudation 
in  the  pupils  is  absorbed.  The  iris  bulges  forward,  and  the  deep  tissues  of 
the  eye,  viewed  through  the  vitreous  humor,  which  before  had  a  dusky-red 
color  from  hyperaemia,  now  present  a  dull-white  color."  The  lens  itself,  at 
first  transparent,  after  a  while  becomes  cataractous.  Sight  is  lost  totally  and 
for  ever. 

If  the  patient  live,  the  volume  of  the  eye  diminishes,  as  the  inflammation 
abates,  to  less  than  the  normal  size,  even  when  there  has  been  no  rupture 
and  escape  of  the  fluids,  and  divergent  strabismus  is  likely  to  occur.  Prof. 
Knapp,  whose  description  of  the  eye  I  have  for  the  most  part  followed,  says : 
"  The  nature  of  the  eye  affection  is  a  purulent  choroiditis,  probably  meta- 
static." Fortunately,  so  general  and  destructive  an  inflammation  of  the  eye 
as  has  been  described  above  is  comparatively  rare.     On  the  other  hand,  con- 


490  CEREBROSPINAL  FEVER. 

junctivitis  of  greater  or  less  severity,  and  hyperaemia  of  the  optic  disc,  con- 
sequent upon  the  brain  disease,  are  not  unusual,  but  they  subside,  leaving  the 
function  of  the  organ  unimpaired.  "  In  some  cases  incurable  blindness  is 
noticed  under  the  ophthalmoscope  picture  of  optic  nerve-atrophy,  probably 
the  sequence  of  choked  disc  "  (Knapp). 

Inflammation  of  the  middle  ear,  of  a  mild  grade  and  subsiding  without 
impairment  of  hearing,  is  common.  The  membrana  tympani  during  its  con- 
tinuance presents  a  dull-yellowish,  and  in  places  a  reddish,  hue.  Occasionally 
a  more  severe  otitis  media  occurs,  ending  in  suppuration,  perforation  of  the 
membrana  tympani,  and  otorrhoea,  which  ceases  after  a  variable  time.  But 
otitis  media  is  not  the  most  severe  of  the  affections  of  the  organs  of  hearing. 
Certain  patients  lose  their  hearing  entirely,  and  never  regain  it,  and  that,  too, 
with  little  otalgia,  otorrhoea,  or  other  local  symptoms  by  which  so  grave  a 
result  can  be  prognosticated.  This  loss  of  hearing  does  not  occur  at  the 
samg  period  of  the  disease  in  all  cases.  Some  of  those  who  become  deaf  are 
able  to  hear  as  they  emerge  from  the  stupor  of  the  disease,  but  lose  this 
function  during  convalescence,  while  the  majority  are  observed  to  be  deaf  as 
soon  as  the  stupor  abates  and  full  consciousness  returns. 

Two  important  facts  have  been  observed  in  reference  to  the  loss  of  hear- 
ing in  these  patients — to  wit,  it  is  bilateral  and  complete.  When  first 
observed  it  is  in  some,  as  stated  above,  complete,  but  in  others  partial,  and 
when  partial  it  gradually  increases  till  after  some  days  or  weeks,  Avhen  it 
becomes  complete.  I  have  the  records  of  10  cases  of  this  loss  of  hearing, 
most  of  them  occurring  in  my  own  practice  in  the  epidemic  of  1872,  but  a 
few  or  them  detailed  to  me  by  the  physicians  who  observed  them  in  the  same 
epidemic.  According  to  these  statistics,  about  1  in  every  10  patients  became 
deaf,  but  in  the  milder  form  of  cerebro-spinal  meningitis  which  has  prevailed 
since  1872  the  proportionate  number  thus  affected  has  been  less  among  my 
patients,  and  the  same  may  be  said  in  reference  to  the  loss  of  sight :  1  of 
the  10  cases  was  a  young  lady,  but  the  rest  were  children  under  the  age  of 
ten  years.  Prof.  Knapp  has  examined  31  cases.  "In  all,"  says  he,  "  the 
deafness  was  bilateral,  and,  with  2  exceptions  of  faint  perceptions  of  sound, 
complete.  Among  the  29  eases  of  total  deafness  there  is  only  1  who  seemed 
to  give  some  evidence  of  hearing  afterward."  The  same  author  has  recently 
informed  me  that  further  experience  has  confirmed  his  previous  statement, 
that  while  the  blindness  produced  by  cerebro-spinal  fever  is  in  the  majority 
of  cases  monolateral,  but  one  case  had  come  to  his  notice  in  which  the  deaf- 
ness was  on  one  side  only. 

One  theory  attributes  the  loss  of  hearing  to  inflammatory  lesions  either 
at  the  centre  of  audition  within  the  brain,  or  in  the  course  of  the  auditory 
nerves  before  they  enter  the  auditory  foramina.  The  other  theory,  which 
is  the  better  established  of  the  two  and  must  be  accepted,  attributes  the  loss 
of  hearing  to  inflammatory  disease  of  the  ear,  and  especially  of  the  labyrinth. 

Symptoms  of  Endemic  or  Naturalized  Cerebro-Spinal  Fever. — 
The  numerous  monographs  on  this  disease  which  have  appeared  during  the 
last  few  years  relate  to  its  epidemic  form,  and  no  published  observations,  so 
far  as  I  am  aware,  describe  the  character  or  symptoms  which  it  presents  or 
the  changes  which  it  undergoes  when  it  occurs  as  an  endemic  or  naturalized 
disease.  The  endemic  disease  must,  of  course,  be  observed  in  the  cities  or 
populous  towns,  for  there  is  no  rural  locality,  so  far  as  I  am  aware,  in  which 
this  disease  is  permanently  established.  In  New  York  the  naturalized  dis- 
ease appears  to  be  accompanied  by  a  less  profound  blood-change  than  occurs 
in  epidemic  cases.  Although  every  year  seeing  a  considerable  number  of 
cases,  I  have  not  in  the  last  ten  years  seen  one  with  the  livid  spots  upon 
the    surface,  due  to    subcutaneous   extravasation  of  blood,  which  were  so 


NATURE.  491 

common  in  the  epidemic  of  1872,  and  which  have  been  so  common  in 
epidemics  both  in  this  country  and  in  Europe  that  the  term  "  spotted  fever  " 
was  applied  to  the  mahidy.  Occasionally  petechiae  occur  in  severe  cases  of 
the  naturalized  disease. 

Naturk. — The  theory  that  cerebro-spinal  fever  is  a  local  disease,  occur- 
ring epidemically,  was  commonly  held  in  the  first  part  of  this  century,  but 
is  now  discarded.  Job  Wilson  in  1815  considered  it  a  form  of  influenza, 
and  could  see  no  utility  in  drawing  a  distinction  between  spotted  fever  and 
influenza.  We  at  the  present  time  can  see  no  resemblance  between  the  two, 
except  that  both  occur  as  epidemics.  The  theory  that  cerebro-spinal  fever  is 
a  peculiar  local  disease  occurring  in  epidemics  is  more  plausible  than  that 
which  holds  that  it  is  a  form  of  influenza.  Even  Niemeyer  says  that  it  pre- 
sents no  symptoms  except  such  as  are  referable  to  the  local  aff"ection.  But 
the  evidence  is  strong  that  cerebro-spinal  fever  is  a  constitutional  malady 
with  the  meningitis  as  a  local  manifestation,  just  like  measles  with  its  bron- 
chitis or  scarlet  fever  with  its  pharyngitis.  The  abrupt  and  severe  com- 
mencement, unlike  that  of  those  forms  of  meningitis  which  are  known  to  be 
strictly  local,  and  the  early  blood-change,  as  shown  in  certain  cases  by  the 
appearance  of  the  skin  and  extravasation  under  it,  indicate  a  general  disease. 
Constitutional  diseases  having  prominent  local  symptoms  and  lesions  are  usu- 
ally regarded  at  first  as  local.  It  is  only  as  time  goes  on  and  they  are  more 
thoroughly  studied  and  understood,  and  clinical  observations  multiply,  that 
their  constitutional   nature  is  recognized. 

The  theory  that  cerebro-spinal  fever  is  a  form  of  typhus  once  had  advo- 
cates, but  it  is  now  so  generally  discarded  as  untenable  and  absurd  that  it 
would  be  a  waste  of  time  to  consider  the  facts  which  differentiate  the  two  mala- 
dies. Cerebro-spinal  fever  should  therefore  be  considered  as  distinct  from  all 
other  diseases,  a  malady  sui  genei'is,  and  in  nosological  writings  it  should  be 
classified  with  those  constitutional  maladies  which  have  specific  causes. 

Although  this  disease  ordinarily  occurs  in  an  epidemic  form  in  localities 
widely  separated  from  one  another,  and,  after  continuing  a  few  weeks  or 
months,  totally  disappears,  perhaps  never  to  return  or  not  till  after  the  lapse 
of  years,  nevertheless  in  localities  it  becomes  established,  so  that  it  is  proper 
to  describe  it  as  an  endemic — a  fact  to  which  we  have  already  referred  as 
regards  certain  American  cities.  I  do  not  know  that  it  is  endemic  in  any 
village  or  rural  locality  in  this  country.  The  large  cities,  with  their  promis- 
cuous population,  foreign  and  native,  their  crowded  tenement-houses,  and 
their  many  sources  of  insalubrity,  furnish  in  an  eminent  degree  the  condi- 
tions which  are  favorable  for  the  development  and  perpetuation  of  the  microbic 
diseases.  Those  diseases  which  in  the  present  state  of  our  knowledge  we 
have  reason  to  believe  are  caused  by  micro-organisms  we  should  expect  to 
prevail  most  where  domiciles  are  crowded  and  filthy  and  systems  are  ener- 
vated by  impure  air,  hardships,  and  privation.  Hence  in  New  York  City,  in 
the  crowded  quarters  of  the  poor,  cerebro-spinal  fever,  like  diphtheria,  is  sel- 
dom or  never  absent. 

Deaths  in  New  York  from   Cerehro- Spinal  Fever. 

Number.  I                                                         Number. 

1872 782  ]  1880 170 

1873 290  1881 461 

1874 158  '  1882 238 

1875 14fi  '  1883 223 

1876 127  1884 210 

1877 116  1885 202 

1878 97  1886 223 

1879 108  I  1887 203 


492  CEREBROSPINAL  FEVER. 

It  is  seen  that  the  greatest  mortality  was  in  the  first  year  after  the  intro- 
duction of  the  disease  into  the  city,  after  which  the  number  of  deaths 
gradually  diminished,  year  by  year,  till  1878,  when  the  lowest  mortality 
was  reached.  After  1878  the  mortality  gradually  increased  till  1881,  in 
which  year  the  number  of  deaths  was  double  that  of  any  other  year  except  1872. 

The  mortuary  reports  of  Philadelphia  likewise  show  that  cerebro-spinal 
fever  has  remained  in  that  city  since  its  introduction  in  1863,  a  period  of 
twenty-five  years,  the  annual  deaths  produced  by  it  varying  between  36,  the 
minimum,  in  1869  and  1870,  and  384,  the  maximum,  in  1864.  In  Provi- 
dence also,  as  appears  from  Dr.  Snow's  reports,  cerebro-spinal  fever  has 
caused  annually  more  or  fewer  deaths  since  1871.  Therefore,  we  repeat, 
this  fact  may  be  added  to  the  sum  of  our  knowledge  of  this  disease,  that 
once  gaining  a  lodgment  where  the  conditions  are  favorable  for  it,  as  in  a 
large  city,  it  may   become  established  and  remain   an  indefinite  time. 

Anatomical  Characters. — I  have  notes  of  the  post-mortem  appear- 
ances in  76  cases,  published  chiefly  in  British  and  American  journals :  29 
died  within  the  first  three  days,  28  between  the  third  and  twenty-first  days, 
and  the  duration  of  the  remaining  19  was  unknown.  These  records  furnish 
the  data  for  the  following  remarks. 

The  blood  undergoes  changes  which  are  due  in  part  to  the  inflammatory 
and  in  part  to  the  constitutional  and  asthenic  nature  of  the  disease.  The  pro- 
portion of  fibrin  is  increased  in  cases  that  are  not  speedily  fatal,  as  it  ordi- 
narily is  in  idiopathic  inflammations.  Analyses  of  the  blood  by  Ames> 
Tourdes,  and  Maillot  show  a  variable  proportion  of  fibrin  from  three  and 
four-tenths  to  more  than  six  parts  in  one  thousand.  In  sthenic  cases  accom- 
panied by  a  pretty  general  meningitis,  cerebral  and  spinal,  there  is,  after  the 
fever  has  continued  some  days,  the  maximum  amount  of  fibrin,  while  in  the 
asthenic  and  suddenly  fatal  cases,  with  inflammation  slight  or  in  its  com- 
mencement, the  fibrin  is  but  little  increased.  The  most  common  abnormal 
appearance  of  the  blood  observed  at  autopsies  is  a  dark  color  with  unusual 
fluidity  and  the  presence  of  dark  soft  clots.  Exceptionally  bubbles  of  gas 
have  been  observed  in  the  large  vessels  and  the  cavities  of  the  heart.  An 
unusually  dark  color  of  the  blood,  small  and  soft  dark  clots,  and  the  presence 
of  gas-bubbles  when  only  a  few  hours  have  elapsed  after  death  indicate  a 
malignant  form  of  the  disease,  in  which  the  blood  is  early  and  profoundly 
altered.  In  certain  cases  this  fluid  is  not  so  changed  as  to  attract  attention 
from  its  appearance.  The  points  or  patches  of  extravasated  blood  which  are 
observed  in  and  under  the  skin  during  life  in  some  patients  usually  remain  in 
the  cadaver.  When  an  incision  is  made  through  them  the  blood  is  seen  to 
have  been  extravasated,  not  only  in  the  layers  of  the  skin,  but  also  in  the 
subcutaneous  connective  tissue.  Extravasations  of  small  extent  are  likewise 
sometimes  observed  upon  and  in  thoracic  and  abdominal  organs. 

In  those  who  die  after  a  sickness  of  a  few  hours  or  days — namely,  in 
the  stage  of  acute  inflammatory  congestion — the  cranial  sinuses  are  found 
engorged  with  blood  and  containing  soft  dark  clots.  The  meninges  envelop- 
ing the  brain  are  also  intensely  hyperaemic  in  their  entire  extent  in  most 
cadavers,  but  in  some  cases  the  hyperaemia  is  limited  to  a  portion  of  the 
meninges,  while  other  portions  appear  nearly  normal.  In  those  cases  which 
end  fatally  within  a  few  hours  this  hyperaemia  is  ordinarily  the  only  lesion 
of  the  meninges ;  but  if  the  case  be  more  protracted  serum  and  fibrin  are 
soon  exuded  from  the  vessels  into  the  meshes  of  the  pia  mater,  and  under- 
neath this  membrane  over  the  surface  of  the  brain.  Pus-cells  also  occur 
mixed  with  the  fibrin,  sometimes  so  few  that  they  are  discovered  only  with 
the  microscope,  but  in  other  cases  in  such  quantity  as  to  be  much  in  excess 
of  the  fibrin  and  to  be  readily  detected  by  the  naked  eye.     Pus,  which  in 


ANATOMICAL  CHARACTERS.  493 

these  cases  probably  consists  of  white  blood-corpuscles  which  have  escaped 
with  the  fibrin  from  the  meningeal  vessels,  often  appears  early  in  the  attack. 
The  arachnoid  soon  loses  its  transparency  and  polish,  and  presents  a  cloudy 
appearance  over  a  greater  or  less  extent  of  its  surface.  This  cloudiness  is 
usually  greatest  along  the  course  of  the  vessels  in  the  sulci  and  depressions 
and  wl>ere  the  fibrinous  exudation  is  greatest,  but  it  occurs  also  in  places 
where  no  such  exudation  is  apparent  to  the  naked  eye. 

The  exudation — serous,  fibrinous,  and  purulent — occurs,  as  in  other  forms 
of  meningitis,  within  the  meshes  of  the  pia  mater,  and  underneath  this  mem- 
brane over  the  surface  of  the  brain.  The  fibrin  is  raised  from  the  surface  of 
the  brain  with  the  meninges  in  making  the  autopsy.  It  is  most  abundant  in 
the  intergyral  spaces,  around  the  course  of  the  vessels,  over  and  around  the 
optic  commissure,  pons  Varolii,  cerebellum,  and  medulla  oblongata,  and  along 
the  Sylvian  fissures.  It  is  most  abundant  in  the  depressions,  where  it  some- 
times has  the  thickness  of  one-tenth  to  one-fourth  of  an  inch,  but  it  often 
extends  over  the  convolutions  so  as  to  conceal  them  from   view. 

Most  other  forms  of  meningitis  have  a  local  cause,  and  are  therefore 
limited  to  a  small  extent  of  the  meninges — as,  for  example,  meningitis  from 
tubercles  or  caries  of  the  petrous  portion  of  the  temporal  bone,  in  both  of 
which  it  is  commonly  limited  to  the  base  of  the  brain  ;  or  from  accidents, 
when  the  meningitis  commonly  occurs  upon  the  side  or  summit  of  the  brain. 
The  meningitis  of  cerebro-spinal  fever,  on  the  other  hand,  having  a  general 
or  constitutional  cause,  occurs  with  nearly  equal  frequency  upon  all  parts  of 
the  meningeal  surface,  except  that  it  is  perhaps  most  severe  in  the  depres- 
sions, where  the  vascular  supply  is  greatest.  In  cases  of  great  severity  the 
inflammatory  exudation,  fibrinous  or  purulent,  or  both,  covers  nearly  or  quite 
the  entire  surface  of  the  brain. 

In  those  who  die  at  an  early  stage  of  the  attack  the  vessels  of  the  brain, 
like  those  of  the  meninges,  are  hyperasmic,  so  that  numerous  '■  puncta  vas- 
culosa  "  appear  upon  its  incised  surface.  At  a  later  period  this  hyperaemia. 
like  that  of  the  meninges,  may  disappear.  If  there  be  much  eff"usion  of 
serum  within  the  ventricles  and  over  the  surface  of  the  brain,  the  convolu- 
tions are  liable  to  be  flattened,  and  the  pressure  may  be  so  great  that  the 
amount  of  blood  circulating  in  the  brain  is  reduced  below  the  normal  quan- 
tity. Thus,  in  the  case  of  a  child  of  three  years  who  lived  sixteen  days,  and 
was  examined  after  death  by  Burdon-Sanderson,  the  ventricles  contained  a 
large  amount  of  turbid  serum  and  the  brain-substance  was  everywhere  pale 
and  anaemic  from  compression. 

Cerebral  ramoUisspment  occurs  in  certain  cases.  At  one  of  the  examina- 
tions in  Charity  Hospital,  the  patient  having  been  only  three  days  sick,  the 
brain  was  found  much  softened.  The  dissection  was  made  seven  hours  after 
death,  so  that  the  softening  could  not  have  been  the  result  of  decomposition. 
At  one  of  the  post-mortem  examinations  in  Bellevue  Hospital  softening 
of  the  fornix,  corpus  callosum,  and  septum  lucidum  was  observed,  and  in 
another  softening  in  the  neighborhood  of  the  subarachnoid  space.  In  a  case 
related  by  Dr.  Moorman^  it  is  stated  that  portions  of  the  brain,  medulla 
oblongata,  and  pons  Varolii  were  softened.  In  a  case  observed  by  Dr.  Upham 
.softening  of  the  superior  portion  of  the  left  cerebral  hemisphere  had  occurred. 
Occasionally  the  whole  brain  is  somewhat  softened.  Burdon-Sanderson,  Eu.s- 
.sell,  and  Githens  each  relate  such  a  case.  3Ioreover,  the  walls  of  the  lateral 
ventricles  are  ordinarily  more  or  less  softened  in  fatal  cases  of  cerebro-spinal 
fever,  as  they  are  in  other  forms  of  meningitis.  In  rare  instances  the  brain 
is  cederaatous,  as  in  a  case  published  by  Dr.  Hutchinson.'     In  this  case  the 

^  American  Journal  of  the  Medical  Science.%  October,  1866. 
^  Ibid.,  July,  1866. 


494  CEREBROSPINAL  FEVER. 

patient  was  only  four  days  sick  and  the  whole  brain  was  oedematous,  serum 
escaping  from  its  incised  surface. 

The  ventricles  contain  liquid,  in  some  patients  transparent  serum,  in 
others  serum  turbid  and  containing  flocculi  of  fibrin  or  fibrin  with  pus.  The 
liquids  in  the  different  ventricles,  since  they  intercommunicate,  are  the  same. 
The  choroid  plexus  is  either  injected  or  it  is  infiltrated  with  fibrin  and  pus. 
With  the  abatement  of  the  inflammation  absorption  commences.  The  serum, 
from  its  nature,  is  readily  absorbed,  and  the  pus  and  fibrin  more  slowly  by 
fatty  degeneration  and  liquefaction.  Occasionally  the  serum  remains,  and 
chronic  hydrocephalus  resiilts.  An  infant  who  contracted  the  disease  at  the 
age  of  five  months,  and  appeared  to  be  convalescent,  had,  two  months  sub- 
sequently, great  prominence  of  the  anterior  fontanel,  and  other  symptoms 
indicating  the  presence  of  a  considerable  amount  of  efi"usion  within  the 
cranium.  In  another  case,  one  year  afterward,  examination  showed  the 
enlargement  of  the  head  and  prominence  of  the  fontanel  which  characterize 
chronic  hydrocephalus.  A  boy  of  ten  years  treated  in  Roosevelt  Hospital  in 
1878  died  three  months  after  the  commencement  of  cerebro-spinal  fever. 
The  records  of  the  autopsy  state  :  "  Body  a  skeleton  ;  brain,  dura  mater,  and 
pia  mater  appear  normal,  except  a  little  thickening  of  latter  at  base  of  brain  ; 
ventricles  much  enlarged  and  full  of  clear  serum  ;  surface  of  walls  of  ven- 
tricles appears  normal,  but  is  soft ;  spinal  cord  and  membranes  apparently 
normal ;  heart,  lungs,  stomach,  and  intestines  normal ;  liver  congested ;  kid- 
neys pale."  In  this  case,  therefore,  all  the  other  lesions  of  the  cerebro-spinal 
axis,  except  the  serous  effusion,  had  nearh^  disappeared.  No  post-mortem 
examinations,  so  far  as  I  am  awai'e,  have  yet  revealed  the  state  of  the  brain 
and  its  meninges  in  those  who  have  had  this  malady  at  some  former  time  and 
have  fully  recovered,  whether  there  may  not  be  some  traces  of  it  which  are 
permanent,  as  opacity  or  adhesions. 

The  remarks  made  in  reference  to  the  cerebral  apply,  for  the  most  party 
also  to  to  the  spinal  meninges.  There  is  at  first  intense  hypersemia  of  the 
membranes,  usually  over  the  entire  surface  of  the  cord,  soon  followed  by 
fibrinous,  purulent,  and  serous  exudation  in  the  meshes  of  the  pia  mater  and 
underneath  this  membrane.  This  exudation  is  sometimes  confined  to  a  por- 
tion of  the  meninges,  more  frequently  that  covering  the  posterior  than  the 
anterior  aspect  of  the  cord,  and  when  it  is  general  it  is  ordinarily  thicker 
posteriorly  than  anteriorly.  In  severe  cases  nearly  or  quite  the  entire  spinal 
pia  mater  may  be  infiltrated  by  inflammatory  products.  Thus,  in  the  case  of 
an  infant  that  died  of  cerebro-spinal  fever  at  the  age  of  ten  weeks,  in  the 
service  of  Dr.  H.  D.  Chapin,  in  the  Out-door  Department  at  Bellevue,  the 
entire  spinal  cord  was  covered  by  a  fibrino-purulent  exudation,  except  a  space 
about  six  lines  in  extent  upon  the  anterior  surface. 

No  constant  or  uniform  lesions  occur  in  the  organs  of  the  trunk,  and 
those  observed  are  not  distinctive  of  this  disease.  Hypostatic  congestion 
of  the  lungs,  bronchitis,  atelectasis,  and  broncho-pneumonia  are  common. 
Pleuritic,  endocardial,  and  pericardial  inflammations  have  occasionally  been 
observed,  but  are  rare.  Effusion  of  serum,  sometimes  blood-stained,  occasion- 
ally occurs  in  the  pleural  and  other  serous  cavities.  The  auricles  and  ven- 
tricles of  the  heart,  as  already  stated,  contain  more  or  less  blood,  with  soft 
dark  clots  in  the  more  malignant  and  rapidly  fatal  cases,  but  larger  and  firmer 
in  those  which  have  been  more  protracted.  The  spleen  is  enlarged  in  less 
than  half  the  patients.  The  absence  of  uniformity  as  regards  the  state  of 
the  spleen,  the  fact  that  in  many  it  undergoes  no  appreciable  change,  is 
important,  since  this  organ  is  so  generally  enlarged  and  softened  in  the  infec- 
tious diseases.  The  stomach,  intestines,  and  liver  are  sometimes  more  or  less 
congested,  but  in  other  cases  their  appearance  is  normal.     The  agminate  and. 


PROGNOSIS.  495 

solitary  glands  of  the  intestines  have  ordinarily  been  overlooked,  but  in  cer- 
tain cases  they  have  been  found  prominent.  The  kidneys  are  normal,  or  they 
exhibit  the  lesions  of  nephritis.  In  1  of  8  autopsies  made  by  Prof.  Welch 
acute  diffuse  nephritis  had  been  present,  as  shown  by  the  state  of  the  kidneys. 
In  the  case  of  a  child  of  nine  years  treated  by  Dr.  F.  A.  Burrall  in  the 
Presbyterian  Hospital  the  urine  was  very  albuminous  and  the  kidneys  pre- 
sented a  fatty  a{)pearance.  Anatomical  chanj^es  in  these  organs,  however,  are 
not  common,  unless  in  slight  degree,  so  that  in  most  patients  their  function  is 
fully  and  properly  performed. 

Prognosis. — Cerebro-spinal  fever  is  justly  regarded  as  one  of  the  most 
dangerous  maladies  of  childhood.  It  is  dreaded  not  only  on  account  of  the 
great  mortality  which  attends  it,  but  also  on  account  of  its  protracted  course, 
the  suffering  which  it  causes,  the  possible  permanent  injury  of  the  important 
organ  which  is  chiefly  involved,  and  the  not  infrequent  irreparable  damage 
which  the  eye  and  ear  sustain. 

I  have  the  records  of  the  result  in  52  cases  which  I  attended  or  saw  in 
consultation  in  the  epidemic  of  1872.  Of  these  just  one-half  recovered.  16 
of  the  2G  who  died  were  hopelessly  comatose  within  the  first  seven  days, 
most  of  them  dying  within  that  time,  and  some  even  on  the  first  and  second 
days,  while  others  of  the  16  lingered  into  the  second  week  and  died  without 
any  sign  of  returning  consciousness.  The  remaining  10.  who  subsequently 
died,  but  did  not  become  comatose  in  the  first  week,  were  nevertheless  .seri- 
ously sick  from  the  first  day,  but  their  symptoms,  though  severe,  were  not 
such  as  necessarily  indicated  a  fatal  result,  so  that  there  was  some  expecta- 
tion of  a  favorable  ending  till  near  death,  which  occurred  for  the  most  part 
from  asthenia.  One  succumbed  to  purpura  haemorrhagica,  the  hemorrhages 
occurring  from  the  mucous  surfaces.  The  patient  died  after  a  sickness  of 
more  than  two  months,  in  a  state  of  extreme  emaciation  and  prostration.  The 
26  who  recovered  convalesced  slowly,  and  usually  after  many  fluctuations. 
Their  highest  temperature  and  most  severe  and  dangerous  symptoms  occurred 
in  the  first  week.  Most  of  them  were  several  weeks  under  observation  and 
treatment  before  they  sufficiently  recovered  to  be  out  of  danger.  The  statis- 
tics of  this  epidemic  therefore  show — and  the  same  is  true  of  other  epidemics 
— that  the  first  week  is  the  time  of  greatest  danger,  and  if  no  fatal  symp- 
toms are  developed  during  this  week  recovery  is  probable  with  proper  thera- 
peutic measures  and  kind,  intelligent,  and  efficient  nursing,  which  is  very 
important. 

Since  1872  I  have  seen  a  larger  number,  but  have  preserved  records  of 
40  cases  which  I  was  able  to  follow  to  the  close.  Some  were  seen  in  consul- 
tation. Of  these  40,  21  recovered  and  19  died.  Of  the  19  fatal  cases,  9 
died  in  the  first  week,  5  in  the  second  week.  1  in  the  third  week,  1  on  the 
twenty-fifth  day,  1  on  the  thirty-first  day,  and  1  in  the  sixteenth  week.  This 
last  patient,  a  boy  of  ten  years,  would,  in  my  opinion,  have  recovered  with 
better  nursing.  His  death  occurred  from  large  bed-sores  which  extended  to 
the  bones,  produced  by  lying  a  long  time  in  one  position  on  a  hard  bed  when 
he  was  too  weak  to  move,  and  often  with  soiled  bedclothes  underneath  him. 
The  remaining  case  of  the   19  died  after  a  prolonged  sickness. 

There  is  probably  no  disease  which  falsifies  the  predictions  of  the  phy- 
sician more  frequently  than  cerebro-spinal  fever.  This  is  due  partly  to  the 
severity  of  the  cerebral  symptoms  in  the  commencement,  which,  did  they 
occur  in  other  forms  of  meningitis  with  which  he  is  more  familiar,  would 
justify  an  unfavorable  prognosis,  and  partly  to  the  remissions  and  exacerba- 
tions, the  occurrence  alternately  of  symptoms  of  apparent  convalescence  and 
recrudescence  or  relapse  which  characterize  the  course  of  this  malad3\  Grave 
initial  symptoms,  which  may  appear  to  have  a  fatal  augury,  are  often  fol- 


496  CEREBROSPINAL  FEVER. 

lowed  by  such  a  remission  that  all  danger  seems  past,  and  in  a  few  hours 
later  perhaps  the  symptoms  are  nearly  or  quite  as  grave  as   at  first. 

Under  the  age  of  five  years  and  over  that  of  thirty  the  prognosis  is  less 
favorable  than  between  these  ages.  An  abrupt  and  violent  commencement, 
profound  stupor,  convulsions,  active  delirium,  and  great  elevation  of  tempera- 
ture are  symptoms  which  should  excite  solicitude  and  render  the  prognosis 
guarded.  If  the  temperature  remain  above  105°  F.,  death  is  probable,  even 
with  moderate  stupor.  Numerous  and  large  petechial  eruptions  show  a  pro- 
foundly altered  state  of  the  blood,  and  are  therefore  a  bad  prognostic  ;  and  so 
is  continued  albuminuria,  since  it  shows  great  blood-change  or  nephritis,  while 
other  organs  than  the  kidneys  are  probably  also  involved.  In  one  case,  a  boy 
whom  I  examined  nearly  a  year  after  the  cerebro-spinal  fever,  the  kidneys 
were  still  affected.  He  had  anasarca  of  the  face  and  extremities,  with  albu- 
minuria. Chronic  Bright's  disease  had  occurred  from  the  acute  nephritis 
which  complicated  cerebro-spinal  fever.  Profound  stupor,  though  a  danger- 
ous symptom,  is  not  necessarily  fatal  so  long  as  the  patient  can  be  aroused  to 
partial  consciousness  and  the  pupils  are  responsive  to  light ;  so  long  as  it 
does  not  pass  into  actual  coma  it  is  less  dangerous  than  active  or  maniacal 
delirium,  which  is  likely  to  eventuate  in  this  coma. 

A  mild  commencement  with  general  mildness  of  symptoms,  as  the  ability 
to  comprehend  and  answer  questions,  moderate  pain  and  muscular  rigidity, 
some  appetite,  moderate  emaciation,  little  vomiting,  etc.,  justify  a  favorable 
prognosis,  but  even  in  such  cases  it  should  be  guarded  till  convalescence  is 
fully  established. 

We  may  repeat  and  emphasize  the  important  fact  shown  by  the  above 
statistics  that  patients  who  live  till  the  close  of  the  second  week  without 
serious  complications  will  probably  recover.  The  danger  after  this  period 
is,  in  most  instances,  from  exhaustion  and  feeble  action  of  the  heart,  result- 
ing from  the  impaired  nutrition  and  the  protracted  course  of  the  disease. 

Complications  which  most  frequently  pertain  to  the  lungs  increase  greatly 
the  gravity  of  many  cases  and  contribute  to  the  fatal  ending.  The  fact  that 
Webber  in  his  prize  essay  describes  a  variety  of  cerebro-spinal  fever  which  he 
designates  pneumonic,  and  that  those  who  make  post-mortem  examinations 
find  that  "  oedema,  hypostatic  congestion  of  the  lungs,  bronchitis,  atelectasis, 
and  broncho-pneumonia  are  extremely  common  lesions  in  cerebro-spinal  men- 
ingitis" (Welch),  indicate  a  source  of  danger  in  addition  to  that  located  in 
the  cerebro-spinal  system.  One  close  observer  of  an  epidemic  writes:  "In 
all  the  fatal  cases  which  came  under  my  notice  the  most  prominent  symptoms 
which  preceded  death  were  those  which  indicate  impairment  and  perversion 
of  the  respiratory  functions.  As  the  breathing  became  more  hurried  and 
difl&cult  the  general  depression  became  more  intense,  the  pulse  became  weaker 
and  quicker,  and  the  temperature  of  the  skin  more  elevated." 

Parenchymatous  degeneration  of  the  liver  and  kidneys  is  another  serious 
complication.  The  kidneys  are  probably  more  frequently,  and  to  a  greater 
extent,  diseased  than  the  liver.  We  have  already  stated  that  nephritis  was 
present  in  1  of  the  8  cases  examined  by  Prof.  Welch.  In  the  Revue  medi- 
cale  for  June  3,  1882,  M.  Ernest  Gaudier  published  the  case  of  a  female 
who  died  comatose  on  the  sixth  day  of  cerebro-spinal  fever.  Examination 
of  the  urine  had  revealed  the  presence  of  "  retractile  albumen  of  Prof. 
Bouchard,  attributable  to  renal  lesions,  and  non-retractile  albumen,  consid- 
ered as  an  indication  of  some  general  infection  of  the  system."  Microscopic 
examination  of  the  kidneys  "  showed  considerable  swelling  and  granular 
degeneration  of  the  renal  epithelial  cells,  with  effusion  of  granular  matter 
within  the  lumina  of  the  tubules."  We  have  seen  from  the  case  referred  to 
above  that  the  renal  complication  may  persist  and  become  chronic.     Those 


DIAGNOSIS— TREATMENT.  497 

who  fully  recover  often  exhibit  symptoms  usually  of  a  nervous  character, 
as  irritability  of  disposition,  headache,  etc.,  for  months  or  years  after  con- 
valescence is  established. 

Diagnosis. — Cerebro-spinal  fever,  on  account  of  the  nature  and  severity 
of  its  symptoms  and  the  suddenness  of  its  onset,  may  be  mistaken  for  scarlet 
fever,  and  vice  versa.  In  one  instance,  to  my  knowledge,  this  mistake  was 
made.  High  febrile  movement,  vomiting,  convulsions,  and  stupor  are  com- 
mon in  the  commencement  of  scarlet  fever,  and  the  same  symptoms  commonly 
usher  in  the  severer  form.s  of  cerebro-spinal  fever.  It  will  aid  in  diagnosis  to 
ascertain  whether  there  be  redness  of  the  fauces,  for  this  is  present  in  the 
commencement  of  scarlet  fever,  and  a  few  hours  later  the  characteristic  efflo- 
rescence appears  on  the  skin. 

The  diagnosis  of  cerebro-spinal  fever  from  the  common  forms  of  menin- 
gitis is  ordinarily  not  diflScult,  for  while  in  the  former  the  maximum  inten- 
sity of  symptoms  occurs  in  the  first  days,  in  the  latter  there  is  gradual  and 
progressive  increase  of  symptoms  from  a  comparatively  mild  commencement. 
Moreover,  cases  of  ordinary  or  sporadic  meningitis  occurring  at  the  age 
when  cerebro-spinal  fever  is  most  frequent  are  commonly  secondary,  being 
due  to  tubercles,  caries  of  the  petrous  portion  of  the  temporal  bone,  or  other 
lesion,  and  are  therefore  preceded  and  accompanied  by  symptoms  which  are 
directly  referable  to  the  primary  disease.  We  have  seen  how  different  it  is 
in  cerebro-spinal  fever,  which  in  most  patients  begins  abruptly  in  a  state  of 
previous  good  health.  Again,  in  cerebro-spinal  fever  after  the  second  or 
third  day  hypersesthesia,  retraction  of  the  head,  and  other  characteristic 
symptoms  occur,  which  are  either  not  present  or  are  much  less  pronounced 
in  ordinary  meningitis.  Some  of  the  milder  cases  of  cerebro-spinal  fever 
might  be  mistaken  for  hysteria,  but  the  pain  in  the  head  and  elsewhere,  the 
muscular  rigidity,  and  especially  the  occurrence  of  more  or  less  fever, 
enable  us  to  make  the  diagnosis.  Continued  fever,  typhus  or  typhoid, 
resembles  cerebro-spinal  fever  in  certain  particulars,  but  it  lacks  the  muscu- 
lar contraction  and  rigidity  which  characterize  the  latter.  It  does  not  usu- 
ally begin  so  abruptly,  with  such  severe  symptoms,  especially  such  severe 
headache,  has  less  marked  fluctuations,  and  a  more  definite  duration.  These 
facts  in  connection  with  the  character  of  the  prevailing  epidemic  will  enable 
us  to  make  the  diagnosis.  In  one  instance  commencing  retro-pharyngeal 
abscess,  probably  associated  with  vertebral  caries,  was  at  first  mistaken  by 
me  for  cerebro-spinal  fever.  The  patient  was  an  infant,  had  a  temperature 
of  104°  F.,  stiffness  of  the  neck  with  some  retraction  of  the  head,  and  cried 
from  pain  when  the  head  was  brought  forward.  The  speedy  occurrence  of 
two  large  abscesses  in  other  parts  of  the  system,  difficult  deglutition,  and 
noisy  respiration,  led  to  a  digital  exploration  of  the  fauces,  when  the  abscess 
was  found  and  opened. 

Treatment. — Since  in  epidemics  of  cerebro-spinal  fever  cases  are  more 
frequent  and  severe  where  antihygienic  conditions  exist,  it  is  evident  that 
measures  looking  to  the  removal  of  such  conditions,  measures  designed  to 
procure  pure  air  in  the  domicile,  wholesome  diet,  and  a  quiet  and  regular 
mode  of  life — in  fine,  measures  designed  to  produce  the  highest  degree  of 
health — are  of  the  first  importance  for  the  prevention  of  the  disease. 
Cleanliness  of  the  streets  and  areas,  as  well  as  of  the  apartments,  good 
sewerage  and  drainage,  the  prompt  removal  of  all  refuse  matter,  avoidance 
of  overcrowding — in  a  word,  the  strict  observance  of  sanitary  requirements 
in  every  particular — will,  there  can  be  little  doubt  from  what  we  know  of 
the  causation  and  nature  of  cei'ebro-spinal  fever,  diminish  the  number  and 
severity  of  the  cases.  The  avoidance  of  fatigue  and  overwork  and  of  men- 
tal excitement,  the  use  of  plain  and  wholesome  diet,  sufficient  sleep,  the 
32 


498-  CEREBROSPINAL  FEVER. 

utmost  regularity  in  the  mode  of  life,  with  the  least  possible  exposure  to 
depressing  agencies,  are  the  important  preventive  measures  which  should  be 
recommended  during  an  epidemic  of  cerebro-spinal  fever. 

The  enjoining  of  a  quiet  and  regular  mode  of  life  as  a  preventive 
measure  during  the  occurrence  of  an  epidemic  of  cerebro-spinal  fever  is 
not  inconsistent  with  the  theory  that  the  cause  is  a  micro-organism.  It  is 
not  unreasonable  to  suppose  that  the  system  may  be  more  or  less  under  the 
influence  of  the  specific  principle,  and  that  this  principle  may  obtain  lodg- 
ment in  the  blood  or  tissues  without  result  until  some  exciting  cause  occurs 
which  depresses  the  system  and  disturbs  the  functions,  when  the  resisting 
power  fails  and  cerebro-spinal  fever  appears ;  just  as  those  exposed  to 
Asiatic  cholera  may  remain  well  until  some  imprudence  in  the  diet  or  the 
mode  of  life  causes  an  outbreak  of  the  malady. 

Curative  Treatment. — In  the  commencement  of  cerebro-spinal  fever 
intense  inflammatory  congestion  occurs  of  the  cerebral  and  spinal  meninges, 
and  also  to  a  certain  extent  of  the  brain  and  spinal  cord.  As  regards  treat- 
ment, the  obvious  indication  is  to  reduce  the  hyperaemia  of  the  vessels  as 
quickly  as  possible  and  subdue  or  diminish  the  inflammation.  For  this  pur- 
pose bags  or  bladders  of  ice  should  be  immediately  applied  over  the  head 
and  to  the  nucha,  and  constantly  retained  there  as  long  as  there  is  no  com- 
plaint of  chilliness,  no  marked  diminution  of  temperature,  and  the  patient 
experiences  some  relief  from  the  intense  headache  and  other  symptoms. 
Bran  mixed  with  pounded  ice  produces  a  more  uniform  coldness  and  is  some- 
times more  agreeable  to  the  patient  than  the  ice  alone.  The  bag  or  bags 
should  be  about  one-third  full,  so  as  to  fit  upon  the  head  like  a  cap,  and  the 
nurse  should  be  instructed  to  renew  the  ice  as  soon  as  it  melts.  In  severe 
cases  with  marked  elevation  of  temperature  it  is  proper  to  apply  cold  over 
the  dorsal  and  lumbar  vertebrae,  as  well  as  upon  the  head  and  nucha.  A 
hot  mustard  foot-bath  or  a  general  warm  bath  in  those  cases  in  which  con- 
vulsions are  present  or  threatening,  or  in  which  thei-e  is  delirium  or  great 
agitation  or  severe  peripheral  pains,  is  also  useful,  since  it  has  a  calmative 
effect  and  acts  as  a  derivative  from  the  hyperaemic  nerve-centres.  One 
writer  states  that  he  obtained  marked  benefit  in  a  case  by  immersing  the 
body  to  the  neck  in  hot  water. 

The  abstraction  of  blood,  usually  by  leeches  applied  to  the  temples, 
behind  the  ears,  or  along  the  spine,  has  been  employed,  but  even  in  the  com- 
mencement of  the  present  century,  when  it  was  customary  to  bleed  generally 
and  locally  in  the  treatment  of  inflammatory  and  febrile  diseases,  a  majority 
of  the  American  physicians  whose  writings  are  extant  discountenanced  the 
abstraction  of  blood  in  the  treatment  of  this  disease.  Drs.  Strong,  Foot, 
and  Miner,  though  under  the  influence  of  the  Broussaisian  doctrine,  were  good 
observers,  and  they  soon  abandoned  the  use  of  the  lancet  and  leeches  in  the 
treatment  of  these  patients  for  more  sustaining  measures.  Strong'  states  that 
certain  physicians  employed  venesection  as  a  means  of  relieving  the  internal 
congestions,  but,  finding  that  the  pulse  became  more  frequent  after  a  mode- 
rate loss  of  blood,  they  soon  laid  aside  the  lancet.  Some  experienced  physi- 
cians of  that  period,  however,  continued  to  recommend  and  practise  deple- 
tion, general  as  well  as  local,  as,  for  example.  Dr.  Gallop,  who  treated  many 
cases  in  Vermont  in  the  epidemic  of  1811. 

Venesection  in  the  treatment  of  cerebro-spinal  fever  is  universally  dis- 
carded at  the  present  time  in  this  country  and  Europe,  but  some  intelligent 
physicians,  as  Sanderson  and  Niemeyer,  approve  of  local  bleeding  in  certain 
cases.  It  is,  in  my  opinion,  after  examining  the  histories  of  many  cases,  uncer- 
tain whether  the  abstraction  of  blood  should  ever  be  recommended,  but  if  it 

'  Medical  and  Fhysiological  Register,  1811. 


TREATMENT.  499 

be  prescribed  it  should  be  on  the  first  day,  when  the  hypergemia  is  f^reatest, 
by  the  application  of  only  a  few  leeches  behind  the  ears,  and  never  except 
when  coma  or  convulsions  are  present  or  threatening  and  the  patient  is  robust. 
The  fact  should  not  be  forgotten  that  cerebro-spinal  fever  is  in  its  nature 
asthenic  and  protracted,  and  that  the  intense  inflammatory  congestion  of  the 
nervous  centres  can  ordinarily  be  relieved,  if  relieved  at  all,  by  the  other 
measures  recommended,  which  do  not  reduce  the  strength.  The  alarming 
symptoms  which  usher  in  an  attack,  the  intense  headache,  restlessness,  deli- 
rium, sometimes  eclampsia  or  coma,  seem  to  demand  the  most  energetic  treat- 
ment, and  yet  it  is  surprising  to  one  who  has  his  first  experiences  with  this 
malady  how  patients  under  proper  treatment,  without  the  abstraction  of 
blood,  emerge  from  an  apparently  almost  hopeless  state  and  ultimately  recover. 
There  may  be  total  unconsciousness,  the  pupils  dilated  like  rings  and  insen- 
sible to  light,  the  head  intensely  hot,  tonic  convulsions  pi'esent  or  alternating 
with  frequent  clonic  convulsions,  and  yet  these  symptoms,  which  in  any  other 
disease  would  be  regarded  as  sufiicient  to  justify  the  prognosis  of  certain 
death,  may  gradually  pass  oft'  toward  the  close  of  the  first  or  in  the  second 
week,  and  the  case  afterward  progress  favorably.  In  the  New  York  epidemic 
of  1872 — previous  to  which  physicians  of  this  city  had  no  personal  experience 
with  cerebro-spinal  fever — many  cases  were  pronounced  hopeless  which  ulti- 
mately did  well  without  abstraction  of  blood.  In  a  case  occurring  in  the 
practice  of  Dr.  Griswold  the  patient  was  comatose  for  three  days,  with  pupils, 
not  responding  or  but  very  feebly  responding  to  light,  but  he  recovered  with- 
out the  abstraction  of  blood  and  with  the  remedies  ordinarily  employed.  In 
a  case  which  we  will  presently  relate  in  speaking  of  another  local  treatment 
the  patient  was  still  insensible  in  the  third  week,  with  pupils  greatly  dilated 
and  insensible  to  light,  and  yet  recovered  without  losing  blood.  Such  cases 
show  that  the  most  urgent  symptoms,  such  as  seem  to  indicate  the  prompt 
employment  of  leeches  in  order  to  reduce  the  meningeal  hyperaemia  and  the 
consecutive  congestion  of  the  nerve-centres,  may  be  relieved  and  the  patient 
recover  without  such  depletion,  and  with  the  preservation  of  the  blood,  which 
is  so  much  needed  in  the  subsequent  asthenic  course  of  the  malady. 

In  only  one  case  have  I  recommended  the  abstraction  of  blood,  and  this 
was  so  instructive  that  I  will  briefly  relate  it :  K  girl  four  years  of  age  was 
seized  on  March  7,  1873,  with  vomiting,  chilliness,  and  trembling,  followed 
by  severe  general  clonic  convulsions  lasting  about  fifteen  minutes ;  was  semi- 
comatose ;  pulse  132,  and  a  few  hours  later  156  ;  temperature  101^°  F. ;  res- 
piration 44 ;  eyes  closed,  pupils  moderately  dilated  and  feebly  responsive  to 
light,  dusky  mottling  of  skin,  constant  tremulousness  with  twitching  of  limbs. 
Bromide  of  potassium  was  administered  in  hourly  doses  of  four  grains,  ice 
applied  to  the  head  and  nucha,  and  a  hot  mustard  foot-bath  followed  by  sina- 
pisms to  the  nucha.  On  the  following  day,  March  8th,  she  was  partly  conscious 
when  aroused,  but  immediately  relapsed  into  sleep ;  head  retracted,  bowels 
constipated;  pulse  136;  temperature  102°;  vomited  occasionally.  It  was 
thought  proper,  on  account  of  the  extreme  stupor,  to  apply  one  leech  to 
each  temple,  and  the  bites  trickled  slowly  nearly  five  hours.  The  other 
treatment  was  continued.  On  the  9th  the  pulse  was  180 — so  feeble  that  it 
was  counted  with  difficulty  ;  temperature  101 2°.  The  patient  was  evidently 
sinking.  It  was  necessary  to  order  whiskey  in  teaspoonful  doses  every  two 
hours,  with  beef  tea  and  other  most  nutritious  drinks.  Evening,  pulse  172, 
still  feeble.  March  10th,  pulse  180,  barely  perceptible  ;  great  hyperaesthesia  ; 
axillary  temperature  100°;  axes  of  eyes  directed  downward.  After  this  the 
patient  gradually  rallied  for  a  time,  the  pulse  becoming  stronger  and  less 
frequent,  but  death  finally  occurred  after  nine  weeks  in  a  state  of  extreme 
emaciation  and  exhaustion.     Slijarht  convulsions  occurred  in  the  last  hours. 


500  CEREBROSPINAL  FEVER. 

It  is  seen  that  in  the  ahove  case,  which  may  be  regarded  as  typical,  the 
patient  passed  into  a  state  of  extreme  prostration  after  the  application  of  the 
leeches,  so  that  for  three  days  I  did  not  believe  that  she  would  live  from  hour  to 
hour,  and  death  occurred  after  an  illness  of  nine  weeks,  apparently  from  sheer 
exhaustion.  Experience  like  this,  which  corresponds  with  that  of  most  other 
observers,  shows  the  necessity  of  preserving  the  blood,  and  thereby  the 
strength,  however  urgent  the  initial  symptoms,  inasmuch  as  cerebro-spinal 
fever  in  its  subsequent  course  is  attended  by  such  marked  asthenia.  On 
May  3,  1878,  a  boy  of  ten  years  was  admitted  into  one  of  the  New  York 
hospitals  in  the  service  of  a  prominent  physician.  It  was  stated  that  he 
had  been  four  days  sick  with  cerebro-spinal  fever,  and  among  other  charac- 
teristic symptoms  he  had  had  delirium  every  night,  and  on  May  2d  delirium 
in  the  day-time,  which  had  abated  considerably  after  free  epistaxis.  In  the 
hospital  the  application  of  ten  leeches  along  the  spine  was  ordered,  but  it 
does  not  appear  to  have  diminished  the  delirium  or  any  other  symptom,  and 
the  following  day  the  pulse  was  so  frequent  and  feeble  that  active  stimula- 
tion by  brandy  was  resorted  to.  He  had  three  strong  convulsions  on  May 
13th,  which  were  relieved  by  ice  to  the  head  and  nape  of  neck  and  by  six 
minims  of  Magendie's  solution.  Severe  pains  occurred  at  times  in  the  back 
and  limbs,  and  on  the  29th,  one  month  after  the  commencement  of  the  dis- 
ease, the  same  pain  frequently  recurring,  twelve  leeches  were  ordered  to  be 
applied  to  the  spine.  On  June  2d  the  limbs  were  flexed  and  quite  stiff,  and 
the  effort  to  move  them  was  attended  by  great  pain.  The  pain  in  the  back 
was  also  more  constant,  and  in  consequence  sixteen  leeches  were  applied  to 
the  spine  The  next  day  there  was  no  pain,  but  the  patient  was  very  stupid. 
On  June  6th  the  records  state  that  he  was  obviously  losing  strength  day  by 
day — that  his  emaciation  was  extreme  and  his  anaemia  very  marked.  But 
he  had  great  vitality,  and,  although  he  had  strabismus,  bed-sores,  incontinence 
of  urine  and  feces,  and  extreme  prostration,  he  lingered  till  August  1st.  At 
the  autopsy :  "  Body  a  skeleton  ;  brain,  dura  mater,  and  pia  mater  appear 
normal,  except  a  little  thickening  of  latter  at  base  of  brain  ;  ventricles  much 
enlarged  and  full  of  clear  serum  ;  surface  of  walls  of  ventricles  looks  normal, 
but  is  soft ;  spinal  cord  and  membranes  appear  normal  to  the  naked  eye." 
No  disease  was  discovered  in  other  organs,  except  that  the  liver  appeared  con- 
gested and  the  kidneys  pale.  It  can  scarcely  be  doubted  that  although  some 
temporally  relief  from  the  pain  may  have  resulted  to  this  patient  by  the 
repeated  application  of  leeches,  which  diminished  the  meningeal  hypei'aemia, 
yet  his  chances  for  ultimate  recovery  would  have  been  far  better  without  such 
depletion.  Therefore  the  histories  of  cases  show  that  the  result  of  abstrac- 
tion of  blood  has  been  unsatisfactory,  on  account  of  the  asthenic  nature  and 
protracted  course  of  cerebro-spinal  fever,  and  it  should  never  be  recommended 
as  a  remedial  agent. 

Some  benefit  is  apparently  derived  from  the  application  of  stimulating 
and  moderately  irritating  lotions  along  the  spine.  A  liniment  consisting  of 
equal  parts  of  camphorated  oil  and  turpentine  briskly  applied  by  friction 
with  flannel  up  and  down  the  spine  till  redness  is  produced  appears  to  cause 
some  alleviation  of  the  suffering,  and  it  does  not  conflict  with  the  use  of  the 
ice-bag.  Dr.  William  H.  Sutton  of  Dallas,  Texas,  has  published  the  follow- 
ing interesting  case,  showing  the  benefit  from  stimulating  and  irritant  appli- 
cations over  the  spine  made  in  an  unusual  manner :  A  child  aged  three  and  a 
half  years  had  been  three  weeks  under  treatment,  through  error  of  diagnosis, 
for  supposed  continued  fever.  When  Dr.  Sutton  assumed  charge  of  the 
case,  November  20,  1877,  the  pupils  were  greatly  dilated  and  insensible  to 
light ;  features  pallid  and  pinched  ;  pulse  130  ;  temperature  103°  F. ;  patient 
totally  unconscious.     November  21st,  morning  temperature  105°,  pulse  140; 


TREATMENT.  501 

evening  temperature  10H°,  pulse  120.  November  22d,  morning  temperature 
106i°,  pulse  100;  restless;  evening  temperature  105^°,  pulse  120;  had  not 
slept,  except  for  moments,  for  nearly  two  weeks.  A  strip  of  flannel  saturated 
with  turpentine  was  placed  over  the  spine  from  the  neck  to  the  sacrum,  and 
a  hot  smoothing-iron  was'  run  up  and  down  it,  and  eight  drops  of  the  fluid 
extract  of  ergot  were  given  every  three  hours.  Dr.  Sutton  adds :  "  The 
father  stated  to  me  that  as  soon  as  the  application  was  finished  the  child  fell 
asleep,  and  slept  several  hours — the  first  for  two  weeks — and  the  fever  rapidly 
declined.  From  this  time  he  began  to  improve,  and  gradually  and  fully  recov- 
ered." The  use  of  irritants  and  derivatives  over  the  spine  in  the  treatment 
of  cerebro-spinal  fever  has  been  long  and  favorably  known,  but  the  mode 
of  producing  irritation  in  the  above  case  was  novel. 

Internal  Treatment. — It  will  aid  in  the  selection  of  the  proper  remedies  to 
recall  to  mind  the  pathological  state  which  we  know  to  be  present  from  the 
many  autopsies  which  have  been  recorded.  We  have  seen  that  the  largest 
mortality,  and  consequently  the  most  dangerous  period,  is  in  the  first  days, 
when  there  is  intense,  suddenly-developed  inflammatory  congestion  of  the 
meninges,  with  more  or  less  secondary  hyperaemia  of  the  underlying  brain 
and  spinal  cord,  producing  great  headache,  delirium,  or  somnolence,  with 
exaggerated  reflex  irritability  of  the  spinal  cord,  so  that  eclampsia  is  a  com- 
mon and  fatal  complication. 

Fortunately,  a  remedy  has  been  discovered  in  modern  times  (the  bromide 
of  potassium)  which  acts  promptly  and  efficiently.  It  can  be  safely  admin- 
istered in  large  and  frequent  doses  to  the  youngest  child.  It  is  quickly  elim- 
inated from  the  system  through  the  kidneys  and  other  emunctories  in  chil- 
dren, so  as  to  prevent  the  occurrence  of  bromism,  at  least  to  the  extent  of 
causing  any  unpleasant  consequences.  It  causes  contraction  of  the  minute 
vessels  of  the  nervous  centres  so  as  to  diminish  the  hyperaemia,  as  shown  by 
the  experiments  and  observations  of  Dr.  Putnam-Jacobi  and  others,  and  at 
the  same  time  it  diminishes,  in  a  marked  degree,  the  reflex  irritability  of  the 
spinal  cord — two  most  beneficial  and  important  effects  of  its  use  in  this  dis- 
ease. Many  children  by  its  timely  employment  are  saved  from  the  dangers 
of  eclampsia,  and  by  its  sedative  effect  on  the  nervous  system  and  contractile 
action  on  the  capillaries  it  probably  diminishes  the  intensity  of  the  inflam- 
mation and  the  amount  of  exudation.  I  usually  prescribe  it,  as  recommended 
by  Dr.  Squibb,  dissolved  in  simple  cold  water.  In  ordinary  cases,  not  attended 
by  eclampsia  or  marked  symptoms  which  show  that  eclampsia  is  threatening, 
I  generally  prescribe  at  my  first  visit  about  four  grains  every  two  hours  to  a 
child  of  two  years  who  has  the  usual  restlessness  and  apparent  headache, 
and  six  grains  to  a  child  of  five  years.  If  eclampsia  occur,  the  bromide 
should  be  given  more  frequently,  as  every  five  or  ten  minutes,  till  it  cea,ses. 
It  is  important  to  be  able  to  determine  when  the  quantity  of  the  bromide 
administered  should  be  diminished  and  when  its  use  should  be  discontinued. 
I  have  very  rarely  observed  bromism  in  children,  and  never  to  the  extent  of 
doing  any  serious  harm,  though  for  many  years  I  have  administered  it  in 
large  and  frequent  doses  whenever  the  occasion  seemed  to  require  it ;  but 
the  symptoms  of  bromism  cannot  readily  be  discriminated  from  those  which 
may  result  from  cerebro-spinal  fever,  such  as  muscular  weakness,  dilated 
pupils,  with  perhaps  impaired  vision,  unsteady  gait,  nausea  or  vomiting,  and 
abdominal  pains.  If  the  case  progress  favorably,  frequent  and  large  doses 
should,  in  my  opinion,  be  given  only  in  the  first  week,  after  which  this  agent 
should  be  given  at  longer  intervals  or  in  smaller  doses.  But  during  exacer- 
bations, which  are  liable  to  occur  from  time  to  time  till  the  patient  is  well  on 
the  way  to  recovery,  the  use  of  the  bromide  in  full  doses  is  again  indicated 
till  the  urgent  symptoms  begin  to  abate. 


502  CEREBROSPINAL  FEVER. 

Phenacetin  promises  also  to  be  another  useful  remedy  in  this  disease,  from 
its  well-known  action  in  relieving  headache,  reducing  fever,  and  procuring 
sleep.  It  may  be  administered  with  the  bromide.  It  appears  to  be  a  very 
useful  adjuvant  to  the  bromide  during  the  first  week,  when  the  temperature 
is  most  elevated  and  the  headache  severe.  At  a  later  stage,  when  asthenic 
symptoms  are  more  pronounced,  its  use  appears  to  be  contraindicated,  unless 
in  exceptional  instances.  Antipyrine  has  been  used  in  place  of  phenacetin, 
but  it  appears  to  be  more  depressing. 

Ergot  is  another  very  important  remedy.  It  is  scarcely  less  useful  than 
the  bromide,  from  its  action  in  contracting  the  arterioles  and  diminishing  the 
flow  of  arterial  blood.  The  fluid  extract,  tincture,  or  wine  of  secale  cornutum 
can  be  employed  or  its  active  principle,  ergotin.  Squibb's  fluid  extract  has 
been  more  used  in  New  York  City  than  any  other  preparation.  I  have  com- 
monly prescribed  it,  except  for  patients  old  enough  to  take  ergotin  in  the  pill. 
The  doses  employed  by  different  physicians  vary  greatly.  Dr.  William  A. 
Thomson,  professor  of  Materia  Medica  in  the  New  York  University,  has  pre- 
scribed, so  far  as  I  am  aware,  the  largest  doses  in  the  treatment  of  this  dis- 
ease— to  wit,  one  teaspoonful  of  the  fluid  extract  of  secale  cornutum  every 
three  hours  to  a  boy  of  ten  years,  in  Roosevelt  Hospital  in  1878,  with  apparent 
benefit  as  regards  the  meningeal  hyperaemia,  although  the  case  was  fatal  after 
the  lapse  of  several  months  from  asthenia.  The  alkaloid  ergotin,  to  which 
the  beneficial  eff"ects  of  the  secale  cornutum  are  due,  may  be  given  in  the  pill 
or  in  solution.  In  case  of  much  irritability  of  the  stomach  it  can  be  employed 
hypodermically,  dissolved  in  water  with  glycerin.  The  efiicacy  of  this  agent 
is  most  marked  during  the  first  and  second  weeks,  when  the  congestion  of 
the  nervous  centres  is  greatest.  At  a  more  advanced  stage,  when  there  is 
less  congestion  and  the  danger  arises  from  the  inflammatory  products  and 
structural  changes,  the  time  for  the  use  of  ergot  is  past,  or  if  it  is  still  of 
some  service  it  is  less  needed  than  at  first  and  should  be  given  less  frequently. 

The  severe  headache  and  restlessness  which  attend  many  cases  require 
the  occasional  use  of  an  opiate  or  the  hydrate  of  chloral.  Chloral  in  proper 
dose  never  fails  to  give  quiet  sleep,  and  it  is  supposed  by  some  who  have 
studied  its  therapeutic  action  that  it  diminishes  the  cerebral  circulation.  It 
is  therefore  a  useful  adjuvant  to  the  bromide.  Five  grains  usually  suffice 
for  a  child  of  six  to  eight  years.  Chloral  is  especially  useful  in  cases 
attended  by  eclampsia  or  by  symptoms  which  threaten  eclampsia,  since  it  acts 
promptly  and  decidedly  in  diminishing  reflex  irritability.  Formerly  it  was 
considered  injudicious  and  unsafe  to  prescribe  opiates  in  meningeal  inflamma- 
tion, since  it  was  supposed  that  they  increased  the  liability  to  coma,  but 
experience  shows  that  they  are  sometimes  very  useful  in  this  disease  when 
administered  in  small  or  moderate  doses,  and  without  the  risk  which  was  once 
supposed  to  be  incurred  by  their  use.  The  thirty-second  part  of  a  grain  of 
morphia  administered  at  intervals  of  some  hours  was  sufficient  to  relieve  the 
suffering  of  one  of  my  patients  at  the  age  of  six  years. 

Quinia  apparently  does  not  exert  any  marked  controlling  effect  on  the 
course  of  cerebro-spinal  fever  or  its  symptoms,  although  the  paroxysmal  cha- 
racter of  the  severe  pains  in  many  patients  suggests  the  use  of  this  agent  as 
an  antiperiodic.  It  was  frequently  prescribed  by  New  York  physicians  in 
the  epidemic  of  1872,  but  I  believe  that  the  opinion  was  unanimous  that  it 
was  not  the  proper  remedy.  I  have  prescribed  it  in  large  and  small  doses,  in 
one  instance  giving  fifteen  grains  to  a  child  of  thirteen  years,  but  do  not  know 
that  I  have  derived  any  benefit  from  its  use  in  this  malady.  It  may  increase 
the  hypersemia  of  the  meninges  and  the  cerebro-spinal  axis. 

When  the  acute  stage  has  abated  measures  designed  to  remove  the  serum 
which  sometimes  remains,  constituting  a  hydrocephalus,  are  indicated.     For 


ACUTE  RHEUMATISM.  oO;3 

this  purpose  the  iodide  of  potassium  is  probably  more  useful  than  any  other 
agent.  It  is  administered  by  some  physicians  early  along  with  the  bromide, 
in  the  same  manner  in  which  they  have  been  in  the  habit  of  treating  other 
forms  of  meningitis.  I  have  prescribed  it  with  the  bromide  and  alone  when 
the  bromide  was  discontin\ied,  but  whether  it  produces  any  marked  sorbefa- 
cient  effect  in  this  disease  apart  from  the  removal  of  serum  seems  to  me 
doubtful. 

The  result  depends  to  a  great  extent  on  the  nursing.  The  skill  of  the 
physician  may  be  thwarted  and  the  life  of  the  patient  lost  by  inefficient 
nursing.  No  other  disease  more  urgently  requires  kind,  intelligent,  and  con- 
stant attendance  night  and  day  on  the  part  of  the  nurse.  Not  only  should 
the  medicines  and  nutriment  be  given  punctually  and  regularly,  but  the 
great  restlessness  of  the  patient  in  the  first  days  requires  constant  readjusting 
of  the  ice-bags,  and  during  the  long  period  of  convalescence  the  utmost  care 
is  required  to  remove  at  once  the  excretions  in  order  to  prevent  bed-sores, 
and  to  give  the  proper  amount  and  kind  of  nutriment  to  prevent  the  emacia- 
tion and  weakness  from  which  many  perish. 

The  diet,  from  the  beginning  to  the  end  of  the  malady,  should  be  the 
most  nutritious  and  such  as  is  easily  digested.  It  is  necessary  to  give  it  in 
the  liquid  form,  unless  in  mild  cases  in  which  the  appetite  may  not  be  entirely 
lost.  It  is  proper  to  aid  the  digestion  by  pepsin  preparations.  Nutritive 
enemata,  consisting  of  beef  tea  or  one  of  the  extracts  of  beef,  milk,  and 
brandy,  aid  in  averting  the  fatal  prostration  in  protracted  cases.  After  the 
acute  stage  has  passed  and  the  meningeal  hyperaemia  has  abated  the  alcoholic 
compounds  in  moderate  doses,  which  in  the  beginning  might  be  injurious, 
may  now  be  useful,  administered  regularly  by  the  mouth.  The  room  should 
be  dark,  well  ventilated,  and  quiet.  All  sympathizing  friends  who  are  not 
required  in  the  nursing  should  be  excluded.  I  know  of  no  other  disease  in 
which  this  is  so  necessary,  for  mental  excitement  may  produce  dangerous 
aggravation  of  symptoms. 


CHAPTER   V. 

ACUTE  KHEUMATISM. 

Rheumatism  is  a  constitutional  disease  with  a  local  manifestation — to 
wit,  inflammation  of  the  fibrous  tissues,  chiefly  in  and  around  the  articula- 
tions, but  occasionally  in  other  parts,  as  the  heart  and  nervous  centres.  It 
was  formerly  supposed  to  be  rare  in  children,  but  more  accurate  observations 
show  that  it  is  scarcely  less  common  during  childhood  than  in  adult  life.  In 
young  patients,  especially  under  the  age  of  six  or  eight  years,  it  is  frequently 
overlooked,  for  the  articular  inflammations  in  such  patients  are  commonly 
slight.  In  the  last  twenty  years,  during  my  connection  with  the  children's 
class  in  the  Bureau  for  the  Relief  of  the  Out-door  Poor,  I  have  examined 
many  children  with  rheumatism  or  the  cardiac  lesions  resulting  from  rheu- 
matism, and  ordinarily  I  have  found  that  few  joints  had  been  affected,  and  that 
there  had  been  but  little  swelling  of  them  or  redness,  and  that  the  patients 
were  usually  not  confined  to  bed,  or  even  to  the  sitting  posture,  but  had  been 
able  to  walk  about,  though  with  restraint  and  complaint  of  pain  or  soreness. 
The  parents  in  many  instances  supposed  that  their  children  were  suffering 
from  "  growing  pains,"  as  they  designated  them.  At  the  same  time,  with 
this  mildness  of  symptoms  the  heart  was  becoming  seriously  and  permanently 


504  ACUTE  RHEUMATISM. 

crippled  by  endocarditis.  Those  who  have  attended  my  clinics  will  recollect 
that  on  some  days  as  many  as  three  or  four  children  with  cardiac  lesions  have 
been  present  Avhose  histories  show  an  overlooked  rheumatism  of  this  mild  type. 
Cases  like  the  following  are  very  common  among  the  city  poor : 

In  January,  1871,  a  little  girl  three  years  old  was  presented,  having  distinct 
aortic  direct  and  mitral  regurgitant  murmurs.  The  mother  was  not  aware  that 
she  had  had  rheumatism,  but  at  the  age  of  twenty  months  she  had  for  several 
days  pretty  active  febrile  symptoms,  which  the  physician  attributed  to  some 
other  ailment.  In  April,  1871,  another  girl,  of  the  same  age,  was  brought  to 
the  clinic,  having  a  distinct  mitral  regurgitant  murmur.  The  mother  stated 
that  she  had  been  well  till  a  month  previously,  when  she  was  confined  to  her 
bed  for  a  few  days,  having  a  high  fever.  She  was  attended  by  a  homoeopathic 
physician,  and  the  exact  character  of  her  sickness  the  mother  was  not  able  to 
state.  Further  medical  advice  was  sought,  as  the  child  remained  delicate^ 
though  her  health  was  better  than  at  first.  There  can  be  little  doubt  that 
the  obscure  fever  in  this  case  was  rheumatic.  In  another  child  treated  else- 
where, not  old  enough  to  relate  the  subjective  symptoms,  there  was,  in  addi- 
tion to  an  intense  fever,  evident  pain  in  one  foot  or  leg  when  the  limb  was 
moved.  Still,  the  nature  of  the  disease  was  not  diagnosticated  till  some  time 
after  recovery,  when  a  valvular  murmur  was  accidentally  discovered.  Such 
histories,  which  are  not  rare,  show  that  rheumatism  often  occurs  in  young 
children,  even  infants,  and  they  inculcate  the  important  practical  lesson  that 
the  disease  at  this  age  may  be  so  obscure  or  latent  as  to  be  overlooked  even 
by  good  diagnosticians. 

Some  observers,  meeting  cases  of  valvular  disease  in  children  without  the 
history  of  rheumatism,  have  concluded  that  rheumatism  is  not  the  chief  cause 
of  endocarditis  at  this  age;^  but  the  explanation  which  I  have  given  seems 
to  me  more  in  consonance  with  the  facts.  Scarlet  fever  not  infrequently 
causes  endocarditis,  but  this  exanthem  seldom  occurs  without  detection,  and 
it  has  been  as  often  absent  as  has  rheumatism  from  the  histories  as  given  by 
the  parents  of  young  children  with  valvular  disease  whom  I  have  examined. 
Moreover,  the  endocarditis  of  scarlet  fever  is  in  many  cases  associated  with^ 
if  it  do  not  result  from,  scarlatinous  rheumatism. 

Rheumatism  in  children  is  primary  or  secondary.  The  secondary  form 
occurs  chiefly  in  the  declining  stage  of  scarlet  fever  and  variola.  It  is  stated 
also  to  occur  occasionally  in  new-born  infants  during  epidemics  of  puerperal 
fever,  but  I  have  not  observed  such  cases. 

Causes. — An  inherited  rheumatic  diathesis  is  universally  recognized  as 
an  important  predisposing  cause  of  this  disease,  so  that  it  frequently  occurs 
in  different  members  of  the  same  family.  When  the  family  history  shows  a 
strong  predisposition  to  rheumatism,  it  occurs  in  the  child  from  a  slight 
exciting  cause ;  if  no  such  predisposition  exist,  it  only  occurs  through 
unusual  circumstances  of  exposure.  Investigations  have  been  made  in  order 
to  determine  whether  acute  rheumatism  is  a  microbic  disease.  Dr.  Alfred 
Mantle  of  England  made  cultures  from  the  serum  of  7  and  from  the  blood 
of  16  patients  with  acute  rheumatism.  He  states  that  he  made  use  of  every 
precaution  to  prevent  contamination  by  germs  from  without.  The  organisms 
obtained  by  Mantle  in  the  cultures  were  a  micrococcus  and  a  small  bacillus. 
He  states  that  these  organisms  produced  lactic-acid  fermentation  in  sterilized 
milk.  He  believes  that  the  microbes  do  not  produce  the  symptoms  of  rheu- 
matism by  their  direct  action,  but  by  the  ptomaines  to  which  they  give  rise, 
and  he  raises  the  question  whether  lactic  acid  is  not  the  chief  ptomaine 
(^Brit.  Med.  Jour.,  1887).  Popow  states  that  the  micrococci  obtained  by  cul- 
tivation from  the  blood  of  rheumatic  patients  inoculated  in  rabbits  caused 
^  Dr.  A.  Steffen,  Jahrbuch  fur  Kiiiderh.,  1870. 


SYMPTOMS.  505 

in  these  animals  the  characteristic  symptoms  of  rheumatism,  and  in  their 
blood  and  synovial  fluid  he  found  the  same  cocci  (  Wiener  me<l.  Presse,  Jan. 
29,  1888).  Cornil  and  Babes  have  also  related  a  fatal  case  of  rheumatism  in 
which  micrococci  and  bacilli  were  found  in  the  right  knee.  Wilson  found 
bacilli  in  the  pericardium  in  two  cases  of  rheumatic  pericarditis.  Petrone 
examined  the  serum  taken  from  the  knee-joint  in  three  cases  of  acute  rheu- 
matism, and  in  all  the  specimens  examined  discovered  microbes  similar  to  those 
detected  by  Klebs  in  rheumatic  endocarditis.  Jaccoud  relates  the  histories 
of  two  newly-born  infants  whose  mothers  at  the  time  of  their  birth  had  acute 
rheumatism.  One  of  them  twelve  hours  after  birth,  and  the  other  three  days 
after  birth,  "  were  attacked  with  fever,  rapid  pulse,  and  well-marked  rheu- 
matic swelling  of  several  articulations."  Under  treatment  one  recovered  in 
eight  days  and  the  other  in  a  little  more  than  two  weeks.  The  above  observa- 
tions lend  support  to  the  theory  that  acute  rheumatism  is  a  microbic  disease, 
and  perhaps  observations  indicate  that  it  is  to  a  certain  extent  infectious. 

Children  who  have  had  one  attack  are  especially  liable  to  another,  and 
when  the  diathesis  is  acquired  slight  exposures  appear  to  be  sufficient  to  cause 
the  disease.  It  has  heretofore  been  the  common  belief  in  the  profession — 
and  this  opinion  is  also  held  by  the  laity — that  exposure  to  cold  is  the  usual 
exciting  cause  of  rheumatism ;  but  if  the  disease  have  a  microbic  origin,  it  is 
a  question  whether  or  to  what  extent  this  theory  is  true.  It  is  stated  in  sup- 
port of  it  that  rheumatism  is  most  common  in  cold  and  changeable  weather 
and  in  those  who  are  most  exposed  to  vicissitudes  of  temperature. 

Scarlatinous  rheumatism  has  been  alluded  to  above.  Frequently  during 
the  course  of  scarlet  fever  inflammation  of  certain  joints  occurs  which  can- 
not be  distinguished  from  that  in  the  ordinary  form  of  rheumatism,  and  in 
some  of  these  instances  endocarditis  or  pericarditis  also  occurs.  Dr.  Ashby 
is  inclined  to  believe  that  scarlatinous  rheumatism  is  produced  by  septic 
poisoning,  but  it  sometimes  occurs  at  such  an  early  stage  or  in  cases  of  such 
mildness  that  the  conditions  giving  rise  to  ordinary  sepsis  do  not  seem  to  be 
present.  It  is  therefore  probable,  in  my  opinion,  that  in  some  instances  at 
least  this  articular  affection  occurring  in  scarlet  fever  is  due  to  the  direct 
action  of  the  scarlatinous  microbe  or  to  a  ptomaine  or  ptomaines  produced 
by  this  microbe. 

Symptoms. — The  commencement  of  acute  idiopathic  rheumatism  is  in 
most  cases  sudden  ;  occasionally  fever  and  a  degree  of  soreness  or  stiffness 
precede  the  articular  affection  for  a  few  hours  or  days.  The  inflammation, 
slight  at  first,  increases  gradually,  attaining  its  maximum  intensity  within  one 
or  two  days.  The  joint  is  painful,  red,  hot,  and  swollen.  The  swelling  is 
due  to  inflammatory  oedema  of  the  tissues  surrounding  the  joint  and  effusion 
within  the  joint.  As  in  all  inflammations,  the  vascularity  of  the  parts 
involved  is  increased,  the  synovial  membrane  loses,  more  or  less,  its  lustre, 
and  the  effused  fluid,  which  is  mainly  serum,  has  been  found,  in  most  of  the 
cases  in  which  an  opportunity  was  presented  of  examining  it,  to  contain  a  few 
leucocytes.  Rarely  fibrin  is  exuded,  producing  a  rubbing  sensation  when 
the  joint  is  moved,  and  perhaps  impairing  the  mobility  of  the  articular 
surfaces.  Fortunately,  however,  in  a  large  majority  of  cases  the  substance 
exuded  both  without  and  within  the  joint  is  mainly  serum,  and  hence  the 
rapid  subsidence  of  the  swelling  when  the  inflammation  ceases.  The  pain  is 
commonly  not  severe  when  the  child  is  quiet,  but  it  is  greatly  increased  if  the 
joint  be  pressed  or  the  limb  moved. 

The  joints  of  the  extremities  are  most  frequently  the  seat  of  rheumatic 
inflammation,  but  occasionally  those  of  the  trunk,  as  the  intervertebral,  the 
symphysis  pubis,  etc.,  are  involved.  As  the  inflammation  abates  in  the  artic- 
ulations first  affected  it  reappears  in  others,  unless  the  materies  morbi  have 


606  ACUTE  RHEUMATISM. 

been  eliminated  from  the  system.  It  is  seldom  that  more  than  two  or  three 
of  the  joints  are  in  a  state  of  active  inflammation  at  the  same  time. 

The  temperature  in  acute  rheumatism  is  elevated  two  or  three  degrees 
above  that  of  health,  and  the  pulse  varies  from  120  to  140,  its  frequency 
depending  on  the  age  of  the  patient  as  well  as  the  gravity  of  the  disease. 
Perspiration  is  a  common  symptom.  The  appetite  is  impaired,  the  tongue 
slightly  coated,  and  the  bowels  constipated.  The  watery  element  of  the 
urine  is  diminished,  as  in  most  febrile  diseases,  and  there  is  not  a  correspond- 
ing reduction  in  the  solid  elements,  so  that  the  urine  is  rendered  more  dense 
and  its  specific  gravity  is  high.  The  amount  of  urea  and  coloring  matter 
excreted  from  the  kidneys  is  augmented  during  the  active  period  of  rheuma- 
tism, and  the  urine  when  it  cools  deposits  urates.  In  ordinary  cases  there  is 
no  prominent  symptom  referable  to  the  nervous  system,  with  the  exception 
of  pain  in  the  aff"ected  joint. 

Acute  rheumatism,  if  only  the  articulations  were  involved,  would  be  a  dis- 
ease of  little  danger,  however  painful,  but  unfortunately  in  its  proneness  to 
produce  specific  inflammation  of  the  sero-fibrous  tissues  the  heart  frequently 
becomes  involved,  less  frequently  the  lungs  and  pleura,  and  in  rare  instances 
the  cerebral  or  spinal  meninges.  The  so-called  cerebral  rheumatism  is  attended 
by  high  fever,  restlessness,  headache,  and  sometimes  delirium  and  coma. 
Twitching  of  the  muscles  and  sometimes  tonic  or  clonic  spasms  occur.  Prof. 
Flint  says :  "  In  the  majority  of  cases  death  takes  place  during  coma.  In 
some  cases  recovery  sets  in  even  after  the  appearance  of  very  grave  symp- 
toms. In  fatal  cases  no  lesions  of  the  brain  or  of  the  meninges  can  really 
be  founji.  The  symptoms  seem  to  be  referable  to  some  profound  infection  or 
intoxication  which  acts  upon  the  thermic  and  other  nervous  centres."  This 
form  of  rheumatism  is  certainly  rare  in  childhood.  Endocarditis  is  the  most 
frequent  of  the  heart  inflammations  occurring  in  rheumatism ;  pericarditis, 
though  less  common,  is  not  infrequent ;  while  in  rare  instances  myocarditis 
occurs,  usually  associated  with  the  other  inflammations.  Endocarditis  is 
limited  to  the  left  side  of  the  heart,  and  seldom  continues  long  without 
engaging  the  valves,  aortic  or  mitral,  or  both,  causing  their  infiltration, 
fibroid  degeneration,  with  consequent  thickening,  and  sometimes  adhesion. 
The  valvular  lesion  thus  produced  is  in  most  instances  permanent,  so  impair- 
ing the  action  of  the  valves  as  to  obstruct  in  greater  or  less  degree  the  flow 
of  blood  through  the  orifice  and  allow  its  regurgitation. 

The  mitral  valve  is  more  frequently  afiected  than  the  aortic  ;  at  least  bruits 
produced  by  this  lesion  are  more  frequent  in  the  mitral  than  aortic  orifice,  and 
when  they  are  heard  in  both  orifices  they  are  commonly  loudest  in  the  mitral. 
This  fact,  noticed  by  different  observers,  I  have  repeatedly  verified  by  obser- 
vations in  this  city. 

I  have  preserved  the  records  of  73  cases  of  valvular  disease  in  children, 
and  in  most  of  them  I  was  able  to  assign  rheumatism  as  the  cause,  but  it 
was  in  a  large  proportion  of  instances  very  slight,  so  as  not  to  confine  the 
patients  to  bed,  and  had  been  considered  by  the  parents  simply  "  growing 
pains,"  so  that  no  treatment  had  been  received.  The  statistics  of  difi"erent 
observers  show  that  endocarditis  in  acute  rheumatism  occurs  more  frequently 
in  children  than  in  adults.  The  first  sign  of  an  endocardial  inflammation  is 
in  most  instances  a  systolic  murmur  produced  in  the  mitral  orifice.  It  can  be 
heard  on  listening  over  the  heart,  and  also  over  the  left  scapula.  It  indicates 
insufficiency  of  the  mitral  orifice  and  regurgitation  of  blood  into  the  left 
auricle.  In  some  cases  the  aortic  valves  are  at  the  same  time  afi"ected,  and 
an  aortic  direct  murmur  occurs,  synchronous  with  the  mitral  regurgitant. 
In  rare  instances  the  endocarditis  extends  to  the  aortic  orifice,  causing  thick- 
ening of  its  valves  and  impairing  their  action,  so  that  an  aortic  bruit  results, 


PATHOLOGY.  507 

while  the  mitral  orifice  is  not  affected,  and  therefore  no  mitral  murmur 
occurs. 

Another  cardiac  bruit  resulting  from  the  endocarditis  occasionally  observed 
is  a  reduplication  of  the  second  sound,  heard  most  distinctly  at  the  apex.  A 
diastolic  sound  sometimes  follows  this  reduplication,  and  when  it  is  well  devel- 
oped it  constitutes  the  so-called  presystolic  murmur.  It  usually  results  from 
mitral  stenosis  caused  by  the  endocarditis. 

Pericarditis  is  not  so  common  in  rheumatism  as  endocarditis,  but  it  some- 
times occurs  in  children  as  well  as  in  adults.  It  occasionally  even  precedes  the 
aiFection  of  the  joints,  being  the  first  in  time  of  the  rheumatic  inflammations. 
It  causes  an  increase  in  the  fever,  palpitation,  quick  and  irregular  pulse,  rest- 
lessness, cardiac  pain,  and  perhaps  dyspnoea.  iVt  first  a  pericardial  friction- 
sound  may  be  detected,  and  subsequently,  when  sero-fibrinous  exudation  has 
occurred,  the  area  of  dulness  may  be  increased,  with  a  muffling  of  the  sounds 
of  the  heart.  If  the  eff'usion  of  serum  be  moderate,  the  .pericardial  sur- 
faces may  become  agglutinated  ,early  in  the  disease,  or  they  may  become 
agglutinated  after  the  serum  is  absorbed,  so  as  to  prevent  friction-sound.  An 
adherent  pericardium  embarrasses  the  action  of  the  heart,  and  is  likely  to  lead 
eventually  to  hypertrophy.  Tonsillitis  occurs  so  frequently  in  children  who 
have  the  rheumatic  diathesis,  and  also  so  frequently  during  rheumatism,  that 
Trousseau  recognized  a  rheumatic  form  of  the  disease.  Bronchitis,  pleurisy, 
and  pneumonia  also  occasionally  occur  as  complications  of  rheumatism. 

While  the  articular  affections  pertain  to  the  clinical  history  of  rheumatism, 
the  internal  inflammation,  whether  of  the  heart,  lungs,  pleura,  or  meninges, 
though  similar  as  regards  its  pathological  character,  is  properly  considered  as 
a  complication.  Acute  rheumatism  is  so  frequently  complicated  by  one  or 
the  other  of  these  afiections  that  any  disproportionate  severity  in  the  general 
symptoms,  as  compared  with  the  inflammation  of  the  joints,  or  any  sudden 
and  unexpected  increase  in  the  symptoms,  should  always  lead  the  physician 
to  examine  thoroughly  the  condition  of  those  organs  which  are  most  frequently 
aff'ected. 

Inflammatory  complications  occur,  as  a  rule,  during  the  active  period  of 
rheumatism,  when  the  inflammation  is  passing  from  joint  to  joint.  If  the 
general  symptoms  begin  to  improve  and  no  new  joints  are  involved,  the 
liability  to  complications  is  greatly  diminished. 

Pathology. — The  joints  aff"ected  by  rheumatism  present  various  grades 
of  inflammation,  but  in  all  typical  cases,  however  intense  the  inflammation, 
suppuration  does  not  occur.  In  a  paper  read  before  the  London  Medical 
Society,  April  9, 1888,  Dr.  Money  stated  that  when  suppuration  does  occur  in 
rheumatism  the  disease  is  complicated  with  sepsis,  and  Sir  Wm.  MacCormac 
and  Dr.  Ord  expressed  a  similar  opinion. 

Acuteness  of  sensation  is  increased  over  the  inflamed  joint.  The  ana- 
tomical changes  in  the  joints  have  been  sufficiently  described  in  our  remarks 
relating  to  the  symptoms.  Recently  several  writers  have  called  attention  to 
the  fact  that  nodules  occasionally  occur  under  the  skin  in  rheumatism. 
Lindmann  relates  two  cases,  an  adult  and  a  child,  in  which  during  the  course 
of  rheumatism  numerous  nodules  appeared  rapidly  under  the  skin.  They 
were  about  the  size  of  a  pea,  hard,  movable,  and  painful,  but  without  red- 
ness. They  disappeai'ed  during  convalescence.  Lindmann  collated  the  rec- 
ords of  59  rheumatic  cases  in  which  nodules  occurred.  A  majority  of  them 
were  females,  and  46  were  children.  These  bodies  usually  appeared  suddenly 
in  the  later  stages  of  rheumatism,  and  varied  from  the  size  of  a  pin's  head 
to  that  of  an  almond.  They  continued  from  a  few  days  to  a  month  or  longer 
(^Deutsche  medin.  Woch.,  p.  519,  1888).  Examination  with  the  microscope 
shows  that  they  consist  of  newly-formed  connective  tissue,  such  as  results 


508 


ACUTE  RHEUMATISM. 


Fig.  31. 


from  inflammation  (^Amer.  Jour,  of  Med.  Set.,  Oct.,  1888).  Garrod  states  that 
these  nodules  and  muscular  atrophy  sometimes  occur  in  the  most  simple  forms 
of  hydrarthrosis,  and  are  usually  attended  by  an  increase  in  the  reflexes,  sug- 
gesting an  excitability  of  the  spinal  cord  (Lond.  Lane,  June  2,  1888).  It  is 
stated  that  Charcot  and  Parisot  also  attribute  the  occurrence  of  these  nodules 
to  an  exaggerated  excitability  of  the  spinal  cord.  On  the  other  hand,  Mayer 
and  Cuilleret  observed  two  cases  of  nodules  and  atrophy  of  certain  muscles 

following  an  attack  of  arthritis,  and 
they  think  that  a  true  myelitis  had 
occurred  to  produce  such  a  result,  along 
with  the  constant  peripheral  irritation 
(^Lyons  Medical,  Apr.  29, 1888).  Homan 
relates  the  case  of  a  patient  aged  eigh- 
teen years  who  had  rheumatism  of  the 
muscles  of  the  left  leg  from  the  hip  to 
the  ankle,  lasting  several  weeks.  In 
the  latter  part  of  his  sickness  the  calf 
of  the  leg  became  unusually  tender,  and 
a  hard  nodule  occurred  in  the  muscular 
substance,  and  was  accompanied  by 
atrophy  of  the  muscular  fibres.  The 
nodule  gradually  subsided  and  disap- 
peared (^St.  Louis  Courier  of  3Icd.^ 
March,  1888).  The  above  observa- 
tions, to  which  more  might  be  added^ 
show  that  the  anatomical  characters  of 
acute  rheumatism  are  not  restricted  to 
the  joints  and  heart,  but  subcutaneous  nodules,  and  more  or  less  muscular 
atrophy,  occasionally  occur.  Cheadle  says  the  nodules  occur  mostly  in  the 
neighborhood  of  joints,  and  that  they  are  rare  in  adults,  but  very  common  in 
children.  They  develop  within  a  few  days,  and  sometimes  in  successive  crops, 
"  but  they  usually  take  many  weeks  to  subside."  The  above  figure  represents 
these  nodules  as  seen  by  Dr.  Cheadle  in  a  boy  of  four  years. 

Fig.  32. 


The  woodcut  (Fig.  32)  shows  the  microscopic  appearance  of  a  nodule  from  a 


DIAGNOSIS. 


509 


Fig.  33. 


child  of  seven  and  a  half  years,  as  observed  by  Dr.  Cheadle ;  it  exhibits  the 
active  cell-infiltration  and  proliferation  of  fibrous  tissue : 

Duration  ;  Prognosis. — With  proper  treatment  and  without  complica- 
tion the  febrile  action  in  a  few  days  begins  to  abate,  and  the  disease  com- 
monly terminates  within  two  weeks.  Its  duration  is  ordinarily  shorter  than 
in  rheumatism  of  the  adult.  Fluctuations,  however,  are  liable  to  occur. 
The  disease  may  appear  to  be  abating  and  the  articular  inflammations  nearly 
cease  when  they  return  for  a  time,  often  without  new  exposure  and  without 
appreciable  cause.  The  prognosis,  even  when  cardiac  inflammation  has  super- 
vened, is  in  most  cases  favorable,  except  so  far  as  the  lesion  resulting  from 
this  inflammation  is  concerned,  which  being  permanent  may  entail  much  sub- 
sequent suffering  and  occasion  death  after  months  or  years.  Indeed,  what 
is  most  to  be  dreaded  in  cases  of  acute  rheumatism  is 
valvular  disease  or  pericardial  adhesion  with  its  remoter 
consequences — namely,  hypertrophy  of  heart,  conges- 
tion and  oedema  of  lungs,  dropsies,  etc. 

Secondary  rheumatism  occurring  in  scarlet  fever  is 
sometimes  also  complicated  with,  or  rather  coexists 
with,  cardiac  inflammation,  pleuritis,  or  pneumonitis, 
rendering  the  prognosis  more  unfavorable. 

In  rare  instances  the  acute  symptoms  of  rheuma- 
tism abate,  but  the  joints  remain  stiflf  and  more  or 
less  swollen  and  painful  when  moved.  The  acute  has 
lapsed  into  a  subacute  or  chronic  rheumatism.  Such 
a  case,  represented  in  the  accompanying  figure,  was 
brought  to  the  children's  class  in  the  Out-door  Depart- 
ment at  Bellevue  Hospital  in  February,  1871.  E. 
H ,  a  female  three  and  a  half  years  old,  had  inter- 
mittent fever  from  the  age  of  nine  to  fifteen  months. 
From  this  time  she  remained  well  till  the  age  of  two 
years,  when  she  was  taken  with  acute  rheumatism, 
commencing  in  her  ankles  and  extending  to  other 
joints.  The  knee-  and  hip-joints  on  both  sides  have 
only  partially  recovered  their  mobility,  and  both  legs 
and  both  thighs  are  permanently  flexed,  so  that  the  gait 
is  slow  and  unsteady.  It  is  impossible  to  straighten 
either  limb  without  causing  great  pain,  and  attempts  to  straighten  the  thigh 
produce  the  arch  in  the  back  very  similar  to  that  in  coxalgia. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases  if  a  proper  examina- 
tion be  made.  In  the  commencement,  if  the  affection  of  the  joints  be 
slight,  rheumatism  might  be  mistaken  for  remittent,  typhoid,  one  of  the 
eruptive  fevers,  or  meningitis ;  but  on  careful  examination  tenderness  of  one 
or  more  of  the  articulations  will  be  observed,  and  probably  some  swelling. 
This  tenderness  is  readily  distinguished  from  the  hyperaesthesia  which  is 
common  in  the  first  stage  of  the  essential  fevers,  and  which  is  observed  when 
pressure  is  made  upon  the  chest  or  abdomen  as  well  as  upon  the  limbs,  and  is 
more  marked  between  the  joints  than  in  them.  Any  doubt  which  may  at  first 
exist  whether  the  patient  may  not  have  one  of  those  diseases  is  soon  dispelled, 
since  their  clinical  history  presents  notable  differences  from  that  of  rheumatism. 

I  have  known  scrofulous  arthritis  or  scrofulous  osteitis  near  the  joint 
present  so  close  a  resemblance  to  acute  rheumatism  as  to  be  at  first  mistaken 
for  it.  In  one  instance  this  inflammation  commenced  nearly  simultaneously 
in  three  joints,  rendering  the  diagnosis  at  first  very  difficult.  But  scrofu- 
lous inflammation,  as  well  as  that  from  pyji^mia,  can  be  diagnosticated  from 
rheumatic   disease   of  the  joints   by  its  greater  persistence,  less  induration 


510  ACUTE  RHEUMATISM. 

and  symmetry  in  the  swelling,  and  by  the  history  of  the  case.  Chronic 
rheumatism  may  produce  deformity  similar  to  that  from  chronic  scrofulous 
inflammation,  as  in  the  case  mentioned  above,  but  the  rheumatic  history, 
number  of  joints  affected,  bilateral  character  of  the  inflammation,  good  gen- 
eral health,  etc.  are  sufiicient  to  establish  a  clear  diagnosis  when  the  disease 
has  been  observed  for  some  days. 

Treatment.  —  The  treatment  of  acute  rheumatism  has  undergone 
marked  variations  in  the  last  thirty  years.  Its  speedy  cure  is  urgently 
demanded,  on  account  of  the  imminent  peril  to  the  heart.  From  1847  until 
a  recent  period  the  alkaline  treatment,  by  the  bicarbonate  of  potassium  and 
bicarbonate  of  sodium,  the  tartrate  of  potassium  and  sodium,  and  the  citrate 
of  potassium,  was  commonly  employed  to  the  extent  of  rendering  the  urine 
alkaline  in  twelve  or  twenty-four  hours.  Statistics  appeared  to  show  that 
the  duration  of  rheumatism  was  abridged  by  the  alkaline  treatment,  and  the 
liability  to  cardiac  complications  was  diminished  as  soon  as  the  urine  became 
alkaline.  Garrod  reported  50  cases  in  which  the  average  duration  was  six 
or  seven  days  under  the  alkaline  treatment.  Fuller  in  1862  stated  that  in 
no  single  instance  in  194  cases  did  cardiac  complications  occur  when  the 
alkaline  treatment  had  been  employed  twenty-four  hours.  Dickinson's  sta- 
tistics also  furnished  strong  evidence  of  the  usefulness  of  alkalies  in  large 
doses,  given  so  as  to  render  the  urine  alkaline  in  twelve  to  twenty-four  hours. 
He  also  stated  that  the  alkaline  treatment  was  inadequate  unless  employed 
so  as  to  render  the  urine  alkaline.  More  recently,  the  late  Prof.  Austin 
Flint  considered  the  evidence  conclusive  in  regard  to  the  efficacy  of  the 
alkaline  treatment  of  rheumatism,  the  doses  employed  being  so  large  that  the 
urine  becomes  alkaline  in  twenty-four  hours. 

But  since  1875  a  new  and,  in  acute  cases  of  rheumatism,  a  very  efficient 
remedy  has  come  into  use — to  wit,  salicylic  acid  or  its  compound,  salicylate 
of  sodium.  The  sodium  salicylate  is  most  frequently  employed.  It  may  be 
given  every  two  hours  to  adults  in  doses  of  ten  to  twenty  grains,  and  to 
children  in  proportionate  doses.  But,  although  salicylic  acid  or  salicylate 
of  sodium  acts  almost  as  a  specific  in  recent  cases  of  rheumatism,  relieving 
the  pain  and  fever  and  diminishing  the  articular  inflammation,  it  often  pro- 
duces certain  ill  eff'ects.  It  impairs  digestion,  causing  nausea,  and  sometimes 
vomiting.  It  produces  tinnitus  aurium,  and  sometimes  headache  or  vertigo, 
and  occasionally  albuminuria,  as  I  have  several  times  observed,  so  that  it 
should  not  be  employed  longer  than  is  required  to  control  the  rheumatism. 
The  employment  of  salicylic  acid  or  salicylate  of  sodium  does  not,  apparent- 
ly, prevent  cardiac  or  other  complications,  and  it  is  probably  best  to  adminis- 
ter it  in  combination  with,  or  alternately  with,  an  alkali. 

The  following  formula  is  essentially  that  which  has  been  employed  in  the 
Out-Door  Department  at  Bellevue  with  apparently  excellent  results  : 

R.  Acidi  salicylic,         .^ij~iij  ; 
Potas.  acetat.,  ,^ss  ; 

Glycerinse,  ,f  j  ; 

Aquse,  q.  s.  ad  ^v.  Misce. 

Give  one  teaspoonful  every  two  or  three  hours  to  a  child  of  six  years. 

An  eligible  vehicle  for  the  sodium  salicylate  is  the  syrup  of  raspberry,, 
as  in  the  following  formula  : 

R.  Sodii  salicylat.,  ^ii.) ; 

Sodii  bicarbonat.,  3\i  j 

Syr.  rubi  idaei,  ,^ij; 

Aquae,  .^iij.     Misce. 

Give  one  teaspoonful  every  two  or  three  hours  to  a  child  of  six  years. 


TREATMENT.  511 

Since  the  oil  of  wintergreen  contains  a  considerable  amount  of  salicylic 
acid,  it  has  been  sometimes  employed,  as  in  the  following  formula  : 

R.  Ol.  gaultheriie,  3j; 

Sodii  salicylat.,  ^iij  ; 

Syr.  simplic.  ,^iij  ; 

Acjiiiie,  5vj.     Misce. 
Dose  :  A  dessertspoonfid  to  a  child  of  five  yeary. 

During  the  declining  period  of  rheumatism  and  in  convalescence  quinine 
or  some  preparation  of  cinchona  should  be  employed  and  the  above  medi- 
cine given  less  often.  This  tonic  does  indeed  appear  to  exert  a  beneficial 
effect  on  the  course  of  rheumatism,  and  is  employed  by  some  judicious  and 
experienced  physicians  from  the  commencement. 

If  there  be  a  high  temperature  and  a  ciuick  pulse,  quinine  administered 
in  an  occasional  large  dose  will  be  found  very  useful.  Three  to  five  grains 
may  be  given  to  a  child  of  five  years. 

Rheumatism  impoverishes  the  blood,  and  the  patient  often  begins  to 
present  an  anaemic  appearance,  when  he  requires  iron  in  addition  to  the  veg- 
etable tonic.     The  citrate  of  iron  and  quinine  may  then  be  employed. 

Secondary  rheumatism  requires  sustaining  treatment  from  the  first. 
Such  cases  ordinarily  do  well  without  antirheumatic  treatment,  with  the  gen- 
eral supporting  measures  employed  for  the  primary  disease. 

Antipyrine  has  recently  been  prescribed  in  adult  cases  during  the  acute  stage 
with  such  marked  relief  of  the  pain  and  reduction  of  temperature  that  it  prom- 
ises to  be  a  valuable  remedy.  Friinkel  administered  it  to  34  patients  between 
the  ages  of  fourteen  and  twenty-eight  years  in  doses  of  fifteen  grains  every 
three  hours.  In  2  of  the  cases  it  disagreed,  and  was  discontinued.  In  the 
other  cases  it  speedily  relieved  pain  and  reduced  the  fever  (Deutsche  med. 
Woch.,  1887).  Dr.  N.  S.  Davis,  Sr.,  obtained  equally  favorable  results  from 
the  use  of  antipyrine,  but  relapses  and  cardiac  complications  occurred  in 
about  the  same  proportion  of  cases  as  during  the  use  of  the  salicylates. 
Antipyrine  has  not  yet  been  sufficiently  employed  in  the  treatment  of 
rheumatism  of  children  to  determine  its  value  or  safety. 

Salol  has  also  been  largely  used  in  adult  cases  during  the  last  two  or 
three  years,  but  Rosenberg  of  Berlin  states  that  it  produces  all  the  unpleas- 
ant effects  of  the  salicylates,  and  does  not  appear  to  be  any  more  efficacious 
in  the  treatment  of  rheumatism.  Dr.  Lombard  of  Paris  believes  that  it  is 
resolved  into  salicylic  and  carbolic  acids  in  the  system,  and  unless  this 
decomposition  occurs  it  is  inert.  He  believes  that  its  value  has  been  over- 
estimated in  the  treatment  of  rheumatism.  Salol,  if  administered  to  chil- 
dren, should  certainly  be  given  in  small  doses,  on  account  of  the  danger  of 
poisoning  from  the  carbolic  acid  in  its  composition.  It  will  therefore  proba- 
h\y  not  come  into  use  as  a  remedy  for  the  rheumatism  of  children. 

Pneumonitis  complicating  rheumatism  is  best 'treated  by  moderate  coun- 
ter-irritation and  emollient  poultices  and  the  internal  use  of  carbonate  of 
ammonium  or  quinine.  In  pericarditis  or  endocarditis  if,  as  is  commonly 
the  case,  the  movements  of  the  heart  be  accelerated,  aconite  or  the  tincture 
or  infusion  of  digitalis  is  demanded  to  the  extent  of  reducing  the  number 
of  pulsations  to  near  the  normal  frequency.  A  child  of  six  years  can  take 
three  drops  of  the  tincture  or  a  large  teaspoonful  of  the  infusion,  to  be 
repeated,  if  necessary,  in  three  hours  till  the  reduction  of  the  pulse  is  effect- 
ed. Patients  often  experience  relief  by  the  use  of  this  agent  from  the  pal- 
pitation and  dyspnoea  consequent  upon  the  embarrassed  movements  of  the 
heart.     If  the  heart  disease  be  severe  and  pulse  feeble,  quinine  is  also  use- 


512  ERYSIPELAS. 

ful.       The   tincture  of  strophanthus  or  that  of  spartein  is  sometimes  pre- 
scribed as  a  substitute  for  the  digitalis. 

The  patient  should  be  kept  quiet  in  a  room  of  uniform  temperature,  and 
not  exposed  to  draughts  of  air.  By  such  precautions  the  danger  of  compli- 
cations is  greatly  diminished.  Repellant  applications,  as  cold  or  irritants, 
should  not  be  applied  to  the  joints  so  long  as  the  disease  is  acute,  for  they 
also  increase  the  danger  of  complications.  The  affected  joints  should  be 
enveloped  in  flannel  or  cotton,  and  the  pain,  if  intense,  may  be  diminished 
by  applying  flannel  wrung  out  of  warm  water.  If  the  disease  become 
subacute  or  chronic,  if  the  urates  have  disappeared  from  the  urine,  and  the 
inflammation  cease  to  pass  from  joint  to  joint,  the  tincture  of  iodine  or  mod- 
erately stimulating  embrocations  applied  to  the  joints  involve  no  danger  and 
are  useful. 


CHAPTER    VI. 

EKYSIPELAS. 


The  term  "  erysipelas  "  is  applied  to  a  constitutional  or  blood  disease 
which  is  characterized  by  inflammation  of  the  skin  and  subcutaneous  connec- 
tive tissue  and  a  tendency  to  spread.  It  is  accompanied  by  pungent  and 
pricking  heat,  swelling,  and  subcutaneous  infiltration. 

In  rare  instances,  in  young  infants,  an  inflammation  which  has  been  desig- 
nated erysipelas  occurs  in  and  around  the  umbilicus.  It  commences  about 
the  time  of  the  detachment  of  the  umbilical  cord,  and  is  accompanied  by 
redness  of  the  skin  and  tumefaction,  with  induration  of  the  connective  tissue 
surrounding  the  umbilicus.  It  usually  causes  ulceration  of  the  umbilical 
fossa,  and  in  fatal  cases  pus  is  sometimes  found  in  the  umbilical  vessels. 
This  disease  does  not  show  any  tendency  to  spread ;  the  diameter  of  the 
inflamed  surface  is  not  more  than  three  or  four  inches,  with  the  umbilicus  at 
the  centre.  It  is  generally  fatal,  but  two  favorable  cases  have  been  reported 
to  me,  in  one  of  which  there  was  considerable  ulceration,  and  after  recovery 
a  firm  cicatrix  occupied  the  site  of  the  umbilicus.  The  most  reasonable  view 
is  that  this  disease  is  primarily  an  inflammation  of  the  umbilical  fossa  and 
vessels  induced  by  uncleanliness,  cachexia,  or  other  cause.  It  lacks  the  dis- 
tinguishing feature  of  erysipelatous  inflammations — namely,  the  tendency  to 
spread — and  I  shall  therefore  take  no  further  notice  of  it  in  this  connection. 
(See  Diseases  of  the  Umbilicus.) 

Erysipelas  occasionally  occurs  in  childhood ;  the  cases  which  are  met  in 
this  period  present  nearly  the  same  features  and  pursue  nearly  the  same 
course  as  in  the  adult.  In  infancy  erysipelas  is  a  common  disease,  and  the 
following  remarks  relate  chiefly  to  erysipelas  occurring  in  this  period  of  life. 
They  are  based  on  data  derived  mainly  from  the  records  of  cases  which 
occurred  in  this  city,  some  in  my  own  practice,  and  others  in  the  practice  of 
physicians  known  to  be  good  observers.  The  points  of  chief  interest  in  41 
cases  are  embraced  in  the  opposite  table : 


TABLE  OF  CASES. 


513 


Cases  of  Infantile  Erysipelas. 


i 

■A 

en 

Age. 

Point  of 
commencement. 

Parts  affected 

Duration. 

Result. 

1 

M. 

5  months. 

Right  knee. 

Entire  surface,  except  face  and  scalp 

5  weeks  and 

3  days. 
7  days. 

Recovered. 

2 

M. 

2  years. 

Left  knee. 

From  a  little  above  the  knee  to  the 

ankle. 
Whole  arm  and  forearm. 

Recovered. 

3 

M. 

10  months. 

Elbow. 

Recovered. 

4 

F. 

20 

Below  light  knee 

Entire  leg,  thigh,  and  trunk  to  the 
umbilicus. 

7  days. 

Recovered. 

5 

F. 

9           " 

Vulva. 

Abdomen,  chest,    and    all    the    ex- 
tremities. 

18    " 

Recovered. 

6 

M. 

9  days. 

(ieultaLs. 

Both  lower  extremities,  abdomen  to 
the  umbilicus. 

6      " 

Died. 

7 

F. 

1  year. 

Vulva. 

Entire  surface,  except  face. 

6  weeks. 

Recovered. 

8 

F. 

6  weeks. 

At  or  near  the  ear. 

Forehead  and  side  of  face. 

1  week. 

Died  in  tetanic 
spa.sms. 

9 

9  mouths. 

Epigastric  region. 

Trunk  and  lower  extremities. 

2  weeks. 

Died  in  tetanic 

10 

F. 

10      " 

At  angle  of  mouth. 

Entire  face  and  scalp. 

10  days. 

spasms. 
Recovered. 

11 

F. 

4  weeks. 

Vulva. 

Entire  surface,  except  face. 

3  weeks. 

Died. 

12 

F. 

3  mouths. 

Vulva. 

Surface  of  abdomen  to  umbilicus  and 
right  lower  extremity. 

■1 

Recovered. 

13 

F. 

4  to  5  mos. 

Vulva. 

All  the  limb.s  and  trunk,  except  the 

chest 
Trunk  and  both  lower  extremities. 

3  to  4  weeks. 

Died. 

14 

F. 

5  months. 

From  syphilitic 

sores  arou  nd  an  us. 

15 

F. 

3 

Vulva. 

Entire  trunk  and  both  upper  ex- 
tremities. 

3  weeks. 

Recovered. 

16 

M. 

8 

Face  near  nostrils. 

Entire  trunk  and  both   upper  ex- 
tremities. 

About  2 
weeks. 

Recovered. 

17 

F. 

4        " 

Vulva. 

Entire  trunk  and  all  the  extremities. 

1  week. 

Died. 

18 

F. 

7         " 

Knee. 

A  portion  of  trunk  and  both  lower 
extremities. 

3  weeks. 

Recovered. 

19 

F. 

G 

Near  the  ear. 

Entire  face  and  forehead. 

10  days. 

Recovered. 

20 

M. 

7  days. 

Left  eyelid. 

Left  side  of  face. 

3      " 

Died. 

21 

M. 

14    " 

Genitals. 

Extended  to  knee,  over  abdomen  to 

4      " 

Died. 

the  chest. 

22 

M. 

3  months. 

Under  the  chiu. 

Chin,  left  cheek,  neck,  left  side  of 
trunk,  left  thigh  and  leg. 

23 

F. 

28      " 

Right  shoulder. 

Arm  and  forearm. 

1  day. 

Diedinconvul 
sions. 

24 

F. 

3  or  4  days. 

Vulva. 

Body  and  all  the  limbs. 

12  days. 

Died. 

25 

F. 

31/^  mos. 

Under  left  ear. 

Neck,  chest,  and  arms. 

About  2 
weeks. 

Died. 

2t) 

•   • 

7  months. 

Below  right  knee. 

Trunk,  neck,  and  head,  and  all  the 
limbs. 

2  weeks. 

Died  comatose. 

27 

F. 

6         " 

Vulva. 

Both  thighs  and  nearly  entire  trunk. 

3  days. 

Died  comatose. 

28 

M. 

19      " 

Near  point  of 
vaccination. 

Shoulder,  arm,  and  forearm. 

21    " 

Recovered. 

29 

M. 

4 

Near  point  of 
vaccination. 

Chest  and  both  upper  limbs. 

2  weeks. 

Recovered. 

30 

F. 

2 

Near  vaccine 
vesicle. 

Trunk  and  all  the  limbs. 

10  days.         j 

Died. 

31 

3  to  4  mos. 

Near  vaccine 
vesicle. 

Arm,  forearm,  and  shoulder  on  one 
side. 

2  to  3  weeks.' 

Died. 

32 

F. 

4  months. 

Near  vaccine 
vesicle. 

Arm,  forearm,  and  trunk. 

2  months. 

Died. 

33 

M. 

2 

Near  vaccine 
vesicle. 

Nearly  entire  surface. 

1  week. 

Died  with  peri- 
tonitis. 

34 

M. 

5^    " 

Near  point  of 
vaccination. 

Arm  and  forearm. 

Recovered. 

35 

M. 

2y^  " 

Near  point  of 
vaccination. 

Arm. 

7  days. 

Died  probably 
of  peritonitis. 

36 

M. 

8 

Jfear  vaccine 
vesicle. 

Arm  and  forearm. 

17    " 

Died. 

37 

5        " 

Left  foot. 

Leg,  thigh,  and  lower  part  of  trunk. 

2  weeks. 

Died  with 
pneumonitis. 

38 

5  weeks. 

At  one  ear. 

Entire  surface. 

2 

Recovered. 

39 

2  months. 

Left  leg. 

Trunk  and  all  the  limbs. 

2 

Recovered. 

40 

4 

Near  point  of 
vaccination. 

Trunk  and  all  the  limbs. 

2 

Died. 

41   M.  1 

14      " 

Face. 

Trunk  and  all  the  limbs. 

4 

Recovered. 

Age. — Of  the  above  case.s.  27  were  under  the  age  of  six  months,  9  from 
six  months  to  twelve,  and  only  5  above  the  latter  age.  A  large  majority, 
therefore,  of  cases  of  infantile  erysipelas  occur  in  the  first  year  of  life. 

Point  of  Commencement. — In  58  cases  in  which  I  have  ascertained 
the  point  of  commencement  it  was  in  13  cases  the  vulva,  17  the  arm  after 
33 


514  ERYSIPELAS. 

vaccination,  7  the  leg,  6  the  face,  3  the  male  genital  organs,  3  at  or  near  the 
ear,  1  the  elbow,  1  the  shoulder,  1  the  nates,  1  the  foot.  In  the  adult,  idio- 
pathic erysipelas  commonly  commences  upon  the  face  and  affects  only  the 
face,  ears,  forehead,  and  scalp.  On  the  other  hand,  in  infantile  erysipelas 
statistics  show  that  the  rash  commences  upon  the  face  only  in  a  small  pro- 
portion of  cases,  1  in  9,  and  that  ic  rarely  extends  to  the  face  when  it  com- 
mences in  other  parts. 

Causes.— The  fact  that  erysipelas  is  infectious  has  led  to  many  micro- 
scopic examinations  in  order  to  discover  the  nature  of  the  microbe  which 
causes  it.  In  most  instances  some  injury  of  the  surface  has  occurred  through 
which  the  poison  is  received — a  scratch  or  abrasion  or  a  slight  cutaneous 
eruption.  Many  instances  have  been  cited  showing  infectiousness.  In  my 
practice  a  child  contracted  it  from  lying  in  bed  with  one  of  the  family 
who  had  facial  erysipelas.  The  following  cases  were  related  before  the  Paris 
Academy  in  1864:  Dr.  Paintevin  contracted  erysipelas  from  two  cases  occur- 
ring in  a  hospital  ward,  and  was  visited  by  Dr.  Testart  of  Guise,  a  place  free 
from  erysipelas.  Three  days  after  returning  home  this  physician  sickened 
with  erysipelas.  His  servant,  who  waited  on  him,  and  a  relative  living  twen- 
ty-four miles  away,  who  called  on  him,  also  contracted  the  disease.  The 
relative's  wife  was  then  seized  with  it,  and  also  three  members  of  a  family 
who  had  called  upon  them.  These  last  patients  communicated  the  disease 
to  a  relative  and  two  Sisters  of  Mercy  who  nursed  them.  These  sisters, 
returning  to  the  convent,  infected  others,  among  whom  was  the  physician  of 
the  convent,  who  died.  The  physician's  daughter  also  contracted  it,  the 
inflammation  beginning  in  leech-bites  which  had  been  made  over  enlarged 
glands.  Infectiousness  has  been  shown  not  only  by  clinical  experience,  but 
also  by  experiments ;  small  tumors  have  been  successfully  inoculated  with 
cultures  of  the  erysipelatous  cocci,  but  some  of  the  patients  thus  treated 
have  died.  The  attempt  to  remove  tumors  by  inoculating  them  with  the 
erysipelatous  virus  shows  the  highly  infectious  character  of  erysipelas,  and 
certain  small  tumors  have  been  removed  by  the  erysipelas,  while  in  other 
instances  the  result  has  been  disastrous,  death  occurring. 

Fehleisen  has  discovered  the  specific  microbe  of  erysipelas — to  wit,  a 
streptococcus  or  chain-coccus,  which  he  has  cultivated,  and  by  inoculating 
the  cultures  he  has  been  able  to  reproduce  erysipelas  in  tumors.  More 
recently  Meerovitch  made  microscopic  examinations  in  thirty-one  cases  of 
erysipelas,  and  invariably  found  a  large  number  of  these  streptococci  in  the 
aff'ected  skin,  and  in  grave  cases  also  a  few  in  the  blood.  He  detected  this 
organism  in  abscesses  and  in  fatal  cases  likewise  in  internal  organs.  The 
cultures  made  in  meat  bouillon  preserved  their  vitality  four  or  five  months. 
It  is  now  known  that  this  organism  sometimes  passes  from  the  maternal 
organism  to  the  foetus  through  the  uterine  circulation.  Ziegler  says  that  the 
micrococcus  which  causes  erysipelas  enters  the  lymphatics  and  spreads  chiefly 
by  them.  They  are  found,  says  he,  in  immense  masses  or  swarms  in  the  lym- 
phatics, and  from  them  they  spread  into  the  tissues,  where  they  excite  inflam- 
mation and  often  tissue-necrosis  (^Lond.  Med.  Recorder.^  Nov.  20,  1888). 

The  blood  may  undergo  certain  changes  which  predispose  to  erysipelas  or 
render  the  system  less  able  to  resist  the  micrococcus.  Among  the  causes  which 
produce  this  state  of  system,  uncleanliness,  residence  in  damp,  dark,  and 
crowded  apartments,  and  defective  alimentation  hold  a  principal  place. 
Hence  this  disease  is  more  common  in  the  poor  quarters  of  a  city  than  in 
the  country,  and  in  dispensary  and  hospital  than  in  family  practice. 

In  a  large  proportion  of  cases  there  is  an  irritation  or  inflammation  at 
some  point,  generally  trivial,  through  which  the  streptococcus  enters  the 
system.     Erysipelas  therefore  commonly  begins  at  a  simple  ecthymatous  or 


PREMONITORY  SYMPTOMS.  515 

impetiginous  eruption,  around  burns  or  suppurating  sores  or  syphilitic  erup- 
tions ;  it  frecjuently  connnences,  as  is  seen  by  the  above  table,  near  the  point 
of  vaccination  immediately  after  vaccination  or  when  the  pock  is  developed, 
or  again  when  it  has  run  its  course  and  been  detached.  In  a  considerable 
proportion  of  cases  it  begins  at  the  point  where  the  skin  is  thin  and  delicate, 
or  where  it  unites  with  a  mucous  surface,  probably  produced  by  some  unelean- 
liness  or  irritation  of  those  parts.  Thus,  I  have  records  of  cases  in  which  it 
commenced  at  the  external  ear,  commissure  of  the  mouth,  and  at  the  vulva. 
Indeed,  the  frequency  with  which  it  commences  at  the  vulva  renders  female 
Infants  more  liable  to  it  than  males.  In  some  instances  erysipelas  begins 
without  any  local  exciting  causes  upon  smooth  and  sound  skin,  even  when 
there  are  sores  upon  various  points  of  the  surface. 

Vaccination,  as  an  exciting  cause  of  erysipelas,  demands  particular  notice. 
Often,  doubtless,  it  is  the  inflammation  which  necessarily  arises  from  the  cut 
or  vesicle  which  operates  as  an  exciting  cause  of  the  erysipelatous  affection, 
and  not  any  deleterious  property  contained  in  the  virus  which  is  employed, 
so  that  an  equal  degree  of  inflammation  occurring  in  any  other  way,  as  from 
a  burn,  would  be  attended  by  a  like  result.  But  facts  show  that  the  virus 
itself  occasionally  contains  a  latent  noxious  principle,  which,  introduced  into 
the  system,  operates  as  a  cause  of  erysipelas.  Thus,  a  little  girl  was  vacci- 
nated by  me  in  November,  1860,  and  about  the  time  when  the  vesicle  began 
to  fill  she  was  seized  with  severe  inflammation  of  the  fauces,  attended  by  tume- 
faction and  infiltration  of  the  submucous  connective  tissue.  The  inflammation 
rapidly  subsided,  and  within  a  week  from  its  commencement  the  throat  affec- 
tion had  nearly  disappeared.  I  now  believe  that  the  disease  of  the  fauces 
was  erysipelatous,  although  it  was  not  suspected  at  the  time  to  have  this 
character. 

As  the  girl  was  otherwise  healthy  and  the  vaccine  vesicle  passed  through 
its  usual  stage  and  presented  the  usual  appearance,  the  scab  was  employed 
six  weeks  afterward  to  vaccinate  two  infants.  Within  twenty-four  hours  after 
vaccination  both  these  infants  were  seized  with  high  fever,  ushering  in  severe 
erysipelas,  commencing  in  one  around  the  point  of  vaccination,  and  in  the  other 
around  syphilitic  sores  near  the  anus.  In  the  former  case  the  erysipelatous 
rash  extended  from  the  shoulder  over  the  entire  limb,  and  was  obstinate,  twice 
reappearing  and  extending  over  the  same  surface ;  in  the  latter  (a  mulatto 
child)  it  extended  over  both  lower  extremities  and  a  considerable  part  of  the 
trunk,  when  the  case  passed  into  the  hands  of  another  physician,  and  the  result 
is  not  known.  The  instrument  with  which  the  vaccinations  were  performed 
was  clean.     The  vaccine  disease  did  not  appear  in  either  of  these  cases. 

Again,  a  well-known  physician  of  this  city  vaccinated  three  infants,  one 
his  own  (No.  32  of  the  table),  with  part  of  a  scab  which  had  been  pronounced 
good,  but  was  taken  from  a  child  that  he  had  not  seen  and  with  whose  state 
he  was  not  familiar.  These  infants  were  all  affected  with  er3rsipelas  from  the 
vaccination,  his  own  dying.  He  had  taken  the  precaution  to  rub  the  lancet 
on  his  boot  before  using  it.  Another  physician  of  this  city  has  informed  me 
that  he  vaccinated  two  children  in  the  same  family  with  a  scab,  with  all  the 
precautions  that  he  ever  had  used,  and  both  were  soon  after  affected  with  ery- 
sipelas of  a  severe  form,  extending  from  the  point  of  vaccination  ;  the  vaccine 
disease  did  not  appear.  I  have  heard  of  no  case  in  which  the  vaccine  lymph 
gave  rise  to  erysipelas,  and  probably  it  rarely  or  never  does.  In  the  lymph 
there  is  no  admixture  of  foreign  substances,  whereas  in  the  scab  there  is  a 
large  proportion  of  animal  matter. 

Erysipelas  neonatorum  is  treated  of  in  our  remarks  on  Sepsis  of  the  New- 
born, page  143. 

Premonitory  Symptoms. — Infantile  erysipelas  in  certain   cases  has  no 


516  ERYSIPELAS. 

premonitory  stage,  or,  if  present,  it  escapes  notice.  In  other  instances  there 
are  well-marked  precursory  symptoms,  as  drowsiness  or  restlessness,  more  or 
less  fever,  oppressed  respiration,  with  perhaps  vomiting  and  sudden  twitching 
of  the  limbs.  In  Cases  28  and  37  of  the  table,  which  occurred  in  my  prac- 
tice, the  fever,  restlessness,  and  dyspnoea  were  so  great  for  three  days  before 
the  appearance  of  the  eruption  as  to  cause  much  anxiety.  In  the  adult 
erysipelatous  patient,  pharyngitis  often  precedes  the  occurrence  of  the  rash 
upon  the  skin.  The  same  inflammation  may  be  present  in  the  premonitory 
period  of  infantile  erysipelas,  as  well  as  during  the  period  of  erysipelatous 
eruption.  The  hurried  and  difficult  respiration  which  is  present  in  the  com- 
mencement of  some  cases  is  probably  due  to  an  erysipelatous  turgescence 
of  the  bronchial  mucous  membrane. 

Symptoms. — The  patient  with  this  disease  is  usually  restless  in  conse- 
quence of  the  burning  pain  which  accompanies  the  eruption.  In  severe  cases 
there  is  little  sleep,  night  or  day,  except  from  medicine.  The  sleep  is  short, 
and  is  often  interrupted  by  sudden  starting  or  twitching  of  the  limbs.  Con- 
vulsions may  occur,  but  are  not  common. 

Fever  is  constantly  present,  and  is  proportionate  to  the  extent  and  grav- 
ity of  the  erysipelas.  I  have  notes  of  cases  in  which  the  pulse  was  more 
than  200  per  minute,  although  other  symptoms  did  not  indicate  immediate 
danger.  The  skin  not  affected  by  erysipelas  is  dry  and  hot,  though  not  pos- 
sessing the  pungent  heat  of  the  inflamed  portion  ;  face  often  flushed  ;  tongue 
moist  and  covered  with  a  light  fur  ;  stomach  usually  retentive.  The  state 
of  the  bowels  varies ;  sometimes  they  are  regular,  sometimes  variable,  and 
in  other  cases  the  stools  are  green  and  more  frequent  than  natural.  I  have 
records  relating  to  the  state  of  the  bowels  in  20  cases,  as  follows  :  in  7,  regu- 
lar;  in  9,  loose;  in  2,  constipated:  in  1,  constipated,  then  loose;  and  in  1, 
constipated,  then  regular.  Diarrhoea,  when  present,  is  usually  mild,  requir- 
ing little  or  no  treatment.  The  erysipelatous  redness  is  not  in  all  cases  so 
pronounced  as  in  the  adult,  but  otherwise  there  is  nothing  peculiar  in  its 
appearance.  In  feeble  infants  with  an  impoverished  state  of  the  blood  its 
color  is  pink,  instead  of  the  deep  red  which  characterizes  the  inflammation 
in  the  robust.  Points  of  vesication  may  occur  where  the  inflammation  is 
most  severe,  as  in  the  adult,  and  subsequently  the  same  desquamation  and 
oedema. 

If  the  infant  be  debilitated  there  is  great  danger  of  the  formation  of 
abscesses  around  which  the  inflammation  lingers  after  it  has  disappeared  from 
every  other  part  of  the  body.  Sometimes  also  in  very  young  infants  gan- 
grene occurs,  especially  in  the  genital  organs  in  the  male.  Several  of  these 
cases  have  been  related  to  me,  all  under  the  age  of  a  month  or  six  weeks, 
and  all  fatal.  Occasionally  the  sloughing  is  so  great  as  to  denude  the  testicle. 
A  noteworthy  feature  of  erysipelas  in  infants  is  its  proneness  to  return. 
When  it  has  been  progressively  subsiding  and  hope  is  entertained  of  its  speedy 
disappearance,  it  not  infrequently  is  suddenly  relighted  from  some  unknown 
cause,  travelling  again  over  the  same  or  parts  of  the  same  surface.  In  one 
case  the  disease,  arising  from  vaccination,  extended  three  times  over  the  arm 
and  forearm ;  and  in  another  case  a  second  time  over  both  legs  and  a  consid- 
erable part  of  the  trunk. 

The  internal  inflammations  which  most  frequently  complicate  erysipelas 
and  give  rise  to  symptoms  which  are  superadded  to  those  pertaining  to  the 
erysipelas  are  pharyngitis  and  peritonitis,  and  more  rarely  broncho-pneumonia 
or  enteritis.  In  a  case  which  I  examined  after  death  in  the  Nursery  and 
Child's  Hospital,  and  in  which,  the  erysipelatous  inflammation  having  extended 
over  the  abdomen,  the  lesions  of  peritonitis  were  present,  it  appeared  from 
the   thinness   of  the  abdominal    walls   that    the    inflammation  had   extended 


FROGNOSIS— PATHOLOGICAL  ANATOMY.  517 

through  them  from  the  external  to  the  internal  surface  or  from  the  skin  to 
the  peritoneum. 

Procinosis. — P>y.sipelas  is  much  more  fatal  in  infancy  than  in  adult  life. 
In  the  death -statistics  of  this  city  for  three  years  I  find  80  deaths  from  ery- 
sipelas of  infants  under  th6  age  of  one  year  to  88  deaths  from  this  disease 
above  that  age.  Age  greatly  influences  the  prognosis.  Infants  under  the 
age  of  three  weeks  usually  die  ;  from  the  age  of  three  weeks  to  six  months 
the  result  is  doubtful ;  while  above  the  age  of  six  months  a  majority  recover 
with  correct  treatment.  It  will  be  seen  by  the  foregoing  table  that  7  infants 
under  the  age  of  six  weeks  had  erysipelas,  and  G  died  ;  from  the  age  of  six 
weeks  to  six  months,  G  recovered  and  9  died  ;  and  above  the  age  of  six  months, 
J(  recovered  and  4  died. 

With  the  exception  of  a  case  of  the  so-called  umbilical  erysipelas,  the 
youngest  child  who  recovered  of  whom  I  have  obtained  information  was 
three  weeks  old.  In  this  case  the  rash  extended  nearly  over  the  entire  sur- 
face, beginning  with  the  face.  Case  38  of  the  table,  treated  by  myself,  was 
very  similar  as  regards  the  extent  of  the  erysipelatous  eruption  and  the 
result.     This  infant  was  five  weeks  old. 

It  is  scarcely  necessary  to  state  that  erysipelas  is  more  favorable  when 
it  affects  the  limbs  than  when  it  invades  the  head,  neck,  or  body ;  when  it 
spreads  slowly  than  rapidly  ;  when  it  is  superficial  than  when  phlegmonous. 
In  those  cases  in  which  the  connective  tissue  is  much  involved  the  infant 
is  not  always  safe  after  the  disease  has  run  its  course ;  he  sometimes  dies 
exhausted  from  the  discharge  of  abscesses;  I  have  records  of  two  such 
cases. 

Duration. — In  16  cases  that  recovered  the  erysipelas  terminated  within 
the  first  week  in  2,  the  second  week  in  G,  the  third  week  in  5,  fourth  week  in 
1,  and  in  2  cases  it  lasted  five  and  six  weeks.  The  average  duration  was 
fifteen  days.  In  19  fatal  cases,  10  died  within  the  first  week,  5  the  second 
week,  3  the  third  week,  and  1  in  the  fourth  week.  The  average  duration  of 
fatal  cases  was  about  ten  days. 

Modes  of  Death. — Death  occurs  in  different  ways :  in  chronic  or  tonic 
convulsions  followed  by  coma,  from  exhaustion,  and  from  internal  inflamma- 
tion, that  from  exhaustion  being  probably  the  most  common. 

Pathological  Anatomy. — The  blood  doubtless  in  this  disease  under- 
goes certain  pathological  alterations  previously  to  the  occurrence  of  the  erup- 
tion, but  the  exact  changes  are  not  known.  Our  knowledge  of  the  morbid 
anatomy  of  erysipelas  relates  chiefly  to  the  local  affections,  which,  with  the 
exception  of  the  inflammation  of  the  skin,  are  not  constant,  and  may  there- 
fore be  regarded  as  complications.  The  cutaneous  inflammation  aff"ects  all 
the  structures  of  the  skin,  and  in  greater  or  less  degree  also  the  subcutaneous 
connective  tissue.  The  inflammation  is  accompanied  by  more  or  less  serous 
eff'usion  or  oedema. 

The  not  infrequent  occurrence  of  peritonitis  in  connection  with  erysipelas 
has  long  been  known.  In  Heberden's  Epitome  Morhorum  Puerilium  the 
anatomical  character  of  erysipelas  is  expressed  in  one  sentence :  "  When  the 
body  has  been  opened  after  death  the  intestines  have  been  found  glued 
together  and  covered  with  coagulable  lymph."  Since  Herberden's  time 
nearly  all  who  have  written  on  diseases  of  infancy  and  childhood  have  men- 
tioned peritonitis  as  one  of  the  most  common  complications  of  erysipelas. 
Underwood  says:  "Upon  examining  several  bodies  after  death  the  contents 
of  the  body  have  frequently  been  found  glued  together  and  their  surface 
covered  with  inflammatory  exudation,  exactly  similar  to  that  of  women  who 
have  died  of  puerperal  fever."  Similar  remarks  in  reference  to  the  frequency 
of  peritonitis  in  this  disease  are  made  by  recent  writers. 


518  ERYSIPELAS. 

The  statistics  in  reference  to  erysipelas  as  well  as  peritonitis  show  that  in 
infants  in  hospital  practice,  and  in  those  affected  by  erysipelas  during  epi- 
demics of  puerperal  fever,  peritonitis  is  a  not  infrequent  complication.  On 
the  other  hand,  as  we  commonly  meet  cases  of  infantile  erysipelas  occurring 
sporadically  in  private  practice,  abdominal  distension  and  tenderness  are  not 
sufficient  to  indicate  peritonitis.  In  only  one  of  the  cases  embraced  in  the 
foregoing  table  was  a  post-mortem  examination  made,  and  in  that  there  had 
been  no  peritonitis.  The  occurrence  of  pharyngitis  in  connection  with  ery- 
sipelas has  been  already  mentioned. 

Enteritis  has  been  alluded  to  as  another  complication  in  infants.  Diar- 
rhoea has  been  stated  to  be  a  symptom  in  certain  cases,  and  it  has  been  found 
to  be  dependent  on  enteritis  of  a  mild  grade.  Billard  made  post-mortem 
examinations  of  16  infants  who  died  of  erysipelas,  and  "  found  in  2  gastro- 
enteritis, in  10  enteritis,  in  3  pneumonia  complicated  with  enteritis  and  cerebral 
congestion,  and  in  1  pleuro-pneumonia." 

Prophylaxis. — A  patient  with  erysipelas  should  be  isolated,  and  the 
bedding  and  linen  worn  by  him  should  be  placed  in  boiling  water  as  soon  as 
removed.  No  one  should  be  allowed  to  occupy  the  bed  or  room  when  vacated 
by  the  patient  until  it  has  been  thoroughly  disinfected. 

Treatment. — The  external  treatment  has  varied  greatly,  but  those  agents 
are  now  most  employed  which  have  soothing  or  antiseptic  properties.  Among 
them  we  may  mention  iodoform  in  collodion.  Trousseau  employed  an  ethereal 
solution  of  camphor  and  tannin.  Scarification  and  leeching,  formerly  employed, 
have  been  abandoned  as  pernicious,  and  astringents,  as  alum  and  sugar  of 
lead,  are  now  known  to  be  inefficacious.  Strong  counter-irritation  over  the 
inflamed  surface  has  also  been  practised.  Baron  Larrey  applied  the  actual 
cautery,  and  since  his  time  nitrate  of  silver,  one  part  to  ten,  has  been  used, 
but  without  appreciable  benefit.  The  solid  nitrate  of  silver  was  employed  in 
two  cases  of  which  I  have  the  records,  and  in  both  the  result  was  pernicious. 
Troublesome  sores  were  produced,  from  which  blood  flowed,  and  in  one  of 
the  cases  the  parents  attributed  the  death  to  this  treatment,  rather  than  to 
the  primary  disease.  The  tincture  of  iodine  is  preferable  to  the  nitrate  of 
silver  for  local  treatment.  It  should  be  applied  in  officinal  strength  over  the 
inflamed  surface  and  to  the  distance  of  two  inches  upon  the  sound  skin.  It 
may  fail  in  arresting  the  extension  of  the  erysipelas,  but  it  does  not  produce 
any  unfavorable  result.  Carbolic  acid  is  a  better  antiseptic  agent  for  local 
treatment,  solutions  of  which  are  known  to  be  absorbed,  by  the  olive  color 
imparted  to  the  urine.  It  should  not,  however,  be  applied  in  young  children 
over  a  great  extent  of  surface,  on  account  of  the  danger  of  carbolic-acid 
poisoning.  Tillmann  and  Fehleisen  ascertained  that  cultures  mixed  with  2 
to  4  per  cent,  of  carbolic  acid  were  sterilized.  Verneuil  sprayed  the  surface 
during  five  minutes  every  hour  with  a  2  per  cent,  solution  of  carbolic  acid. 
Hueter  made  hypodermic  injections  of  a  3  per  cent,  solution  of  carbolic  acid, 
and  found  that  a  syringeful  sufficed  for  two  square  inches.  He  employed 
as  many  as  twelve  syringefuls  at  one  time,  without,  it  is  said,  any  unfavor- 
able result ;  but  probably  it  would  be  better  to  limit  the  number  to  two  or 
three  each  day,  to  avoid  the  risk  of  carbolic-acid  poisoning.  The  application 
may  also  be  made  with  surgeon's  lint  constantly  saturated  with  a  2  to  4  per 
cent,  solution  of  carbolic  acid  in  glycerin  and  water.  Wilde  employs,  inas- 
much as  it  involves  less  risk  than  the  use  of  carbolic  acid,  one  or  two  syringe- 
fuls of  an  8  per  cent,  solution  of  the  sodium  sulphocarbolate.  It  is  said 
that  it  immediately  reduces  the  temperature,  and  the  erysipelas  disappears  in 
three  or  four  days.  The  use  of  turpentine  externally  also  has  its  advocates. 
Luecke  says  that  when  applied  upon  the  erysipelatous  surface  it  reduces  the 
fever  and  the  burning.     A  mixture  of  one  part  of  carbolic  acid  and  ten  of 


TREATMENT.  519 

turpentine  has  lately  been  recoraraended.  Nussbaum  recommends  for  exter- 
nal treatment  one  part  of  ichtliyol  to  ton  of  vaseline  ;  and  Lorenz,  two  parts 
of  ichtliyol  to  one  part  of  glycerin  and  one  of  ether.  Finally,  hypodermic 
injections  of  corrosive  sublimate  have  been  lately  used,  the  solution  vary- 
ing from   1   part  in  oUOO  to   1   part  in  500. 

On  this  side  of  the  Atlantic  great  uniformity  prevails  as  regards  the 
internal  treatment  of  erysipelas.  Sustaining  measures  are  prescribed,  and 
the  tincture  of  the  chloride  of  iron  is  the  tonic  generally  preferred.  What- 
ever the  intensity  of  the  febrile  reaction  and  the  stage  of  the  disea.se,  if  there 
be  no  intestinal  complication  ferruginous  or  other  tonics  .should  be  adminis- 
tered. The  largest  doses  of  the  tincture  of  the  chloride  of  iron  given  in  any 
of  the  cases  in  the  above  table  were  in  Case  No.  4 — namely,  ten  drops  every 
two  hours — and  this  patient  recovered  in  seven  days  from  a  pretty  severe 
attack.  Probably,  however,  nothing  is  gained  by  such  large  doses,  and  they 
may  irritate  the  intestinal  surface  and  increase  the  liability  to  enteritis,  which, 
we  have  seen,  complicates  a  certain  proportion  of  cases.  Four  drops  may  be 
given  every  three  hours  to  a  child  from  one  to  two  years  of  age.  Instead 
of  the  iron,  or  in  addition  to  it,  one  of  the  preparations  of  cinchona  may  be 
prescribed. 

Erysipelas  being  an  asthenic  disease,  it  is  very  important  that  the  diet 
should  be  highly  nutritious  and  easily  digested.  Milk,  perhaps  peptonized, 
should  be  given  freely,  and  the  various  meat  peptones  are  also  useful. 
Brandy  or  wine  is  also  required.  If  vomiting  be  a  pronounced  symptom 
it  may  be  necessary  to  employ  rectal  alimentation. 


PART    IV. 


SECTION  I. 


DISEASES     OF    THE    CEREBRO-SPIN AL    SYSTEM. 

Diseases  of  the  brain  and  spinal  cord  are  less  frequent  than  those  of  the 
respiratory  and  digestive  systems,  and,  being  less  amenable  to  treatment,  they 
largely  increase  the  aggregate  of  deaths.  They  contrast  with  the  diseases  of 
the  other  systems  in  their  greater  relative  frequency  in  infancy  and  childhood 
than  in  adult  life.  This  is  explained,  as  regards  the  brain,  by  the  rapid  devel- 
opment and  active  molecular  change  in  this  organ  in  early  life,  its  great  im- 
pressibility by  the  emotions,  and  the  thinness  of  the  covering  which  protects 
it  from  external  agencies. 

Some  of  the  most  important  of  the  diseases  of  the  cerebro-spinal  system 
are  peculiar  to  early  life,  as  tetanus  infantum  and  spina  bifida.  The  dis- 
eases of  this  system  also  contrast  with  other  local  affections  in  their  greater 
obscurity,  especially  in  their  commencement ;  for,  while  maladies  of  the  tho- 
rax can  be  readily  ascertained  by  auscultation  and  percussion,  or  those  of  the 
abdomen  by  the  nature  of  the  evacuations  or  the  degree  of  tenderness  or  dis- 
tension, our  means  of  conducting  examination  through  the  bony  encasement 
of  the  cerebro-spinal  axis  are  meagre  and  unsatisfactory.  The  condition  of 
the  brain  and  spinal  cord  must  be  determined  chiefly  by  the  study  of  symp- 
toms, and  not  by  direct  examination.  The  state  of  the  anterior  fontanel 
in  young  infants,  however,  enables  us  to  determine  the  presence  or  absence 
of  active  congestion  of  the  brain.  If  there  be  an  excess  of  arterial  blood, 
it  is  convex.  Prominence  of  the  fontanel  is  common  in  inflammatory  and 
febrile  diseases,  and  is  a  sign  of  considerable  diagnostic  and  prognostic 
value. 

Within  a  few  years  the  ophthalmoscope  has  been  employed  as  a  means 
of  diagnosis  in  cerebral  diseases,  and,  although  the  use  of  this  instrument 
for  such  purposes  is  but  recent,  enough  has  been  elicited  to  prove  its 
value  as  an  aid  in  determining  tlae  state  of  the  brain.  Prof.  H.  D.  Noyes 
remarks  on  this  subject :...."  The  argument  for  making  ophthalmoscopic 
examination  in  all  cases  of  brain  disease  becomes  irresistible.  Indeed,  a 
moment's  reflection  would  lead  to  this  conclusion  without  any  considerations 
drawn  from  pathology.  The  optic  nerve  is  only  an  outlying  portion  of  the 
brain  ;  its  extremity  is  fully  exposed  to  view.  Situated  within  about  two 
inches  of  the  brain,  it  is  the  only  nerve  in  the  body  which  we  can  inspect ; 
it  contains  blood-vessels  which  communicate  directly  with  the  intracranial 
circulation.  We  thus  come  into  relation  with  the  cerebrum  by  continuity  of 
nerve-structure  and  also  of  blood-vessels." 

Structural  changes  in  the  optic  nerve  and  retina  have  been  discovered  by 

520 


DISEASES   OF  THE  CEREBROSPINAL  SYSTEM.  521 

means  of  the  ophthalmoscope  in  meninfijitis,  hydrocephalus,  phlehitis  of  the 
sinuses,  apoplexy,  etc.  Among  the  lesions  which  have  been  observed  by  this 
instrument  are  hypenemia,  more  or  less  opacity  and  tumefaction  of  the  optic 
nerve,  engorgement  of  the  vessels  of  the  retina,  with  serous  or  sero-fibrinous 
exudation  and  ecchyniotic  points.  In  certain  protracted  diseases,  as  chronic 
hydrocephalus,  in  which  dimness  or  loss  of  sight  occurs,  the  ophthalmoscope 
discloses  a  state  of  atrophy  of  the  optic  nerve.  Heretofore  this  instrument 
has  been  chiefly  employed  by  oculists,  but  as  it  comes  into  more  general  use 
there  can  be  little  doubt  that  it  will  be  recognized  as  an  important  aid  in  the 
diagnosis  of  obscure  cerebral  diseases. 

Still,  with  all  possible  aid  to  diagnosis,  the  obscurity  which  attends  the 
invasion  of  many  of  the  cerebro-spinal  diseases  must  be  acknowledged.  To 
the  hasty  and  careless  physician  their  symptoms  are  often  deceptive.  Careful 
weighing  of  the  phenomena  and  thorough  and  protracted  examination  are 
requisite  in  order  to  insure  correct  diagnosis  and  proper  treatment.  Some  of 
the  cerebro-spinal  affections  are,  in  reality,  sequelae  of  other  diseases — as,  for 
example,  spurious  hydrocephalus — and  some  are,  strictly  speaking,  only 
symptoms,  as  convulsions ;  but  on  account  of  their  importance,  and  because 
they  require  special  treatment,  it  is  proper  to  consider  them  as  diseases  p«r  se. 

The  brain  presents  certain  peculiarities  in  infancy  and  childhood.  In  the 
foetus,  while  the  other  organs  are  well  formed,  the  brain,  especially  its  cerebral 
portion,  is  still  diffluent,  and  at  birth  it  has  so  little  consistency  that  it  must 
be  handled  carefully  to  prevent  laceration.  This  softness  is  due  to  the  large 
proportion  of  water  which  it  contains.  The  following  analyses  show  the 
composition  of  the  brain  in  three  periods  of  life  : 

Infant.  Youth.  Adult. 

Albumen 7.00  10.20              9.40 

Cerebral  fats 3.45  5.H0              6.10 

Phosphorus 0.80  1.65               1.80 

Osmazome,  salts 5.96  8.59  10.19 

Water 82.79  74.26  72.51 

At  birth  the  brain  has  a  nearly  uniform  white  color.  The  gray  substance, 
in  which  the  nervous  power  originates,  is  undeveloped.  The  date  of  its 
appearance  corresponds  with  the  first  exhibition  of  emotion  or  intelligence, 
and  the  decided  gray  color  which  we  observe  in  the  brain  of  the  adult  does 
not  appear  until  the  age  of  full  mental  activity. 

In  the  new-born  the  brain  is  large  in  proportion  to  the  rest  of  the  body, 
and  its  growth  during  infancy  and  childhood  is  rapid.  Until  the  fifth  year, 
as  appears  from  the  observations  of  Dr.  Peacock,  its  weight  is  about  one- 
seventh  or  one-eighth  that  of  the  entire  system,  the  proportion  varying  some- 
what in  different  cases. 

The  brain  does  not  attain  its  full  size,  as  stated  by  Dr.  West,  at  the  age 
of  seven  years,  but,  according  to  Dr.  Peacock's  statistics,  it  continues  to 
increase  till  the  age  of  twenty-five  or  thirty,  although  its  growth  is  less  rapid 
after  the  age  of  seven  years  than  previously. 

The  membranous  covering  of  the  cerebro-spinal  axis  is  scarcely  less 
interesting  to  the  pathologist  than  the  axis  itself.  I  shall  speak  in  the 
following  pages  of  the  arachnoid  and  cavity  of  the  arachnoid  for  convenience 
of  description,  although  aware  of  the  fact  that  some  eminent  authorities,  as 
Virchow  and  Kblliker,  whose  opinions  in  reference  to  the  minute  anatomy 
of  the  system  always  command  attention,  if  not  assent,  believe  that  there 
is  no  arachnoid,  but  what  has  heretofore  been  called  by  this  name  is  on 
the  one  side  the  smooth  surface  of  the  dura  mater  and  on  the  other  of  the 
pia  mater. 


522  MICROCEPHALUS— ATROPHY  OF  BRAIN. 

The  dura  mater  is  seldom  involved  in  the  diseases  of  early  life,  except  as 
it  is  affected  by  pressure,  while  the  pia  mater  and  arachnoid  are  the  seat  and 
source  of  some  of  the  most  important  diseases,  as  meningitis,  meningeal 
apoplexy,  etc. 

The  more  complicated  and  delicate  the  structure  of  an  organ  the  more 
liable  it  is  to  errors  of  nutrition  and  growth.  There  is,  therefore,  no  organ 
which  is  so  liable  to  irregular  development  as  the  brain.  It  may  be  entirely 
wanting,  or  it  may  be  partially  developed,  certain  portions  being  absent,  or, 
lastly,  its  growth  may  be  excessive,  constituting  hypertrophy. 


CHAPTER  I. 

MICEOCEPHALUS— ATKOPHY  OF  BRAIN. 

An  abnormally  small  brain  usually  results,  according  to  my  observations, 
from  a  defect  in  the  foetal  development.  At  birth  the  cranium  is  not  only 
prematurely  small,  but  the  cranial  bones  are  firmly  united,  so  that  the  sutures 
and  fontanels  are  obliterated.  Whether  the  primary  fault  has  been  an  exag- 
gerated ossification,  so  that  the  brain  cannot  develop  and  is  compressed,  or 
the  development  of  the  brain  is  primarily  arrested  from  some  unknown  cause, 
and  the  cranial  arch  consequently  does  not  have  its  normal  expansion,  is 
uncertain.  The  following  are  cases  of  microcephalus  as  I  have  usually 
observed  it :  In  August,  1878,  an  infant  was  brought  into  the  Bureau  for 
the  Relief  of  the  Out-door  Poor  with  marked  microcephalism.  Its  age  was 
nineteen  months,  and  the  bone  formation  was  so  slow  that  only  two  teeth  had 
appeared ;  the  circumference  of  its  head  was  fourteen  and  a  half  inches ;  it 
had  had  repeated  convulsions  since  the  age  of  five  months,  and  the  mother 
stated  that  its  head  had  been  round  and  hard  from  its  birth.  The  following 
case  of  microcephalus  was  brought  to  the  Out-door  Department  in  Jan.,  1890  : 
Y ,  female,  aged  fourteen  months,  was  born  asphyxiated,  and  was  resus- 
citated with  difficulty.  The  cranial  bones  were  firmly  united  at  birth,  so  that 
the  sutures  and  fontanels  were  obliterated,  and  the  cranium  was  unyielding 
in  every  part  on  pressure.  Clonic  convulsions  occurred  at  the  age  of  one 
month,  and  have  been  frequent  to  the  present  time.  The  infant  has  internal 
strabismus,  its  mouth  is  open  and  drivelling,  and  it  is  evidently  idiotic. 
Though  fourteen  months  have  elapsed  since  birth,  the  circumference  of  the 
head,  measured  over  the  occipital  protuberance  and  the  most  prominent  part 
of  the  forehead,  is  thirteen  and  a  quarter  inches,  and  the  distance  from  one 
auditory  meatus  to  the  other,  measured  over  the  top  of  the  head,  seven 
inches.  In  microcephalus  death,  sooner  or  later,  is  the  common  result ;  life 
ends  in  convulsions  and  coma. 

Again,  the  brain  of  the  child  when  undergoing  development,  with  the 
cranial  bones  sufficiently  yielding,  may  not  only  cease  to  grow,  but  may  even 
diminish  in  size  in  consequence  of  protracted  and  exhausting  diseases.  Dim- 
inution in  the  size  of  the  brain  occurs  especially  after  fevers  and  diarrhceal 
affections  of  long  standing  and  attended  with  much  emaciation.  The  waste 
of  the  brain  corresponds  with  the  general  loss  of  flesh.  If  the  cranial 
sutures  be  not  united,  the  occipital  and  sometimes  the  frontal  bones  are 
depressed  according  to  the  diminished  size  of  the  brain,  and  are  overlaid  by 
the  parietal.  In  foundlings  of  two  or  three  months  this  loss  of  brain-sub- 
stance is  often  very  striking.     In  infants  of  this  class  who  have  died  of 


HYPERTROPHY  OF  BRAIN.  523 

protracted  diarrhoea  it  is  not  unusual  to  observe  the  occipital  bone  not 
only  depressed,  but  extending  one,  two,  or  even  three  lines  underneath 
the  parietal. 

If  the  child  with  shrunken  brain  from  protracted  and  exhausting  disease 
be  old  enough  to  express  its  thoughts,  it  often  seems  foolish,  talks  but  little, 
and  perhaps  says  the  same  thing  over  and  over  again.  In  one  case  in  my 
practice  a  little  girl,  having  passed  through  a  long  course  of  typhus,  persist- 
ently repeated  during  her  convalescence  with  a  silly  smile  the  questions 
addressed  to  her.  This  peculiarity  continued  two  or  three  weeks,  although 
her  appetite  was  good  and  her  restoration  to  health  rapid.  In  another  case  a 
little  boy  during  convalescence  was  wont  to  laugh  heartily  at  the  appearance 
of  the  ordinary  articles  of  furniture  in  the  room.  Both  showed  more  impair- 
ment of  mind  during  convalescence  than  in  the  midst  of  the  fever.  The 
friends  of  such  children  are  in  a  state  of  great  anxiety  lest  their  minds  be 
permanently  enfeebled,  but  as  the  appetite  and  strength  return  the  nutrition 
of  the  brain  is  re-established  and  the  mind  regains  its  former  vigor.  In  cases 
of  wasted  brain  with  cranial  bones  united  the  deficiency  is  supplied  by  serous 
effusion,  which  is  gradually  absorbed  as  the  health  of  the  patient  is  re-estab- 
lished and  the  brain  enlarges.  This  effusion  occurs  not  only  over  the  con- 
vexity of  the  brain,  but  also  at  its  base,  and  sometimes  in  the  ventricles. 
Dr.  West  states  that  in  atrophy  of  the  brain  from  protracted  disease  its  tex- 
ture is  firmer  than  usual.  I  have  not  noticed  this  in  infants,  but  my  atten- 
tion has  not  been  directed  particularly  to  this  point.  It  is  probable  that 
there  is  some  change  in  the  anatomical  character  of  the  brain  aside  from 
mere  waste. 

Partial  atrophy  of  the  brain  sometimes  also  occurs  from  primary  disease 
located  in  this  organ  ;  the  affected  portion  wastes,  while  the  remainder  of  the 
brain  has  its  normal  development. 


CHAPTER    II. 

HYPERTROPHY    OF    BRAIN. 

In  contrast  with  atrophy  of  the  brain  is  the  opposite  state,  or  hypertro- 
phy. The  size  of  this  organ  within  the  limits  of  health  varies  greatly  in 
different  individuals,  but  sometimes  there  is  so  great  an  increase  in  volume 
as  properly  to  constitute  a  disease.  Fortunately,  hypertrophy  of  brain  is 
rare  in  America. 

Pathological  Anatomy. — The  excess  of  growth  which  characterizes 
this  disease  has  been  ascertained  to  be  confined  to  the  white  portion  of  the 
brain,  and  ordinarily  to  that  part  contained  in  the  cerebral  hemispheres. 
Hypertrophy  of  the  brain  is  attended  by  induration,  which  exists  in  dif- 
ferent degrees  in  different  cases.  It  is  in  some  so  slight  as  to  be  scarcely 
appreciable,  while  in  others  it  is  apparent  at  once  by  pressure  with  the  finger 
or  incision  with  the  scalpel.  Rilliet  and  Barthez  state  that  the  induration  in 
some  cases  resembles  in  degree  and  appearance  that  produced  by  the  action 
of  alcohol.  The  white  substance  of  the  cerebrum  is  not  only  resisting  and 
elastic,  but  its  color  is  unusually  pale  ;  it  presents  even  a  brillant  or  polished 
appearance.  At  the  same  time,  the  gray  substance  is  more  or  less  faded,  and 
its  depth  in  the  convolutions  is  less  than  in  the  normal  state  of  the  organ. 
Rokitansky  says  :   "  The  cineritious  matter  is  generally  of  a  pale  grayish-red 


524  HYPERTROPHY  OF  BRAIN. 

color.  The  medullary  is  always  dazzling  white  and  remarkably  pale  and 
anasmic."  An  unusual  case  is  related  by  Burnet  in  which  the  gray  substance 
in  the  corpora  striata  retained  its  usual  color  and  was  indurated  like  the  white 
substance.  In  exceptional  instances  the  cerebellum  as  well  as  cerebrum  under- 
goes hypertrophy,  becoming  at  the  same  time  more  or  less  indurated.  In 
Burnet's  case  there  was  induration  of  the  optic  nerves.  "  The  internal  struc- 
ture," he  says,  "  of  the  optic  nerves,  especially  in  their  bulbs,  had  the  polish, 
homogeneous  appearance,  elasticity,  and  almost  the  hardness  of  cartilage." 
Rilliet  and  Barthez  state  that  in  two  cases  the  spinal  cord  presented  even 
more  marked  induration  than  the  encephalon.  Congestion  is  not  a  feature 
of  hypertrophy.  On  the  other  hand,  there  is  often  less  vascularity  of  the 
brain  and  its  membranes  than  in  the  healthy  state.  If  the  cranial  bones  be 
completely  ossified  at  the  time  when  hypertrophy  commences,  and  firmly 
united,  enlargement  of  the  brain  is  partially  prevented.  The  convolutions 
are  then  thin,  much  flattened,  the  sulci  more  or  less  eff^aced,  the  membranes 
pale  and  dry,  and  the  ventricles  are  small  and  nearly  destitute  of  serum.  At 
the  autopsy  of  such  a  case,  when  the  dura  mater  is  incised  the  expansion  of 
the  brain  prevents  the  proper  refitting  of  the  skullcap.  Occasionally,  hyper- 
trophy causes  more  or  less  absorption  of  the  cranium,  and  perhaps  the  sutures 
already  united  are  pressed  apart. 

If  hypertrophy  commence  in  young  infants  with  the  fontanels  and  sutures 
still  open,  they  usually  remain  open  or  are  a  long  time  in  uniting.  The  inter- 
spaces continue,  not  only  in  consequence  of  the  growth  of  the  brain,  which 
tends  to  separate  the  bones,  but  also  in  consequence  of  feeble  ossification. 
The  shape  of  the  head  arrests  attention.  Hypertrophy  usually  produces 
most  enlargement  between  and  above  the  ears,  while  the  frontal  portion  of 
the  head,  though  somewhat  enlarged,  is  less  developed. 

The  direction  of  the  eyes  is  not  changed,  as  is  common  in  congenita! 
hydrocephalus. 

Rokitansky  says  (vol.  iii.  p.  285)  :  "  With  regard  to  the  question  to  be 
decided  by  the  theory  and  microscopic  examination  as  to  the  nature  of  the 
added  material  upon  which  the  increase  of  volume  depends,  I  have  formed  the 
following  opinion  from  repeated  investigations  : 
"  1.  The  disease  is  genuine  hypertrophy  ; 

"2.  It  consists,  as  such,  not  in  an  increase  in  the  number  of  nerve-tubes 
in  the  brain  from  new  ones  being  formed,  nor  in  an  increase  in  the  dimensions 
of  those  which  already  exist,  either  as  thickening  of  their  sheaths  or  as  aug- 
mentation of  their  contents,  by  either  of  which  the  nerve-tubes  would  become 
bulky ;  but, 

"  3.  It  is  an  excessive  accumulation  of  the  intervening  and  connecting 
nucleated  substance." 

It  is  now  generally  admitted  that  the  views  of  E-okitansky  are  correct — 
that  hypertrophy  of  the  brain  is  due  to  an  augmentation  in  the  amount  of 
connective  tissue  which  lies  between  and  unites  the  tubules. 

Causes. — Hypertrophy  of  the  brain  results  from  an  ei-ror  in  the  nutri- 
tive process  which  sometimes  seems  to  be  associated  with  the  rachitic  state 
or  a  condition  analogous  to  rachitis.  It  is  not  common — is  indeed  rare — in 
this  country,  and  is  more  common  in  countries  like  England  where  rachitis  is 
more  prevalent  than  with  us.  Rilliet  and  Barthez  consider  frequent  conges- 
tions of  the  brain  as  a  common  cause.  The  hypertrophy  is  most  frequently 
met  in  hospitals  for  children  and  among  the  poor  of  cities  whose  systems  are 
rendered  cachectic  by  residence  in  damp  and  dark  localities  and  by  unwhole- 
some diet.  In  the  deep  valleys  of  Switzerland  and  in  parts  of  South  America 
and  Asia  hypertrophy  of  the  brain  is  common,  under  the  name  of  cretinism. 
It  is  associated  with  rachitis  and  stunted  growth.     The  abnormal  develop- 


SYMPTOMS.  525 

nieiit  which  occurs  in  cretinism  begins  in  infancy  or  early  childhood,  and  the 
unfortunate  subjects  of  it  are  short-lived.  Cretinism  has  been  attributed  to 
a  residence  in  localities  wet  and  deprived  in  great  measure  of  solar  light,  and 
to  general  disregard  of  the  laws  of  health  on  the  part  of  those  affected,  as 
well  as  their  parents. 

The  observations  of  different  physicians  also  establish  a  connection  between 
some  cases  of  hypertrophy  and  the  saturation  of  the  system  by  lead.  In  what 
way  lead-poisoning  leads  to  hypertrophy  is  obscure,  but  the  concurrent  testi- 
mony of  different  observers  is  so  strong  that  we  cannot  doubt  that  it  does 
sometimes  have  that  effect.  But  in  a  considerable  proportion  of  cases,  as  in 
the  one  presently  to  be  related,  the  cause  is  obscure. 

Symptoms. — The  symptoms,  as  is  the  case  with  most  organic  diseases  of 
the  brain,  vary  considerably  in  different  patients.  Sometimes  there  is  at  first 
more  or  less  depression  or  languor.  If  the  child  be  old  enough  to  speak,  he 
may  complain  of  pain  in  the  abdomen  or  limbs,  evidently  neuralgic,  or  of 
headache.  After  a  variable  time  vomiting  succeeds,  and  finally  convulsions, 
affecting  the  muscles  of  the  face  as  well  as  extremities ;  the  convulsions  are 
usually  clonic,  but  sometimes,  as  regards  at  least  the  extremities,  of  a  tonic 
character.  The  pupils  may  be  contracted  or  dilated ;  there  is  restlessness  alter- 
nating with  drowsiness,  and  finally  coma  succeeds. 

Hypertrophy  may  continue  a  considerable  time  before  serious  symptoms 
arise ;  but  when  once  developed  these  symptoms  ordinarily  continue  with 
more  or  less  severity  till  death.  Death  commonly  results  within  a  week 
after  their  commencement,  but  sometimes  not  till  several  weeks  have  elapsed. 
When  death  occurs  at  an  early  period  in  the  disease,  there  is  usually  firm 
ossification  and  union  of  the  cranial  bones,  and  therefore  but  moderate 
enlargement  of  the  cranium. 

If  hypertrophy  commence  at  a  period  not  far  removed  from  birth,  the 
bones  of  course  yield  more  readily  to  the  pressure  and  acute  symptoms  do 
not  occur  so  soon.  After  a  time,  however,  in  all  or  nearly  all  cases,  convul- 
sions supervene.  These  indicate  the  gravity  of  the  disease  and  are  prognos- 
tic of  its  fatal  termination. 

In  a  patient  observed  by  Burnet  violent  convulsions,  followed  by  loss  of 
consciousness,  marked  the  commencement  of  acute  symptoms.  Five  days 
subsequently  the  following  symptoms  were  recorded :  mobility  of  the  eyes, 
without  expression  ;  pupils  contracted  and  directed  upward  ;  divergent  stra- 
bismus of  the  left  eye  ;  the  senses  in  their  normal  state,  with  the  exception 
of  sight;  the  limbs  move  by  volition.  For  a  month  there  was  little  change. 
Then  occurred  drowsiness  and  increased  prostration,  and  five  weeks  later  the 
child  succumbed  with  the  symptoms  of  double  pneumonia. 

Such  is  the  clinical  history  of  hypertrophy.  In  cases  of  firm  ossification 
of  the  cranial  bones,  and  therefore  no  marked  enlargement  of  the  skull,  the 
symptoms  are  similar  to  those  which  occur  if  the  dimensions  of  the  head  be 
increased,  but  compression  and  death  result  sooner. 

The  following  case,  in  which  the  sutures  were  firmly  united,  I  attended 
in  1864.  The  head  was  large,  but  not  so  large  as  to  attract  attention  from 
its  disproportion  : 

Case. — A  boy  aged  two  years  and  two  months  had,  when  about  one  year  old, 
intermittent  fever,  and  since  then  his  countenance  was  uniformly  pallid  and  his 
flesh  soft.  Weaned  at  the  usual  time,  he  remained  well  till  the  1st  of  January, 
1864.  In  the  beginning  of  this  month  he  was  observed  to  be  feverish  for  some 
days  and  his  appetite  poor.  His  health  then  gradually  improved,  and  he  was 
thought  to  be  entirely  well. 

On  the  26th  of  February  he  was  suddenly  seized  with  convulsions,  general  at 
first,  but  most  severe  and  continuing  longest  on  the  left  side.      The  convul- 


526  HYPERTROPHY  OF  BRAIN. 

sions  lasted  a  little  more  than  three  hours.  He  recovered  fully  his  conscious- 
ness by  the  following  day,  but  his  appetite  remained  poor ;  he  was  no  longer 
amused  by  his  playthings  and  was  very  fretful.  The  surface  was  pallid ;  bowels 
constipated ;  pulse  but  little,  perhaps  not  at  all,  accelerated.  He  continued  in 
this  state  till  the  6th  of  March,  when  he  had  another  slight  convulsive  attack, 
and  from  this  time  he  never  fully  recovered  his  consciousness.  He  was  fretful 
if  disturbed,  his  face  generally  pallid,  while  the  pulse  and  respiration  were  not 
perceptibly  altered. 

On  the  following  day,  the  7th,  the  left  pupil  was  somewhat  larger  than  the 
right,  but  both  were  sensitive  to  light.  The  difference  in  size  continued  till 
near  the  close  of  life.  Although  vision  was  imperfect,  if  not  altogether  lost,  the 
sense  of  hearing  was  not  impaired. 

When  questioned,  he  uniformly  answered,  "  No,"  with  a  drawling  voice,  evi- 
dently not  understanding  what  he  said. 

As  the  disease  advanced  the  respiration  became  at  times  sighing,  but  the 
rhythm  of  the  pulse  was  not  materially  altered.  The  temperature  of  the  surface 
was  changeable,  sometimes  cool,  sometimes  warm,  and  the  congested  spots  or 
patches,  so  common  in  cerebral  affections,  were  also  observed  at  times  on  the 
face,  ears,  or  forehead.  Through  most  of  his  sickness  he  took  drinks  readily 
and  the  urine  was  freely  discharged,  probably  from  the  iodide  of  potassium, 
which  he  took  in  one  and  a  half  grain  doses  every  two  hours. 

He  became  more  and  more  drowsy,  again  had  slight  convulsive  movements, 
and  finally  died,  with  much  apparent  suffering,  on  the  14th  of  March.  The 
pulse  became  more  accelerated  during  the  last  two  or  three  days.  On  the  day 
preceding  his  death  the  pupils  were  contracted  and  not  affected  by  light. 

Sectio  Cadav. — Body  somewhat  emaciated  and  eyes  sunken ;  occipito-frontal 
circumference  of  the  head  nineteen  and  a  half  inches ;  distance  from  one  audi- 
tory meatus  to  the  other  over  the  vertex,  thirteen  and  a  half  inches ;  convolu- 
tions over  the  surface  of  the  brain  much  flattened  and  compressed ;  brain  gen- 
erally deficient  in  blood ;  medullary  substance  firm  and  of  a  pure  white  color ; 
meninges  healthy ;  no  other  abnormal  appearances  were  observed ;  weight  of 
brain,  forty-two  ounces.  Gowers  says  that  enlargement  of  the  brain  occurs, 
under  three  circumstances:  "(1)  In  very  young  children  soon  after  birth;  (2) 
Toward  the  end  of  the  first  year  of  life,  in  association  with  rickets;  ....  (3) 
In  older  children  and  adults,  but  of  its  nature  little  is  known."  He  adds : 
"  ....  It  is  clear  that  the  pathology  of  enlargement  of  the  brain  needs  recon- 
sideration in  the  light  of  fresh  investigation."  '  It  seems  to  me  that  hypertrophy 
of  the  brain  as  observed  in  the  cities,  where  most  of  the  cases  in  this  country 
apparently  occur,  is  usually  one  of  the  manifestations  of  rachitis,  and  that  the 
large  head  of  the  rachitic  is  commonly  due  to  an  increase  in  the  neuroglia  or 
connective  tissue. 

Diagnosis. — The  diagnosis  of  hypei'trophy  is  not  always  easy.  The  symp- 
toms are,  in  the  main,  such  as  occur  in  other  pathological  states,  especially  con- 
genital hydrocephalus.  There  is  most  danger  of  mistaking  the  overgrowtli 
for  this  disease.  Hypertrophy  has,  indeed,  often  been  treated  for  hydro- 
cephalus. There  are,  however,  certain  signs  by  which  we  may  distinguish 
one  from  the  other.  In  the  ordinary  form  of  congenital  hydrocephalus,  even 
when  the  amount  of  liquid  is  small,  the  orbital  plates  of  the  frontal  bones 
are  pressed  in  such  a  way  that  the  axis  of  the  eyes  is  changed  so  as  to  have 
a  downward  direction.  The  white  of  the  eye  can  be  seen  between  the  iri& 
and  the  upper  eyelid.  This  gives  a  characteristic  and  striking  expression  to- 
the  face.  The  exception  to  this  is  in  those  rare  cases  in  which  the  liquid  is. 
external  to  the  brain.  In  hypertrophy  this  peculiar  change  in  the  axis  of 
the  eyes  does  not  -occur.  Moreover,  in  hypertrophy  there  is  not  that  uni- 
form expansion  of  the  head  which  is  observed  in  hydrocephalus,  as  has  been 
stated  above.  There  are,  commonly,  greater  enlargement,  more  prominence 
of  the  anterior  fontanel,  and  wider  separation  of  the  cranial  bones  in  hydro- 
cephalus than  in  hypertrophy.     But  since  in  some  cases  of  hydrocephalus 

'  Manual  of  Diseases  of  the  Nervous  System,  1888. 


PROGNOSIS— TREATMENT.  527 

the  sutures  are  united  and  the  fontanels  closed,  and  there  is  no  change  in 
the  direction  of  the  eyes,  the  reason  of  the  difficulty  in  making  a  positive 
differential  diagnosis  between  these  two  diseases  in  certain  instances  is 
apparent. 

Hypertrophy  with  consolidation  of  the  cranial  bones,  and  therefore  little 
(inlargenient  of  the  head,  may  be  mistaken  for  meningitis.  The  history  of 
the  case  and  the  means  by  which  we  diagnosticate  the  latter  affection,  which 
will  be  described  in  their  proper  place,  will  usually  enable  the  physician  to 
make  a  correct  diagnosis. 

Prognosis. — In  forming  an  opinion  as  to  the  probable  termination  xjf  the 
disease  we  must  have  regard  to  the  age  and  general  condition  of  the  child,  as 
well  as  to  the  degree  of  hypertrophy.  If  the  disease  commence  at  an  early 
age,  when  the  cranial  bones  are  not  firmly  united,  it  is  probable  that  there 
will  be  no  compression  of  the  brain,  so  as  to  endanger  life,  for  a  considerable 
period.  We  may  then  hope  by  proper  measures  to  remove  the  constitutional 
state  which  gives  rise  to  the  hypertrophy,  before  the  enlargement  is  such  as 
to  cause  cerebral  symptoms.  If  the  bones  have  already  united  when  the 
disease  commences,  even  slight  hypertrophy  will  produce  symptoms,  and  a 
speedily  fatal  result  is  inevitable.  Evidentl3\  also,  a  child  in  a  marked 
degree  rachitic  or  scrofulous  is  much  less  likely  to  recover  than  one  whose 
general  health  and  constitution  are  less  impaired. 

Treatment. — The  treatment  in  hypertrophy  should  be  directed  mainly 
to  the  constitution.  Measures  calculated  to  improve  the  nutritive  process 
are  those  most  likely  to  check  the  abnormal  growth  of  the  brain.  As  the 
disease  is  one  of  perverted  nuti'ition,  and  usually  coexists  with  a  vitiated  or 
impoverished  state  of  the  blood,  tonic  and  alterative  remedies  are  required. 
The  syrupus  ferri  iodidi  is  therefore  useful,  as  it  is  both  tonic  and  alterative. 
This  may  be  given  in  doses  of  three  or  four  drops,  to  a  child  one  year  old, 
three  times  daily.  Cod-liver  oil,  with  or  without  the  iron,  is  beneficial  in 
some  cases. 

Gowers,  although  he  gives  a  good  description  of  hypertrophy  of  the  brain 
in  his  recent  classical  treatise  on  diseases  of  the  nervous  system,  is  silent  as 
regards  treatment.  In  my  opinion,  the  hygienic  and  medicinal  treatment 
should  be  the  same  as  that  for  rachitis,  to  which  the  reader  is  referred. 


CHAPTER   III. 

THROMBOSIS   IN   THE  CEANIAL   SINUSES   (PHLEBITIS). 

The  formation  of  fibrinous  coagula  within  a  vein  or  sinus  is  designated 
thrombosis  (thrombus,  clot).  Coagulation  of  fibrin  in  the  cranial  sinuses 
occasionally  occurs,  constituting  a  very  serious  pathological  state.  This 
may  result  from  local  disease  in  the  sinuses  or  in  their  vicinity  or  from 
disease  external  to  the  cranium.  The  immediate  cause  of  thrombosis, 
whatever  its  location,  is  sufficient  arrest  of  the  circulation  to  allow  the 
fibrin  to  coagulate. 

Tubercular  and  enlarged  bronchial  glands,  compressing  more  or  less  the 
venae  innominata  or  the  descending  vena  cava,  sometimes  give  rise  to  throm- 
bosis in  the  cranial  sinuses,  the  fibrin  coagulating  in  consequence  of  retarda- 
tion in  the  current  of  blood.  I  have  known  thrombosis  in  the  same  situation 
also  to  result  from  clonic  convulsions,  occurring  in  connection  with  severe 


528  THROMBOSIS  IN  THE  CRANIAL  SINUSES. 

spasmodic  cough  in  pertussis,  since  both  the  cough  and  convulsions  retard 
the  flow  of  blood  in  the  veins  and  sinuses  within  the  cranium.  At  the  post- 
mortem examination  of  at  least  four  such  cases  I  found  whitish  clots  in  the 
lateral  sinuses. 

Thrombosis  in  the  cranial  sinuses  may  also  occur  from  inflammation, 
either  in  the  walls  of  the  sinuses  or  immediately  exterior  to  them.  This 
is  the  disease  which  writers  have  designated  phlebitis  of  the  cranial  sinuses, 
and  for  a  correct  understanding  of  the  morbid  anatomy  of  which  the  profes- 
sion are  indebted  to  Virchow. 

Anatomical  Characters. — If  a  child  die  with  the  cranial  sinuses  and 
the  veins  of  the  brain  and  of  the  meninges  in  their  normal  state,  the  blood 
in  these  vessels  is  found  at  the  autopsy  dark  but  liquid,  or  there  are  small, 
dark,  and  soft  clots  in  the  larger  sinuses.  If  there  were  congestion,  but  no 
coagulation,  in  these  vessels  in  the  last  hours  of  life,  the  clots  are  more  num- 
erous, larger,  and  longer,  sometimes  extending  from  the  sinuses  into  the 
larger  veins  which  empty  into  them,  but  they  are  still  dark  and  soft,  readily 
falling  into  pieces  when  handled.  If,  again,  there  have  been  that  degree  of 
congestion  and  stasis  which  has  resulted  in  ante-mortem  coagulation  or  in 
thrombosis,  the  clots  are,  in  part  at  least,  whitish  and  of  a  fibrinous  or  gelat- 
inous appearance ;  they  were  formed  while  the  red  corpuscles  were  still 
carried  along  in  the  circulation. 

Most  of  the  clots  in  thrombosis  are  free,  while  others  are  attached  lightly 
to  the  internal  surface  of  the  sinus ;  occasionally  they  are  so  large  as  to  dis- 
tend the  vessel.  They  extend  also  in  many  cases  into  the  cerebral  veins 
which  connect  with  the  sinuses,  producing  prominence  and  firmness,  so  as  to 
resemble  (Rilliet  and  Barthez)  an  artificial  injection.  The  clots  do  not  pre- 
sent a  uniform  character.  In  parts  of  a  sinus  they  consist  of  almost  pure 
fibrin  of  a  yellowish-white  color ;  in  other  portions  they  present  a  gelatinous 
appearance  from  the  large  number  of  white  corpuscles,  while  other  portions 
are  more  or  less  tinged  from  the  presence  of  red  corpuscles.  The  central 
part  of  the  clot  after  a  time,  if  the  case  be  sufficiently  protracted,  softens 
and  presents  a  puriform  appearance.  The  substance,  which  is  only  disinte- 
grated fibrin,  was  supposed  to  be  pus  till  the  microscope  revealed  its  true 
character.  It  is  obvious  that  small  clots  forming  within  a  sinus  and  having 
no  attachment  to  its  walls  are  liable  to  be  carried  by  the  current  of  blood 
into  the  general  circulation,  unless  there  be  complete  obstruction.  Virchow 
has  also  shown  how  a  thrombus  may  extend,  by  gradual  prolongation,  nearer 
and  nearer  the  heart,  so  that  one  commencing  in  a  sinus  may  after  a  time 
reach  into  the  jugular  vein.  Diff"erent  observers,  as  M.  Tonnele  and  also 
MM.  Rilliet  and  Barthez,  have  traced  the  fibrinous  masses  as  far  as  the  cava. 
The  latter  writers  relate  the  case  of  a  girl  four  and  a  half  years  old  in  whom 
the  sinuses  on  the  left  side,  especially  those  nearest  the  petrous  portion  of 
the  temporal  bone,  were  completely  filled  with  clots  of  a  yellowish-white 
color  intermixed  with  central  dark  spots.  Similar  coagula  were  also  found  in 
the  left  jugular  vein  as  far  as  the  brachio-cephalic  trunk.  Whether  the  walls 
of  the  sinus  undergo  any  change  depends  on  the  nature  of  the  disease  which 
causes  the  thrombosis.  If  it  be  phlebitis,  the  coats  are  thickened  from  infil- 
tration and  injected  and  the  internal  coat  has  lost  its  polish.  If  it  be  some 
obstructive  disease  in  the  course  of  the  circulation  or  a  general  cause,  the 
coats  of  the  vessels  are  unaltered,  except  that  they  may  be  stained  by  imbibi- 
tion of  the  coloring  matter  of  the  blood.  In  an  infant  who  died  of  this  dis- 
ease in  the  practice  of  Dr.  West  "  the  sinuses  on  the  left  side  were  healthy, 
but  the  blood  was  almost  entirely  coagulated.  The  posterior  half  of  the  lon- 
gitudinal sinus,  the  torcular,  the  left  lateral,  and  the  left  occipital  sinuses, 
were  blocked  up  with  fibrinous  coagula,  precisely  such  as  one  sees  in  inflamed 


CA  USES.  529 

veins,  ;ind  the  clot  extended  into  tlie  internal  jugular  vein.  The  coats  of  the 
longitudinal  and  of  the  inner  half  of  the  lateral  sinus  were  much  tliickened. 
and  their  lining  mcmhrane  had  lost  its  polish,  was  uneven,  and  presented  a 
dirty  appearance." 

The  mode  in  which  congestion  and  coagulation  occur  within  a  sinus  in 
conse(|uence  of  the  pressure  of  a  tumor  upon  this  vessel,  or  upon  a  vein 
into  which  the  blood  from  this  sinus  flows,  is  sufficiently  obvious.  The  mode 
of  the  production  of  thrombosis  as  a  result  of  clonic  convulsions  or  of  the 
spasmodic  cough  of  pertussis  is  also  apparent.  How  it  results  from  inflam- 
mation of  the  walls  of  a  sinus — that  is,  from  phlebitis — was  not  understood 
till  explained  by  Virchow. 

The  fibrinous  coagula  which  till  the  sinus  are  not  an  exudative  product, 
as  was  formerly  supposed.  Inflammation  (in  most  cases  otitis,  with  caries  of 
the  petrous  portion  of  the  temporal  bone)  approaches  a  sinus.  The  inflam- 
matory products  pressing  against  the  walls  of  the  sinus  diminish  its  calibre 
at  that  point,  and  hence  the  retardation  of  blood  and  the  coagulation.  Or 
the  walls  of  the  sinus  may  be  thickened  by  inflammatory  infiltration,  or  even 
by  the  formation  of  little  abscesses  within  the  coats  in  consequence  of  the 
inflammation,  so  as  to  produce  bulging  inward,  and  the  result,  as  regards  the 
circulation,  is  the  same.  Whether,  therefore,  the  inflammation  occur  without 
a  sinus  or  within  its  walls,  thrombosis  equally  results,  provided  that  the 
diameter  of  the  vessel  is  sufficiently  narrowed  by  the  presence  and  pressure 
of  inflammatory  products. 

There  is  no  exudation  on  the  internal  surface  of  a  sinus  or  vein  when 
inflamed,  as  there  is  upon  serous  surfaces.  "  On  the  contrary,^  when  the  wall 
is  inflamed  the  exuded  matter  (exsudatmasse)  passes  into  the  wall,  which 
becomes  thicker,  cloudy,  and  subsequently  begins  to  suppurate.  Nay,  even 
abscesses  may  form  which  cause  the  wall  to  bulge  on  both  sides  like  a 
variolous  pustule,  without  any  coagulation  of  the  blood  ensuing  in  the  cavity 
of  the  vessel.  At  other  times,  certainly,  phlebitis,  properly  so  called  (and  in 
like  manner  arteritis  and  endocarditis),  is  the  cause  of  thrombosis,  in  conse- 
quence of  the  formation  of  inequalities,  elevations,  depressions,  and  even 
ulcerations,  upon  the  inner  wall,  which  favor  the  production  of  the  thrombus. 
Still,  whenever  phlebitis,  in  the  usual  sense  of  the  word,  takes  place,  the 
alteration  in  the  coat  of  the  vessel  is  almost  always  a  secondary  one,  and, 
indeed,  occurs  at  a  comparatively  late  period." 

This  view  of  the  pathology  of  thrombosis  comports  with  facts  observed 
at  autopsies,  and  which  cannot  be  explained  according  to  the  old  theory  of 
phlebitis — namely,  smoothness  of  the  internal  surface  of  the  sinus  ;  natural 
color  of  this  sinus  or  simple  staining  from  blood ;  the  non-attachment  or 
slight  attachment  of  the  coagula,  etc. 

Causes. — Some  of  these  have  been  ah-eady  stated  at  the  commencement 
of  this  article.  It  is  evident  from  what  has  been  said  that  this  disease  may 
be  produced  by  any  cause  which  obstructs  the  return  circulation  from  the 
head.  I  have  already  alluded  to  tumors  which  press  upon  the  sinus  or  on 
the  vein  below  the  sinus,  as  a  cause.  Among  the  causes  may  be  mentioned 
also  abdominal  tumors,  narrowing  of  the  chest  from  rachitis  or  caries  of  the 
vertebrae,  and,  finally,  compression  of  the  jugular  vein  by  a  peripharyngeal 
abscess. 

Sufficient  allusion  has  already  been  made  to  inflammation  of  the  internal 
ear  as  a  not  infrequent  cause.  Thrombosis  is  indeed  one  of  the  dangerous 
results  of  chronic  otitis.  Another  cause  is  a  reduced  or  cachectic  state  of 
system,  apart  from  any  local  or  obstructive  disease.  It  is  a  noteworthy  fact 
that  a  large  proportion   of  those  aff'ected  with   thrombosis,  even   when   it  is 

^  Cellular  Pathology,  translation,  p.  236. 
34 


530  THROMBOSIS  IN  THE  CRANIAL  SINUSES. 

immediately  due  to  obstructive  disease,  are  cachectic.  The  explanation  of 
this  fact  is  not  difficult.  In  reduced  states  of  the  system  the  action  of  the 
heart  is  feeble,  and  passive  congestion  of  the  vessels  within  the  cranium  is 
liable  to  occur.  Passive  congestion  of  the  veins  and  sinuses  in  protracted 
diarrhoeal  maladies,  which  is  described  in  our  remarks  upon  another  disease, 
is  an  example  in  point.  In  this  state  of  feeble  circulation  very  slight 
obstructive  disease  may  be  sufficient  to  cause  thrombosis. 

Symptoms. — The  symptoms  of  this  disease  are  often  obscure.  All  of 
them  may  and  do  occur  in  other  maladies  of  the  encephalon.  In  cases 
related  by  M.  Tonnele  cerebral  symptoms  were  well  marked,  such  as  faint- 
ness,  dilatation  of  the  pupils,  strabismus,  grinding  of  the  teeth,  convulsive 
movements.  There  may  be  an  almost  total  absence  of  such  symptoms  as 
would  direct  attention  to  the  state  of  the  head.  This  is  due  to  the  sudden 
occurrence  of  death  after  the  clots  have  formed  in  the  sinuses.  If  the  clots 
are  large,  death  soon  results  in  consequence  of  congestion  of  the  brain  and 
meninges,  which  is  proportionate  to  the  amount  of  obstruction.  Extravasa- 
tions of  blood  and  transudation  of  serum  not  infrequently  accompany  the 
congestion  and  hasten  the  result. 

Dr.  West  relates  the  case  of  a  girl  who  had  a  mild  attack  of  scarlet  fever 
at  the  age  of  eight  months,  and  did  not  fully  recover  her  health.  She  con- 
tinued restless  and  feverish,  and  had  two  violent  convulsions  two  weeks  after 
the  scarlatina.  In  the  following  months  she  had  anasarca,  and  when  she  was 
nearly  a  year  old  another  attack  of  convulsions  occurred.  Fluctuation  was 
now  observed  in  the  abdomen,  and  in  a  few  days  a  sero-purulent  fluid  began 
to  escape  from  the  umbilicus.  When  this  discharge  had  continued  eleven 
days,  symptoms  of  a  liquid  in  the  right  pleural  cavity  were  suddenly  devel- 
oped. She  grew  weak  and  emaciated,  and  finally  was  seized  with  extreme 
faintness,  with  which  she  died  in  forty-eight  hours  at  the  age  of  thirteen  and 
a  half  months. 

At  the  post-mortem  examination  a  large  amount  of  pus  was  found  in  the 
abdominal  and  right  pleui'al  cavities.  On  the  right  side  of  the  cranium  the 
sinuses  were  filled  with  coagula  and  their  coats  seemed  healthy.  The  left 
lateral  and  occipital  sinuses,  the  torcular,  and  part  of  the  longitudinal  sinus, 
also  contained  coagula,  which  extended  into  the  jugular  vein.  The  walls  of 
the  longitudinal  sinus  and  the  internal  part  of  the  lateral  sinus  were  thick- 
ened, and  their  inner  surface  had  lost  its  polish  and  was  uneven.  There  was 
congestion  of  the  brain,  with  points  of  extravasated  blood.  If,  as  is  prob- 
able, the  convulsions  were  due  to  some  other  cause,  the  only  symptom  which 
was  clearly  referable  to  the  thrombosis  was  the  sudden  faintness.  In  the 
four  cases  of  thrombosis  occurring  in  pertussis  already  alluded  to,  in  which 
I  was  enabled  to  ascertain  by  post-mortem  examination  the  presence  and 
extent  of  the  clots,  the  symptoms,  which  were  apparently  due  to  the  throm- 
bosis, were  those  of  cerebral  congestion.  Among  these  symptoms  stupor, 
and  finally  coma,  were  prominent. 

Diagnosis. — It  is  evident,  from  what  has  been  said,  that  thrombosis  of 
the  cranial  sinuses  can  rarely  be  diagnosticated  with  certainty.  The  pre- 
existence  of  otitis  will  sometimes  lead  us  to  suspect  its  presence,  especially  if 
the  otitis  have  been  accompanied  by  deep-seated  pains.  Symptoms  of  cere- 
bral congestion,  serous  effusion,  or  apoplexy,  occurring  in  connection  with 
otitis,  protracted  convulsions,  or  glandular  or  other  tumors  situated  so  as  to 
compress  the  vessels  which  return  blood  from  the  brain,  indicate  thrombosis. 

Prognosis. — The  prognosis  in  any  case  is  obviously  unfavorable.  The 
cause  is,  ordinarily,  permanent  or  not  readily  removed,  so  that  the  clots  grad- 
ually increase.  If  the  cause  be  a  local  obstructive  disease,  death  is  almost 
certain,  since  in  nearly  every  instance  the  obstruction  is  of  such  a  nature  that 


CONGESTION  OF  THE  BRAIN.  531 

it  Ciinnot  be  removed  by  medical  or  surgical  treatment.  It  is  possible  that 
recovery  may  take  place  if  the  clots  are  few  and  small,  and  the  cause  of  the 
thrombosis  be  mainly  feebleness  of  circulation  in  consequence  of  a  state  of 
debility.  We  know  that  clots  may  li(iuefy,  and  their  elements  re-enter  the 
circulation  ;  but  such  a  result  of  thrombosis  in  a  cranial  sinus,  if  it  ever 
occur,  is  rare.  The  thronibus  by  its  presence  serves  as  a  point  of  attach- 
ment around  which  more  fibrin  coagulates,  so  that  the  obstruction  gradually 
increases  till  death  occurs. 

Treatment. — Thrombosis  should  be  treated  by  cool  applications  to  the 
head  in  order  to  diminish  the  congestion — by  stimulants  and  sustaining  meas- 
ures in  case  the  systolic  movement  of  the  heart  be  feeble.  Tonics,  vegetable 
or  ferruginous,  are  indicated  if  there  be  a  cachectic  state. 


CHAPTER    IV. 

CONGESTION  OF  THE   BE  A  IN. 

Congestion  of  the  brain  is  not  peculiar  to  infancy  and  childhood,  but  is 
much  more  common  in  these  periods  of  life  than  subsequently.  This  is  due, 
in  a  great  measure,  to  the  fact  that  in  the  young  the  circulation  is  more  read- 
ily disturbed  by  moral  as  well  as  physical  causes  than  in  the  adult. 

Congestion  of  the  brain  is  occasionally  primary  ;  more  frequently  it  occurs 
as  a  concomitant  or  sequel  of  some  other  affection.  Diseases,  whether  con- 
stitutional or  local,  which  in  the  adult  have  no  appreciable  effect  on  the  vas- 
cularity of  the  brain  often  cause  in  the  child  a  decided  increase  of  blood  in 
this  organ. 

Causes.— Cerebral  congestion  is  of  two  kinds,  active  and  passive.  The 
former  results  from  a  cause  which  directly  affects  the  brain  and  increases  the 
flow  of  blood  toward  it,  or  from  a  cause  operating  primarily  on  the  heart  and 
increasing  the  frequency  and  force  of  its  systolic  movement ;  the  latter  is  due 
to  some  obstruction  in  the  course  of  the  circulation  or  to  feeble  propelling 
power  on  the  part  of  the  heart. 

Among  the  causes  which  most  frequently  produce  active  congestion  of 
the  brain  in  the  child  may  be  mentioned  blows  or  falls  on  the  head,  excessive 
fatigue  or  excitement,  heat,  perhaps  sometimes  dentition,  and  also  various 
inflammatory  and  febrile  affections,  especially  in  their  first  stages. 

Cerebral  symptoms  occurring  in  the  course  of  an  essential  fever  are  no 
doubt  often  due,  in  a  great  measure,  to  the  irritating  effect  on  the  brain  of 
the  specific  principle,  whatever  it  may  be,  circulating  in  the  blood.  Occur- 
ring in  inflammatory  diseases  which  are  located  elsewhere  than  within  the 
cranium,  they  are  often  attributed  to  functional  disturbance  of  the  brain.  The 
brain,  it  is  said,  sympathizes  with  the  affected  part  through  the  system  of  nerves 
which  unites  them.  But  observations  show  that  symptoms  referable  to  the 
brain,  arising  in  the  commencement  of  the  essential  fevers  and  of  the  phleg- 
masiae,  are  in  many  instances  preceded  by,  and  are  therefore  doubtless  in 
greater  or  less  degree  dependent  on,  hyperasmia  of  this  organ. 

Difficult  as  it  is  to  ascertain  the  state  of  the  brain  in  many  diseases  in 
which  it  is  involved,  we  may  determine  whether  or  not  there  be  congestion 
in  the  young  child  by  observing  the  anterior  fontanel.  If  it  be  elevated  and 
tense  in  an  acute  disease,  hyperaemia  is  indicated.  Now,  it  is  often  unusually 
prominent  in  fevers  and  inflammations,  especially  in  their  first  stages,  whea 


532  CONGESTION  OF  THE  BRAIN. 

cerebral  symptoms  are  present.  Its  elevation,  under  such  circumstances,  is 
obviously  coincident  with  cerebral  congestion. 

The  acute  inflammations  which  are  most  likely  to  be  attended  by  cerebral 
congestion  are  those  of  the  mucous  surfaces  and  pneumonia.  Severe  coryza, 
tracheo-bronchitis,  entero-colitis,  and  colitis,  commencing  suddenly  with  great 
febrile  excitement,  are  frequently  accompanied  in  their  initial  stage  by  active 
congestion  of  the  cerebral  vessels.  Cases  like  the  following,  which  I  find  in 
my  note-book,  are  not  infrequent :  An  infant  four  months  old  had  been  sick 
about  two  days  with  coryza  and  bronchitis  when  I  was  called  to  see  it ;  the 
pulse  numbered  156,  respiration  64 ;  it  nursed  and  was  somewhat  restless ; 
cough  frequent  and  dry ;  bowels  moderately  relaxed.  The  mucous  mem- 
brane of  the  fauces  was  injected,  and  coarse  mucous  rales  were  present  in 
the  chest.  The  anterior  fontanel  rose  above  the  level  of  the  cranium  and 
pulsated  forcibly.  Soon  after  convulsions  occurred,  which  were  relieved  by 
appropriate  measures,  and  on  the  following  day  the  fontanel  had  subsided. 
The  patient  gradually  recovered  without  any  untoward  symptom. 

Cerebral  congestion  and  convulsions  often  mark  the  initial  stage  of  active 
intestinal  phlegmasiae.  This  is  especially  true  of  dysentery.  The  little 
patient,  perhaps  from  the  very  inception  of  the  colitis,  is  drowsy ;  its  surface 
hot ;  pulse  full  and  rapid.  There  is  sudden  and  momentary  starting  or  twitch- 
ing of  the  limbs.  The  anterior  fontanel,  if  still  open,  is  elevated,  and  it  is  not 
till  the  lapse  of  several  hours  that  the  cause  of  these  symptoms  is  apparent 
from  the  occurrence  of  bloody  stools. 

The  causes  of  passive  congestion  of  the  brain  are  very  diff"erent  from  those 
of  the  active  foi-m.  A  common  cause  is  obstruction  in  a  sinus  or  vein  by  a 
fibrinous  concretion  or  by  a  tumor  or  abscess  external  to  it. 

I  have  occasionally  met  cases  in  which  this  form  of  cerebral  congestion 
appeared  to  be  plainly  referable  to  obstruction  to  the  return  of  blood  from 
the  brain  by  the  pressure  of  bronchial  glands,  enlarged  by  hyperplasia  in 
tubercular  disease,  these  bodies  diminishing  by  external  pressure  the  calibre 
of  the  venEe  innominatae  or  the  descending  vena  cava.  Rilliet  and  Barthez 
have  called  attention  to  such  cases  in  the  clinical  history  of  tuberculosis. 
The  following  case  may  be  cited  as  an  example ;  it  occurred  in  the  infants' 
service  of  Charity   Hospital  in  this  city  in  April,  1866 : 

An  infant  about  one  year  old,  affected  with  tuberculosis,  both  bronchial 
and  pulmonary,  was  observed  during  the  ten  days  preceding  its  death  to  bore 
the  pillow  with  its  head  almost  constantly,  so  as  to  wear  the  hair  from  the 
occiput.  The  movement  of  the  head  was  the  only  prominent  cerebral  symp- 
tom. Nothing  abnormal  was  noticed  in  the  appearance  of  the  eyes,  nor  was 
the  stomach  irritable.  A  spasmodic  cough  and  progressive  emaciation  attracted 
attention,  but  these  were  referable  to  the  tubercular  disease.  At  the  autopsy 
we  found  the  cerebral  sinuses,  veins,  and  capillaries  greatly  congested.  On 
tracing  the  veins  which  return  blood  from  the  brain,  an  inflamed  and  enlarged 
bronchial  gland  was  discovered  in  the  angle  formed  by  the  convergence  of 
the  right  and  left  venae  innominatae.  This  gland,  which  contained  but  a 
single  point  of  cheesy  degeneration,  had  attained  such  a  volume  by  prolifera- 
tion of  its  cells  that  it  pressed  upon  both  vessels,  so  that  it  had  obviously 
retarded  the  circulation  in  each  and  given  rise  to  cerebral  congestion. 

Passive  congestion  often  occurs  in  the  infant  at  birth,  either  from  tedious- 
ness  of  the  labor  or  delay  in  the  expulsion  of  the  body  after  the  birth  of  the 
head.  If  it  be  simple  congestion,  and  not  congestion  with  hemorrhage,  it 
soon  passes  off.  Passive  congestion  of  the  brain  also  occurs  in  severe 
paroxysms  of  whooping  cough,  in  which  return  of  blood  from  this  organ 
is  temporarily  retarded.  All  are  familiar  with  the  congestion  which  occurs 
in  parts  external  to  the  cranium  from  the  severity  of  the  cough,  producing 


SYMPTOMS— PROGNOSIS.  533 

epistaxis,  extravasations  under  the  conjunctiva,  etc.  The  extra-cranial  con- 
gestion obviously  indicates  the  presence  and  degree  of  congestion  v^ithin  the 
cranium. 

Those  who  practise  in  malarious  regions  sometimes  meet  cases  of  dan- 
gerous passive  congestion  of  the  brain,  the  result  of  malaria,  occurring 
especially  in  the  cold  state  of  intermittent  fever.  In  these  cases  the  surface 
is  pallid,  its  temperature  reduced,  and  the  pulse  feeble.  The  blood,  leaving 
the  peripheral  vessels,  collects  in  undue  (quantity  in  the  internal  organs,  pro- 
ducing congestion  of  the  brain  as  well  as  of  the  thoracic  and  abdominal 
viscera.  In  the  child  with  malarial  disease,  in  whom  there  is  less  vigor  of 
constitution  than  in  the  adult,  death  sometimes  results  from  this  passive 
congestion.  Two  such  cases  have  occurred  in  my  practice,  although  in  this 
latitude  the  malarial  maladies  are  mild  in  comparison  with  the  type  which 
they  present  in  many  parts  of  the  United  States. 

Symptoms. — The  symptoms  of  active  congestion  of  the  brain  are  stupor, 
great  heat  of  head,  throbbing  of  carotids,  restlessness  when  aroused,  twitching 
of  the  limbs,  and  perhaps  convulsions.  There  is  also  sometimes  intolerance 
of  light,  and  the  anterior  fontanel,  if  open,  pulsates  strongly.  In  passive 
congestion  many  of  the  symptoms  are  the  same  as  in  the  active  form. 
Stupor,  twitching  of  the  limbs,  and  fretfulness  or  irritability  when  the  patient 
is  disturbed  are  common,  ordinarily  without  increase  of  temperature  :  the 
surface  may  indeed  be  cool  and  the  face  is  not  flushed  nor  the  eyes  injected. 
The  strong  pulsation  and  elevation  of  the  anterior  fontanel,  so  conspicuous  in 
active  congestion,  are — the  former  always,  the  latter  often — lacking.  In  both 
acute  and  passive  cerebral  congestion  constipation  is  a  common  symptom. 

In  many  cases  the  symptoms  of  congestion  of  the  brain  are  associated 
with  others  which  proceed  directly  from  the  cause  of  the  congestion,  but  it  is 
not  difficult,  unless  in  exceptional  instances,  to  determine  which  are  due  to 
the  congestion  and  which  to  the  antecedent  and  coexisting  pathological  state. 

Anatomical  Characters. — In  active  congestion  there  is  an  excess  of 
arterial  blood  in  the  brain  and  its  membranes.  The  arteries,  to  their  minutest 
branches,  are  seen  to  be  full,  presenting  the  bright  hue  of  oxygenated  blood. 
In  passive  congestion  the  sinuses  and  veins  are  distended.  The  pia  mater, 
choroid  plexus,  and  the  vessels  of  the  brain  have  a  darker  appearance  than  in 
active  congestion.  In  both  forms  of  congestion,  unless  they  quickly  abate, 
other  anatomical  changes  soon  occur.  If  there  be  great  distension  of  the 
capillaries,  these  vessels  are  liable  to  give  way,  and  we  find  here  and  there 
little  patches  of  extravasated  blood.  In  other  cases  the  over-distension  is 
relieved  by  the  transudation  of  the  serous  portion  of  the  blood  through  the 
coats  of  the  vessels.  The  cephalo-rachidian  fluid  is  then  found  in  excess 
external  to  the  brain  and  in  the  ventricles. 

Prognosis. — The  duration  and  the  result  of  congestion  of  the  brain 
depend,  in  great  measure,  on  the  nature  of  the  cause.  If  the  cause  be 
trivial,  as  mental  excitement,  fatigue,  exposure  to  heat,  there  is  usually 
prompt  relief  if  the  condition  of  the  patient  be  understood  and  properly 
treated.  If  the  cause  be  general  or  constitutional,  as  one  of  the  essential 
fevers  or  whooping  cough,  or  if  it  be  local,  but  its  seat  external  to  the 
cranium,  the  prognosis,  so  far  as  the  congestion  is  concerned,  is  not  unfavor- 
able if  there  be  a  timely  and  judicious  use  of  remedies.  The  most  unfavor- 
able cases  are  those  in  which  the  cause  is  seated  in  the  encephalon  and  those 
in  which  there  is  some  obstructive  disease  in  the  course  of  the  circulation. 
Congestion  occurring  from  a  structural  change  within  the  cranium  is,  from 
the  nature  of  the  cause,  without  remedy  and  ordinarily  fatal.  Obstructive 
diseases  of  the  circulatory  system,  wherever  located,  being  for  the  most  part 
permanent,  give  rise,  as  a  rule,  to  incurable  congestion. 


534  INTRACRANIAL  HEMORRHAGE. 

Congestion  of  the  brain,  if  it  be  not  relieved  in  a  few  hours,  becomes  less 
and  less  amenable  to  treatment.  It  soon  passes  beyond  the  resources  of  our 
art  and  ends  in  coma ;  it  is  seldom  protracted  beyond  a  few  days.  Extrava- 
sations of  blood,  common  in  active  congestion,  and  serous  effusion,  common  in 
the  passive  form,  diminish  the  chances  of  a  favorable  result. 

Treatment. — The  indication  for  treatment  in  active  congestion  is  plain. 
Measures  should  be  employed  which  produce  derivation  from  the  brain. 
Unless  there  be  an  asthenic  primary  affection,  in  the  course  of  which  the 
congestion  is  developed,  active  purgation  is  required.  A  saline  purgative  is 
ordinarily  preferable.  If  the  stomach  be  irritable  there  is  no  better  purga- 
tive than  calomel.  In  all  cases  of  active  congestion,  whatever  the  cause,  the 
bowels  should  be  kept  open.  It  is  often  better  not  to  wait  for  the  tardy  action 
of  a  cathartic,  but  to  give  at  once  an  enema  of  soap  and  water  or  salt  and 
water.  External  derivative  agents  are  also  indieated.  A  warm  mustard  foot- 
bath, sinapisms  to  the  back  of  the  neck  or  chest  and  to  the  feet,  and  cold 
applications  to  the  head,  are  measures  which  should  never  be  neglected.  In 
many  cases  those  medicines  are  useful  which  reduce  the  contractile  power  of 
the  heart,  as  antipyrine,  antifebrin,  or  phenacetin. 

This  treatment,  if  employed  early,  will  relieve  the  congestion  in  a  large 
proportion  of  cases ;  but  if  there  be  no  improvement,  if  the  child  be  robust, 
and  if  the  primary  affection  be  such  as  does  not  contraindicate  loss  of  blood, 
leeches  should  be  applied  to  the  temples  or  some  part  of  the  head.  If  after 
the  lapse  of  some  hours  cerebral  symptoms  continue,  apoplexy  or  serous 
effusion  has  probably  occurred.  Congestion  is  then  no  longer  the  prominent 
lesion,  and  it  is  proper  to  designate  the  disease  by  another  name. 

The  treatment  appropriate  for  passive,  congestion  is  somewhat  different ; 
cold  applications  to  the  head  and  those  of  a  derivative  nature  to  the  extremi- 
ties are  useful.  As  this  form  of  the  disease  is  not  primary,  but  is  dependent 
on  some  antecedent  pathological  state,  it  is  evident  that  it  can  only  be  treated 
successfully  by  removing  or  obviating  the  cause  as  far  as  possible.  But  the 
nature  of  the  various  obstructions  to  the  intracranial  circulation  is  such  that 
our  ability  to  accomplish  this  end  is  very  limited. 

If  the  cause  be  constitutional,  or  if  it  be  some  disease  in  the  neck  or 
chest,  it  may  sometimes  be  partially  or  even  wholly  removed,  but  if  seated 
within  the  cranium  it  is  beyond  our  control.  In  general,  it  may  be  said  that 
depletion  is  not  required  or  tolerated  in  passive  congestion,  and  stimulants 
are  often  needed. 


CHAPTER    V. 

INTEACKANIAL  HEMOKRHAGE   (MENINGEAL   HEMORRHAGE, 
CEREBRAL    HEMORRHAGE). 

Hemorrhage  within  the  cranium  is  not  very  infrequent  in  infancy  and 
childhood,  and  there  is  no  part  of  the  encephalon,  whether  the  meninges  or 
brain,  in  which  it  does  not  sometimes  occur.  If  the  blood  be  extravasated 
upon  the  surface  of  the  brain  or  between  the  meninges,  the  disease  is  desig- 
nated by  writers  meningeal  apoplexy ;  if  in  the  substance  of  the  brain, 
cerebral  apoplexy.  Extravasation  may  also  occur  in  one  of  the  lateral 
ventricles.  This  may,  for  convenience,  be  described  as  a  form  of  meningeal 
apoplexy. 


CA  USES— A  NA  TOMICA  L  CHA  RA  GTERS.  535 

Causes. — Apoplexy  is  usually  (there  is  an  exception)  preceded  by  con- 
gestion. If  the  congestion  increase  to  a  certain  degree,  the  distended  capil- 
laries give  way  and  extravasation  of  blood  results.  Therefore  the  causes  of 
congestion  which  have  been  enumerated  in  the  preceding  chapter  are,  in  great 
measure,  those  of  apoplexy.  •  Recent  microscopic  examinations  have  demon- 
strated that  the  corpuscular  elements  of  the  blood  may  escape  from  capillaries 
without  rupture.  While,  therefore,  it  is  probable  that  intracranial  hemorrhage 
in  early  life  commonly  occurs  from  rupture,  its  occasional  occurrence  through 
the  walls  of  tlie  capillaries  must  be  admitted. 

Intracranial  hemorrhage  is  not  infrequent  in  the  new-born.  It  results  in 
them  from  tediousness  of  the  birth  and  severity  of  the  labor-pains.  At  first 
there  is  extreme  congestion  of  the  meningeal  and  cerebral  vessels,  correspond- 
ing with  that  of  the  scalp  and  face.  This  congestion,  continuing,  soon  ends 
in  extravasation  of  blood.  In  some  of  these  cases  forceps  have  been  used  to 
effect  the  delivery,  but  it  is  doubtful  whether  the  use  of  instruments  materially 
increases  the  congestion  or  the  amount  of  extravasation.  Certainly,  in  a 
large  proportion  of  intracranial  as  well  as  supracranial  hemorrhages  of  the 
new-born  instruments  have  not  been  used.  An  additional  cause  of  the 
hemorrhage  is,  in  some  instances,  the  use  of  ergot,  which,  by  producing 
strong  and  continuous  pains,  interrupts  the  placental  circulation  and  increases 
the  congestion  of  the  foetal  veins  and  capillaries. 

In  infants  a  few  days  old  intracranial  hemorrhage  may  result  from  that 
rapid  and  fatal  disease,  tetanus  infantum.  The  hemorrhage  is  preceded  by 
intense  passive  congestion,  which  the  tetanic  rigidity  and  spasms  produce  by 
obstructing  i-espiration  and  circulation.  Few  cases  of  tetanus  infantum  occur 
without  more  or  less  extravasation  of  blood,  either  meningeal  or  cerebral. 
Another  cause  of  this  disease  is  obstruction  in  the  vessels  which  return  the 
blood  from  the  brain.  The  various  structural  changes  which  produce  this 
obstruction  in  different  cases  have  been  sufficiently  described  in  our  remarks 
on  cerebral  congestion  and  thrombosis. 

The  congestion  which  precedes  hemorrhage,  when  occurring  under  the 
conditions  described  above,  is  passive. 

Among  the  causes  which  produce  hemorrhage  through  the  intermediate 
state  of  active  congestion  may  be  mentioned  great  mental  excitement,  of 
which  M.  Legendre  relates  a  case,  and  lengthened  exposure  to  the  sun's  rays, 
an  example  of  which  Rilliet  and  Barthez  have  seen.  It  is  also  said  that 
compression  of  the  aorta  by  an  enlarged  liver  or  an  abdominal  tumor  has 
sometimes  produced  meningeal  or  cerebral  hemorrhage  by  causing  an  increased 
afflux  of  blood  to  the  head.  A  very  important  cause  to  which  I  have  not 
alluded  is  that  general  state  of  the  circulatory  sj^stem  which  is  designated 
by  the  term  purpura  hjemorrhagica.  This  sometimes  results  from  the  anti- 
hygienic  conditions  in  which  the  child  is  placed.  In  other  instances  it  results 
from  some  antecedent  disease,  protracted  and  debilitating,  which  has  pro- 
duced a  profound  alteration  in  the  state  of  the  blood  and  the  vessels.  The 
capillaries  become  less  firm  and  elastic  and  easily  give  way,  so  that  in  such 
patients  ecchymotic  points  are  ordinarily  found  in  different  parts  of  the  sys- 
tem. The  diseases  which  occasionally  end  in  this  hemorrhagic  diathesis  are 
numerous.  I  have  known  it  to  occur  after  measles,  scarlet  fever,  and  small- 
pox. It  is  also  an  occasional  sequel  of  chronic  diarrhoea  or  intermittent  and 
typhoid  fevers,  and  of  rachitis. 

Anatomical  Characters. — Hemorrhage  in  or  upon  the  brain  in  infancy 
and  childhood  differs  in  important  particulars  from  that  occurring  in  adult  life. 
In  the  adult,  and  more  so  as  life  advances,  the  arteries  become  less  detensible 
and  more  brittle,  so  that  when  hemorrhage  occurs  it  is  usually  from  one  of 
these  vessels.     In  early  life,  on  the  other  hand,  the  blood  does  not  ordinarily 


536  INTRACRANIAL  HEMORRHAGE. 

escape  from  an  artery,  but,  as  has  been  stated,  from  the  capillaries.  The 
extravasation  is  not,  therefore,  so  rapid  and  violent,  and  is  not  attended  by 
such  laceration  and  injury  of  surrounding  parts  in  infancy  and  childhood  as 
at  a  subsequent  age.  In  the  adult  the  hemorrhage  commonly  occurs  in  the 
substance  of  the  brain.  The  flow  of  blood  from  the  ruptured  artery  separates 
the  brain-substance,  producing  a  cavity  in  which  a  clot  forms.  This  consti- 
tutes the  usual  form  of  apoplexy  in  the  adult.  In  the  first  years  of  life,  on 
the  contrary,  the  extravasation  is  commonly  from  the  meninges,  and  the 
symptoms  to  which  the  effused  fluid  gives  rise  are  for  the  most  part  due  to 
its  mechanical  effect.  Cases  of  hemorrhage  in  the  substance  of  the  brain 
constitute  a  small  minority,  unless  during  the  days  immediately  succeeding 
birth.  In  early  life,  therefore,  on  account  of  its  greater  frequency,  menin- 
geal hemorrhage  is  a  disease  of  more  importance  than  cerebral,  and  its  ana- 
tomical character  should  be  carefully  studied. 

In  Meningeal  Hemorrhage  the  extravasation  may  be  between  the 
cranium  and  dura  mater,  upon  the  visceral  layer  of  the  arachnoid,  in  the 
meshes  of  the  pia  mater,  or  in  a  lateral  ventricle  from  rupture  of  the  capil- 
laries in  the  choroid  plexus.  Much  the  most  common  seat  is  external  to  the 
pia  mater  in  the  so-called  cavity  of  the  arachnoid ;  the  blood  escaping  in  this 
situation  spreads  uniformly  in  all  directions.  It  soon  separates  into  two  por- 
tions, the  solid  and  liquid.  The  solid  portion,  or  the  clot,  is  free  or  but 
slightly  attached  to  the  adjacent  membrane.  The  meninges  in  the  vicinity 
of  the  extravasated  blood  preserve  their  normal  appearance  or  are  but  slightly 
injected;  the  clot  gradually  becomes  extended  on  all  sides,  so  as  to  form  a 
lamina  at  the  seat  of  the  extravasation,  thinner  at  its  circumference  than 
centre,  and  at  first  of  a  dark-red  color.  The  color  gradually  fades,  and  the 
lamina,  becoming  smooth  and  polished  and  at  the  same  time  more  and  more 
attenuated,  finally  resembles  the  arachnoid  in  appearance.  Its  diameter 
varies  in  different  cases  from  a  few  lines  to  two  or  three  or  more  inches. 
M.  Tonnele  relates  two  observations  in  which  the  adventitious  membrane 
extended  over  the  superior  surface  of  both  hemispheres,  and  in  one  of  them 
also  over  the  falx  cerebri. 

The  extravasation  may  occur  at  any  part  of  the  surface  of  the  brain,  but 
its  usual  seat  is  the  vertex.  The  next  most  frequent  locality  is  the  base  of 
the  brain.  The  subsequent  history  of  the  delicate  membrane  into  which  the 
clot  is  gradually  transformed  is  interesting.  It  often  extends  so  as  to  cover 
more  space  than  was  occupied  by  the  extravasated  blood,  and  its  edges  are 
then  scarcely  distinguishable,  in  consequence  of  their  extreme  tenuity  and 
their  close  resemblance  to  the  arachnoid.  The  attachments  of  this  mem- 
brane, so  far  as  it  forms  any,  are  usually  to  the  parietal  surface  of  the  arach- 
noid. Sometimes  a  portion  of  the  membrane  is  attached,  while  the  rest  lies 
free,  bathed  on  either  side  by  the  liquid  portion  of  the  blood  which  still 
remains  from  the  extravasation.  According  to  M.  Legendre,  in  the  most 
favorable  cases  the  serum  is  absorbed,  and  the  membrane  which  has  resulted 
from  the  clot,  and  which  I  have  described,  becomes  intimately  adherent  to 
the  internal  surface  of  the  dura  mater.  It  forms  an  integral  part  of  this 
membrane,  and  there  only  remain  a  little  thickening  and  increased  opacity, 
indicating  the  seat  of  the  extravasation.  The  health  is  fully  re-established. 
But  the  result  in  other  cases  is  as  follows :  The  serum  is  not  absorbed, 
and  the  newly-formed  membrane,  uniting  at  points  with  the  inner  surface  of 
the  dura  mater  or  its  arachnoidal  covering,  encloses  the  fluid  so  as  to  produce 
a  circumscribed  hydrocephalus. 

Sometimes  there  is  only  one  cyst;  in  other  instances  the  membrane, 
especially  if  large,  unites  in  such  a  way  as  to  give  rise  to  more  cysts  than 
one.     The  size  of  the  cyst  varies  according  to  the  quantity  of  fluid,  which 


ANATOMICAL  CHARACTERS.  537 

may  be  only  a  few  drachms  or  several  ounces.  Killiet  and  Barthez  report  a 
case  in  which  there  was  a  pint  of  fluid  lying  over  each  hemisphere,  there 
being  two  cysts.  If  the  cranial  bones  are  not  united,  so  that  they  yield  to 
the  pressure,  the  size  of  the  cranium  is  increased,  and  if  the  extravasation 
be  confined  to  one  side,  an  •  ineijuality  results  and  the  symmetry  of  the  head 
is  destroyed.  The  fluid  which  causes  the  enlargement  of  the  head  in  such 
cases  is  in  part  the  serum  of  the  extravasated  blood  and  in  part  a  subsequent 
secretion. 

Various  writers  relate  cases  of  ventricular  hemurrhage.  Valleix  met  it 
in  an  infant  that  died  at  the  age  of  two  days.  In  the  Edinburgh  Journal 
of  Medicine  and  Siuycrj/,  October,  1831,  an  interesting  case  is  related.  A 
boy  nine  years  old  died  of  hemorrhage  in  both  ventricles,  and  also  at  the 
base  of  the  brain  and  in  the  spinal  canal.  In  the  Nursery  and  Child's  Hos- 
pital of  this  city  the  post-mortem  examination  was  made  of  an  infant  who 
died  at  the  age  of  one  month.  In  the  posterior  cornu  of  the  left  lateral 
ventricle  were  two  clots,  elongated  and  black,  one  larger  than  the  other.  In 
the  corresponding  cornu  on  the  opposite  side  was  a  smaller  clot.  A  similar 
post-mortem  appearance  was  observed  at  the  autopsy  of  a  young  infant 
that  died  in  Charity  Hospital.  A  dark  crescentic  clot  lay  in  each  pos- 
terior cornu.  The  clot,  if  remaining  a  long  time,  undergoes  degeneration. 
In  the  case  of  an  adult  in  which  a  year  had  elapsed  after  the  extravasation  I 
found  it  to  contain  crystals  of  cholesterin  and  carbonate  of  lime. 

Cerebral  Hemorrhage,  or  hemorrhage  in  the  substance  of  the  brain, 
may  occur  at  any  time  in  infancy  and  childhood.  The  blood  is  sometimes 
extravasated  in  points  here  and  there  over  the  entire  organ  or  a  part  of  the 
organ  ;  in  other  cases  it  is  extravasated  in  one  or  perhaps  two  cavities,  as  in 
the  ordinary  form  of  apoplexy  in  the  adult.  In  the  first  form  of  cerebral 
hemorrhage,  or  that  in  which  the  blood  escapes  from  numerous  points  through 
the  brain,  there  is  evidently  little  laceration  or  injury  of  the  organ.  The 
brain-substance  surrounding  the  hemorrhagic  points  sometimes  preserves  the 
usual  appearance.  It  is  white  and  firm.  In  other  cases  it  presents  a  reddish, 
or  yellowish  appearance,  and  is  softened  to  the  depth  of  a  line  or  two.  If 
the  hemorrhage  occur  in  a  cavity,  as  in  apoplexy  of  adults,  the  nerve-fibres 
are  evidently  torn  and  separated  and  there  is  more  or  less  compression  of  the 
surrounding  brain-substance.  Unless  the  disease  be  of  long  standing,  the 
cavity  contains  a  dark  and  soft  clot  bathed  with  serum  which  has  a  reddish 
or  a  yellowish-red  appearance.  The  brain  in  the  immediate  vicinity  of  the 
cavity  is  sometimes  softened.  Rilliet  and  Barthez  state  that  they  have  seen 
8  cases  of  cerebral  hemorrhage  of  the  capillary  form  ;  10  cases  in  which  the 
hemorrhage  was  in  cavities ;  and  in  2  of  the  18  both  forms  were  present.  In 
5  of  those  in  which  the  form  was  capillary  the  disease  was  limited  to  portions 
of  the  brain,  while  in  the  remaining  3  the  hemorrhagic  points  were  found  in 
nearly  every  part  of  the  brain. 

Apoplectic  cavities  are  seldom  seen  in  the  cerebellum,  and,  whether  the 
hemorrhage  be  capillary  or  in  a  cavity,  there  is  in  most  cases,  as  previously 
stated,  more  or  less  congestion  of  the  vessels  of  the  brain. 

The  proportion  of  cases  of  cerebral  to  other  forms  of  hemorrhage  is 
believed  by  some  to  be  greater  in  the  new-born  than  at  any  other  period  of 
life.  Valleix  relates  -4  cases  of  intracranial  hemorrhage  occurring  at  this  age, 
2  of  which  were  cerebral,  1  ventricular,  and  in  the  other  the  extravasation 
was  in  the  cavity  of  the  arachnoid.  Mignot  has  published  8  cases  occurring 
in  the  new-born,  in  2  of  which  the  hemorrhage  was  in  cavities  in  the  cere- 
brum;  in  3,  in  the  lateral  ventricles;  and  in  3,  external  to  the  brain.  If  the 
same  proportion  be  observed  in  other  statistics,  1  in  3  of  the  cases  of  intra- 
cranial hemorrhage  occurrinti  in  the  new-born  is  cerebral. 


538       '  INTRACRANIAL  HEMORRHAGE. 

Symptoms. — The  symptoms  in  intracranial  hemorrhage  are  not  uniform  ; 
they  vary  according  to  the  seat  as  well  as  the  quantity  of  the  effused  blood, 
In  some  cases  the  extravasation  occurs  without  such  symptoms  as  would 
direct  attention  to  the  brain.  When  the  hemorrhage  occurs  at  the  time  of 
birth  in  consequence  of  strong  and  long-continued  labor-pains,  the  infant  is 
often  born  apparently  dead.  This  is  due  partly  to  the  hemorrhage,  partly  to 
the  great  congestion  of  the  brain  which  precedes  and  accompanies  the  hemor- 
rhage. Resuscitation  is  gradual  and  difficult.  The  infant's  features  are  livid 
and  perhaps  swollen  ;  its  respiration  is  gasping,  and  both  pulse  and  respira- 
tion are  slow.  Its  cry  is  feeble,  with  but  slight  movement  of  the  facial 
muscles,  and  the  lungs  are  but  partially  inflated ;  the  eyelids  are  closed  and 
the  limbs  almost  motionless.  By  artificial  respiration  and  by  friction  the 
pulse  and  breathing  may  be  rendered  more  frequent,  but  the  latter  remains 
irregular  and  gasping.  Finally,  the  limbs  grow  cold,  the  surface,  from  a  state 
of  lividity,  becomes  pallid,  and  death  occurs  in  profound  coma.  M.  Cruveil- 
hier  made  many  observations  at  the  Maternite  in  reference  to  the  death  of 
new-born  infants,  and  he  believes  that  one-third  of  those  who  die  in  birth  at 
the  full  period  die  of  apoplexy.  I  have  made  post-mortem  examinations  in  a 
few  cases  when  death  had  occurred  from  this  cause,  and  in  all  the  hemorrhage 
was  meningeal.  One  of  these  was  born  on  the  30th  of  December,  1864. 
The  birth  was  delayed  by  unusual  projection  of  the  promontory  of  the 
sacrum,  so  that  finally  the  application  of  forceps  was  necessary.  The  infant 
was  apparently  stillborn,  but  by  persistent  efforts  on  the  part  of  the  physician 
who  assisted  it  was  resuscitated  so  as  to  live  several  hours,  though  with  con- 
stant embarrassment  of  respiration  and  with  lividity.  At  the  autopsy  a  large 
extravasation  of  blood  was  found  in  the  cavity  of  the  arachnoid  over  a  con- 
siderable part  of  the  convexity  of  the  brain,  and  the  substance  of  the  brain 
was  deeply  congested. 

Apoplexy  in  the  new-born  does  not  always  terminate  fatally,  or,  when 
fatal,  in  the  sudden  manner  which  I  have  described.  Valleix  relates  the 
case  of  an  infant  who  died  of  pneumonia  at  the  age  of  three  and  a  half 
months.  Its  birth  had  been  protracted  and  difficult,  but  was  completed  with- 
out the  use  of  instruments.  It  had  had  during  its  entire  life  paralysis  of  the 
right  side.  At  the  autopsy  a  clot  was  found  near  the  base  of  the  right 
thalamus  opticus,  evidently  existing  from  birth.  Around  the  clot  the  brain 
was  softened  to  the  depth  of  some  lines  and  was  of  a  bluish-red  color.  A 
very  similar  case  is  related  by  M.  Vernois.  An  infant  lived  forty-nine  days 
with  paralysis  of  the  left  side,  and  died  of  pneumonia.  At  the  autopsy  a 
hemorrhagic  excavation  in  process  of  cicatrization  was  found  behind  the  right 
corpus  striatum  and  the  thalamus  opticus. 

Intracranial  hemorrhage  occurring  from  accidents  of  birth  is  generally 
attended  by  marked  symptoms,  such  as  have  been  described.  But  when  it 
occurs  subsequently  to  birth,  whether  in  infancy  or  childhood,  the  symptoms 
vary  greatly  in  different  cases  and  are  generally  obscure.  I  will  briefly  state 
the  symptoms  which  have  been  observed  in  both  the  cerebral  and  meningeal 
forms  of  this  disease.  First,  the  cerebral.  Sedillot  relates  the  case  of  a  child 
seven  and  a  half  years  old  whose  bare  head  had  been  exposed  several  hours 
to  the  sun's  raj's.  Suddenly,  after  a  paroxysm  of  anger,  it  was  seized  with 
great  pain,  corresponding  with  the  posterior  and  inferior  fossse  of  the  cranium. 
It  uttered  piercing  cries  and  died  in  a  quarter  of  an  hour,  A  clot  was  found 
in  the  right  lobe  of  the  cerebellum.  Richard  Quinn  (Rilliet  and  Barthez) 
gives  the  history  of  a  boy  nine  years  old  who  in  playing  with  a  hoop  sud- 
denly stopped,  carried  his  hands  to  his  head,  and  fell  backward  unconscious. 
Three  or  four  hours  afterward,  when  examined,  he  was  found  pale,  surface 
cool,  respiration  slow  and  at  times  stertorous,  pulse  50  to  60  per  minute ; 


SYMPTOMS.  539 

the  left  arm  was  flexed,  the  left  leg  paralyzed  ;  the  right  leg  and  arm  con- 
vulsed ;  right  pupil  strongly  dilated,  the  loft  contracted.  He  died  seven 
hours  after  the  commencement  of  the  attack,  and  a  large  clot  was  found 
in  the  centrum  ovale  on  the  right  side. 

Rilliet  and  Harthez  relate  the  following  case  from  (.'ampbell  :  A  boy  with 
good  previous  health  was  suddenly  seized  about  7  A.  M.  with  repeated  vomiting, 
followed  in  an  hour  and  a  half  by  violent  convulsions ;  he  rolled  his  eyes  and 
uttered  inarticulate  cries  ;  pulse  frequent  and  hard  ;  pupils  contracted  ;  trunk 
and  lower  extremities  cool.  In  the  afternoon  he  presented  symptoms  of  com- 
pression of  the  brain,  such  as  dilatation  of  the  pupils,  freffuent  and  feeble 
pulse.  Death  occurred  in  the  evening,  and  a  hemorrhagic  cavity  was  found 
occupying  the  right  middle  lobe  of  the  cerebrum.  Guibert  relates  a  case  of 
extravasation  in  the  superior  part  of  the  right  hemisphere  of  the  brain  in  a 
boy  fourteen  years  old.  The  principal  symptoms  were  feebleness  of  the 
limbs,  inability  to  walk,  cephalalgia,  involuntary  evacuations,  fever,  grinding 
the  teeth,  rigors  severe  and  prolonged,  lividity,  loss  of  intellectual  facul- 
ties, dilatation  of  the  pupils,  insensibility  to  light,  stertorous  respiration. 
Death  occurred  in  about  an  hour. 

Rilliet  and  Barthez  narrate  the  history  of  a  girl  two  years  old  who,  after 
an  attack  of  measles,  was  taken  with  convulsions  accompanied  with  fever  and 
prostration.  The  convulsive  movements  affected  especially  the  eyes  and  upper 
extremities;  the  right  leg  was  immovable;  the  left  pupil  dilated.  These 
symptoms  resulted  from  hemorrhage  in  the  corpus  striatum  and  opticus 
thalamus.  The  same  authors  relate  also  the  case  of  a  girl  seven  years  old 
who  died  with  a  large  apoplectic  cavity  in  the  left  thalamus  opticus.  The 
symptoms  were  headache,  convulsive  movements,  loss  of  consciousness,  delir- 
ium, vomiting  and  constipation,  and  convergent  strabismus.  These  symp- 
toms nearly  disappeared,  but  in  a  few  days  the  headache  returned,  with 
strabismus  and  a  slight  drawing  of  the  face  toward  the  left ;  on  the  twenty- 
seventh  day  convulsive  movements  of  the  right  eye  were  observed,  with 
paralysis  of  the  arm.  Finally,  contraction  of  the  arms  occurred,  with  accele- 
ration of  pulse,  irregular  breathing,  dilated  pupils,  paralysis,  and  retraction 
of  the  head,  followed  by  death  on  the  forty-eighth  day. 

These  cases,  and  those  from  Valleix  and  Vernois  which  have  been  related 
in  our  remarks  on  hemorrhage  of  the  new-born,  are  sufficient  to  show  the 
character  of  the  symptoms  in  that  form  of  cerebral  hemorrhage  in  which  the 
extra vasated  blood  forms  a  cavity  in  the  interior  of  the  brain. 

If  the  amount  of  extravasation  be  large  and  the  substance  of  the  brain 
be  much  lacerated  and  compressed,  death  may  occur  almost  immediately,  and 
therefore  without  symptoms,  or  before  it  is  pos.sible  to  determine  whether 
or  not  symptoms  are  present.  If  the  disease  be  not  so  speedily  fatal  the 
symptoms,  as  appears  from  the  above  cases,  are  headache,  confusion  of 
thought,  or  even  insensibility;  cries,  sometimes  piercing;  cold  extremities, 
pallor,  slow  and  perhaps  stertorous  respiration  ;  convulsive  movements  fol- 
lowed by  paralysis,  or  convulsions  aifecting  one  or  more  limbs,  with  paralysis 
of  others  ;  pupils  contracted  or  dilated,  sometimes  one  contracted  and  the 
other  dilated  ;  strabismus,  rolling  of  eyes,  vomiting. 

These  symptoms  have  all  been  observed  in  different  cases,  but  they  are 
not  all  present  in  any  one  case.  Those  which  are  generally  present,  and  on 
which  we  mainly  rely  for  diagnosis,  are  headache,  convulsive  movements, 
paralysis,  confusion  of  thought,  irregularity  in  the  pupils,  and  strabismus. 

In  the  capillary  form  of  cerebral  hemorrhage  there  is  usually  some 
complication,  so  that  it  is  not  easy  to  determine  how  far  symptoms  are  due 
to  the  hemorrhage  and  how  far  to  the  coexisting  pathological  state. 

There  are,  indeed,  but  few  published  observations  of  hemorrhage  in  the 


540  INTRACRANIAL  HEMORRHAGE. 

substance  of  the  brain  unaccompanied  with  meningeal  hemorrhage,  hemor- 
rhage into  a  ventricle,  or  some  other  distinct  disease ;  but  so  far  as  I  have 
been  able  to  ascertain  the  symptoms  referable  to  this  form  of  extravasation, 
they  are  as  follows  :  The  child  is  drowsy  :  fretful  when  disturbed  ;  it  per- 
haps moans.  There  are  sometimes  slight  convulsive  movements  and  partial 
paralysis.  If  there  be  considerable  extravasation,  the  respiration  is  irregular 
and  sighing.  Death  occurs  in  coma,  occasionally  preceded  by  convulsions. 
Taupin  relates  the  case  of  a  child  nine  years  old  who  died  with  this  form  of 
hemorrhage,  accompanied  by  softening  of  the  brain.  The  disease  began  at 
night  with  delirium,  agitation,  and  piercing  cries.  In  the  morning  the  patient 
lay  in  bed,  drowsy,  not  complaining  of  pain  and  not  replying  to  questions ; 
pupils  dilated  and  insensible  to  light;  left  eye  half  open  during  sleep  and  its 
axis  changed  ;  eyebrows  contracted  ;  face  pale  ;  mouth  open  ;  had  no  convul- 
sions, but  transient  stiffening  of  the  limbs,  during  which  the  thumbs  were 
firmly  compressed  by  the  fingers ;  senses  unimpaired,  but  the  face  drawn  to 
the  right ;  deglutition  difiicult ;  pulse  small,  irregular,  and  feeble  ;  respira- 
tion 32,  sighing.  In  the  evening  he  had  rigidity  of  the  limbs  and  back,  and 
finally  was  taken  with  general  convulsions,  in  which  he  died  at  eleven  o'clock. 
The  hemorrhagic  points  in  this  case  were  numerous.  A  boy  five  years  old, 
whose  case  is  described  by  Rilliet  and  Barthez,  died  of  this  disease,  pneu- 
monia, and  white  softening  of  the  intestine.  During  the  last  five  days  there 
were  cerebral  symptoms,  the  chief  of  which  were  drowsiness,  fretfulness 
when  disturbed,  and  moaning  without  apparent  cause.  Another  child,  whose 
case  is  described  by  Rilliet  and  Barthez,  died  at  the  age  of  four  years  with 
cerebral  capillary  hemorrhage,  accompanied  by  yellow  softening.  Six  months 
before  death  he  had  general  convulsions,  followed  by  spasmodic  movements 
of  the  left  side.     These  subsided,  but  the  left  side  remained  feeble. 

In  Meningeal  Hemorrhag'e  there  are  often  convulsions,  general  or  par- 
tial— in  some  patients  tonic,  in  others  clonic.  When  partial,  the  convulsive 
movements  may  only  occur  in  the  muscles  of  the  face  and  eyes.  With  the 
spasmodic  muscular  action  is  a  degree  of  drowsiness  with  irritability.  Paral- 
ysis, so  common  in  the  apoplexy  of  the  adult,  and  not  infrequent,  as  we 
have  seen,  in  the  cerebral  form  in  early  life,  is  sometimes,  but  not  ordinarily, 
present  in  meningeal  hemorrhage.  Instead  of  paralysis,  there  are  vomiting, 
some  febrile  action,  thirst,  and  loss  of  appetite.  The  symptoms  are  different, 
however,  according  to  the  exact  seat  of  the  hemorrhagic  extravasation  and 
the  duration  of  the  disease.  If  the  extravasation  end  in  the  formation  of  a 
cyst,  the  symptoms  are  those  of  hydrocephalus.  The  following  condensed 
history  of  cases  which  I  have  selected  as  typical  will  give  us  a  clearer  idea 
of  the  history  and  course  of  the  various  forms  of  meningeal  hemorrhage 
than  can  be  imparted  by  a  narration  of  symptoms. 

M.  Tonnele  relates  the  case  of  a  child  who  was  taken  with  faintness  and 
convulsive  movements.  On  the  following  day  the  trunk  and  inferior  extrem- 
ities became  rigid  ;  deglutition  was  painful ;  the  pupils  were  largely  dilated, 
immovable ;  face  pale  ;  pulse  feeble  and  intermittent.  Death  occurred  the 
same  day.  The  dura  mater  was  distended.  A  layer  of  coagulated  blood  of 
great  thickness  extended  over  the  convexity  of  each  hemisphere.  The  veins 
ramifying  into  the  superior  portion  of  the  cerebrum  were  distended  with 
coagulated  blood.  The  hemorrhage  was  in  the  meshes  of  the  pia  mater. 
Drs.  Lombard  and  Panchard  of  Geneva  relate  a  somewhat  similar  case.  A 
child  thirteen  months  old  was  convalescing  from  inflammation  of  the  bron- 
chial and  intestinal  mucous  surfaces  when  it  was  seized  with  general  convul- 
sions ;  the  mouth  and  eyes  were  open  and  the  eyes  directed  upward ;  pupils 
contracted ;  pulse  frequent  and  irregular.  The  convulsions  abated  some- 
what, but  soon  reappeared   with  violence.     The   patient  became   insensible, 


DIA  GNOSIS— TREA  TMENT.  541 

and  died  nineteen  hours  after  the  coumiencement  of  cerebral  symptoms. 
The  extravasated  blood  covered  the  upper  surface  of  both  hemispheres. 
From  the  above  cases  we  see  the  symptoms  and  the  course  of  meningeal 
hemorrhage  when  the  e-x^travasation  is  so  large  that  death  speedily  results. 
In  protracted  cases  of  meningeal  hemorrhage  there  is  either  a  gradual  disap- 
pearance of  symptoms  and  return  to  health,  or,  circumscribed  hydrocephalus 
occurring,  the  symptoms  of  that  di.sease  arise. 

Diagnosis. — It  is  evident,  from  what  has  been  stated,  that  the  diagnosis 
of  intracranial  hemorrhage  is  attended  with  unusual  difficulty,  since  the 
symptoms  of  this  disease  occur  also  in  other  and  distinct  pathological  states. 
The  history  of  the  case,  and  especially  the  character  of  the  cause,  if  ascer- 
tained, will  aid  in  diagnosis.  If  there  has  been  an  obvious  determination 
of  blood  to  the  brain  or  some  known  obstruction  to  the  return  of  blood  from 
that  organ,  the  persistence  of  cerebral  symptoms  would  justify  us  in  con- 
cluding that  either  serous  or  sanguineous  effusion  had  supervened  on  a  state 
of  congestion.  The  points  of  differential  diagnosis  between  apoplexy  and 
meningitis  are  the  sudden  and  full  development  of  symptoms  in  one  case, 
the  gradual  commencement  and  gradual  increase  of  symptoms  in  the  other ; 
differences  also  of  symptoms  in  certain  respects ;  for  example,  as  regards 
fever,  constipation,  etc. 

There  is  one  symptom  in  cerebral  hemorrhage  which  is  of  great  diagnos- 
tic value — namely,  paralysis.  Its  presence  affords  strong  evidence  that  there 
is  extravasation  of  blood,  and  probably  in  a  cavity  of  the  substance  of  the 
brain.  If  the  extravasation  end  in  the  formation  of  a  cyst,  the  symptoms 
and  appearance  of  hydrocephalus,  which  after  a  time  arise,  throw  light  on 
the  nature  of  the  disease. 

Prognosis. — There  can  be  no  doubt  that  many  cases  of  intracranial  hem- 
orrhage occur  and  terminate  favorably  without  the  nature  of  the  disease  being 
suspected.  In  such  cases  the  amount  of  extravasated  blood  is  small  or  mod- 
erate. In  several  published  cases  in  which  the  accuracy  of  the  diagnosis 
was  shown  by  post-mortem  examinations,  the  patients  were  convalescing 
from  the  hemorrhage  when  they  succumbed  to  intercurrent  diseases.  If, 
however,  the  amount  of  extravasated  blood  be  such  as  to  give  rise  to  those 
symptoms  which  have  been  described,  the  prognosis  is  unfavorable.  Recur- 
ring convulsions  and  persistent  stupor  from  which  it  is  difficult  to  arouse  the 
patient  are  unfavorable  symptoms.  If  the  convulsions  cease  and  conscious- 
ness return,  even  if  there  be  paralysis,  the  result  may  be  favorable. 

Treatment. — The  proper  treatment  in  intracranial  hemorrhage  depends 
on  the  state  of  the  patient,  the  time  which  has  elapsed  since  the  extravasation, 
and  the  degree  of  it  as  shown  by  the  nature  and  severity  of  the  symptoms. 
If,  as  is  often  the  case,  the  patient  be  robust  and  be  visited  soon  after  the 
commencement  of  the  attack,  cold  applications  should  be  made  to  the  head, 
mustard  to  the  back  of  the  neck  and  perhaps  chest,  and  derivation  should 
be  produced  by  mustard  pediluvia.  In  many  cases,  especially  in  active  con- 
gestion, it  is  advisable  to  apply  leeches  to  the  temple  and  the  bowels  should 
be  opened  by  a  stimulating  enema.  In  active  congestion  also  prompt  purga- 
tion by  salines  or  other  cathartics  is  sometimes  of  great  importance.  The 
object  of  such  treatment  is  to  relieve  congestion  of  the  cerebral  and  menin- 
geal vessels,  and  thereby  prevent  further  extravasation  of  blood.  If  the 
congestion  be  active,  the  pulse  continue  full  and  frequent,  and  the  face  be 
flushed,  it  is  proper  in  many  cases  to  control  the  action  of  the  heart  by  a 
sedative.  For  this  purpose  the  tincture  of  aconite-root  may  be  given  in 
doses  of  one  drop  to  a  child  five  years  old,  repeated  in  three  hours  if 
necessary,  or  antipyrine  or  phenacetin.  If  the  stupor  or  convulsions  con- 
tinue after  sufficient  time  have  elapsed  for  the  patient  to  receive  the  full 


542  CONGENITAL  HYDROCEPHALUS. 

benefit  of  the  above  remedies,  more  counter-irritation  is  required.  Cantha- 
ridal  collodion  should  be  applied  behind  each  ear.  If  the  hemorrhage  occur 
from  passive  congestion  or  in  a  cachectic  state  of  system,  active  depressing 
remedies  should  not  be  employed.  External  derivatives  are  of  service,  as 
well  as  cool  applications  to  the  head,  and  we  should  attempt,  as  far  as  possi- 
ble, to  remove  the  cause  of  the  congestion  and  hemorrhage.  If  it  depend 
on  a  cachectic  state,  tonic  or  other  remedies  calculated  to  relieve  this  state 
are  indicated.  The  hemorrhage  from  such  a  cause  is  usually  in  points  in 
the  substance  of  the  brain  or  in  moderate  quantity  over  the  surface  of  this 
organ,  and  by  a  timely  use  of  constitutional  remedies  possibly  we  may  pre- 
vent further  extravasation  of  blood  and  increase  the  chance  of  the  patient's 
recovery. 

If  a  cyst  result  from  the  hemorrhagic  effusion,  the  treatment  which  is 
proper  is  that  described  in  the  chapter  on  Acquired  Hydrocephalus. 


CHAPTER    VI. 
CONGENITAL    HYDROCEPHALUS. 

Congenital  hydrocephalus  consists  in  an  excess  of  the  cerebro-spinal 
fluid,  lying  either  external  to  the  brain  or  more  frequently  in  its  interior. 
It  is  due  to  some  vice  in  the  development  of  the  brain  or  its  membranes  or 
to  a  pathological  state  occurring  in  them  during  intra-uterine  life.  This  dis- 
ease is  in  some  patients  apparent  from  the  symptoms  and  appearances  at  birth, 
but  not  always.  Occasionally  nothing  unusual  is  observed  in  the  shape  of 
the  head  or  aspect  of  the  infant  till  after  the  lapse  of  some  weeks,  when  the 
characteristic  physiognomy  begins  to  appear,  In  these  cases  the  disease  is 
still  congenital,  since  there  is  every  reason  to  believe  that  the  abnormal  state 
to  which  the  excessive  production  of  fluid  is  due  existed  from  birth.  In  cases 
of  arrested  or  partial  development  of  the  brain — as,  for  example,  when  a  con- 
siderable portion  of  the  hemispheres  is  absent — there  is  often  an  unusually 
large  quantity  of  fluid  which  serves  as  a  compensation  for  the  lack  of  brain. 
I  do  not  regard  such  cases  as  examples  of  hydrocephalic  disease,  since  the 
effect  of  the  fluid  is  not  injurious,  but  rather  useful.  I  restrict  the  term 
congenital  hydrocephalus  to  those  cases  in  which  the  brain  is  complete,  or, 
if  incomplete,  the  quantity  of  fluid  is  more  than  sufiicient  to  supply  the 
deficiency. 

Anatomical  Characters. — According  to  M.  Breschet,  the  fluid  in  con- 
genital hydrocephalus  may  be — 1st,  between  the  dura  mater  and  the  cranium  ; 
2d,  between  the  dura  mater  and  the  parietal  arachnoid ;  3d,  in  the  cavity  of 
the  arachnoid ;  4th,  in  the  ventricles ;  5th,  between  the  arachnoid  and  the 
brain. 

In  a  large  majority  of  hydrocephalic  patients  the  effusion  occurs  in  the 
ventricles.  As  the  quantity  of  fluid  increases  the  pressure  from  within 
gradually  unfolds  the  convolutions  of  the  brain,  at  the  same  time  producing 
expansion  of  the  cranial  arch.  When  the  amount  of  fluid  is  considerable — 
and  it  becomes  so  in  the  course  of  a  few  weeks  or  months — the  hemispheres 
are  spread  out  in  a  thin  lamina  on  either  side,  gradually  decreasing  in  thick- 
ness from  the  base  of  the  cranium  to  the  vertex,  where  the  brain-substance 
is  sometimes  so  thin  as  to  be  scarcely  perceptible.  Complete  absence  of  brain^ 
in  this  situation — namely,  at  the  vertex,  even  in  extreme  cases  of  expansion! 


ANATOMICAL  CHARACTERS. 


543 


and  flattening  of  the  hemispherus  from  the  pressure  of  the  liquid — is  rare, 
though  the  brain-substance  at  this  point  is  sometimes  almost  as  thin  as  either 
of  the  membranes,  so  that  the  wall  of  the  sac  is  translucent.  The  mem- 
branes which  surround  the  brain  do  not  usually  undergo  any  alteration, 
except  such  as  arises  from  the  distension.  The  falx  cerebri  sometimes  dis- 
appears, and  sometimes  the  meninges  present  a  whiter  hue  from  raacei'ation 
than  in  health.  The  distension  also  causes  such  an  expansion  of  the  pia 
mater  that  it  becomes  very  thin,  and  in  places  scarcely  visible,  but  its  pres- 
ence in  every  point  can   be  demonstrated. 

The  accompanying  woodcut  represents  congenital  hydrocephalus  as  it 
ordinarily  occurs.  I  saw  this  infant  when  it  was  a  few  days  old,  and 
examined  it  from  time  to  time  till  its  death.  The  parents  are  healthy  and 
have  other  healthy  children.     This  infant  when  nine  days  old  began  to  have 


Fig.  34. 


clonic  convulsions  of  a  mild  form  in  the  muscles  of  the  face,  neck,  and  limbs, 
which  occurred  almost  daily  till  the  age  of  six  weeks,  and  sometimes  every 
five  or  ten  minutes.  When  the  convulsions  ceased  in  the  sixth  week  the 
head  was  observed  to  enlarge,  and  its  excessive  growth  continued  till  death, 
which  occurred  at  the  age  of  seven  months  and  one  week.  While  the  vol- 
ume of  the  head  progressively  increased,  the  trunk  and  limbs  emaciated. 
At  death  the  occipito-frontal  circumference  of  the  head  was  nineteen  and  a 
half  inches  ;  the  vertical  from  auditory  meatus  to  meatus  thirteen  and  a  half 
inches. 

The  changes  which  the  cranial  bones  undergo,  both  in  their  chemical 
character  and  in  their  shape  in  hydrocephalic  patients,  if  the  amount  of  fluid 
be  considerable,  are  interesting  and  remarkable.  The  base  of  the  cranium 
undergoes  little  change,  but  those  portions  of  the  frontal,  parietal,  and  occip- 
ital bones  which  constitute  the  arch  are  expanded  in  all  directions,  while  they 
become  much  thinner.  There  is  deficiency  of  lime  in  their  constitution,  so 
that  the  organic  elements  are  greatly  in  excess.  This  renders  them  flexible 
and  semi-transparent.  Notwithstanding  the  expansion  of  the  bones,  there 
are  usually  interspaces  between  them,  of  greater  or  less  size  according  to  the 
amount  of  fluid. 


544  CONGENITAL  HYDROCEPHALUS. 

The  scalp,  being  stretched  by  the  pressure  underneath,  becomes  tense  and 
thin,  and  is  scantily  covered  with  hair.  The  veins  which  ramify  in  it  are 
unusually  prominent  and  large,  and  the  head  is  elastic  on  pressure  from  the 
amount  of  liquid  beneath.  In  the  common  form  of  congenital  hydrocephalus 
— namely,  that  in  which  the  liquid  is  in  the  interior  of  the  brain — the  shape 
of  the  orbital  plates  of  the  frontal  bone  is  often  changed,  so  that  the  eyeballs 
have  a  downward  direction.  This  change  in  the  axis  of  the  eyes  occurs  at 
an  early  period,  and  it  continues  through  the  entire  disease,  becoming  more 
and  more  marked  as  the  quantity  of  liquid  increases.  If  the  amount  be 
large,  the  lower  part  of  the  cornea  is  buried  under  the  under  eyelid,  while 
the  conjunctiva  is  visible  between  the  cornea  and  the  upper  eyelid.  The  per- 
sistent downward  direction  of  the  eyes  is  characteristic  of  this  disease,  and  in 
connection  with  enlargement  of  the  head  is  an  important  diagnostic  sign. 
Nevertheless,  hydrocephalus,  even  of  the  ventricular  variety,  sometimes 
occurs   without   change   in   the   direction   of   the   eyes. 

If  we  examine  the  interior  of  the  cavity  after  the  fluid  is  evacuated,  we 
will  find  at  its  base  the  parts  which  lie  in  the  floor  of  the  lateral  ventricles, 
but  changed  in  appearance  in  consequence  of  pressure.  The  cornua  are 
enlarged  and  the  tlaalami  optici  and  corpora  striata  are  flattened.  In  the 
early  stages  of  the  disease,  when  the  amount  of  fluid  is  small,  there  is  prob- 
ably no  absorption  or  destruction  of  parts  in  the  interior  of  the  brain.  The 
various  portions  of  this  organ  retain  nearly  their  normal  relation  to  each 
other.  As  the  quantity  of  fluid  increases  the  foramen  of  Monro,  which 
unites  the  lateral  ventricles,  becomes  enlai'ged,  the  septum  lucidum  which 
separates  them  disappears,  and  the  two  ventricles  form  a  common  cavity.  In 
most  fatal  cases  we  find  this  single  large  cavity.  The  surface  which  sur- 
rounds the  cavity  occasionally  presents  a  whitish  or  semi-opaque  appearance, 
which  has  led  to  the  belief  that  at  a  pei'iod  antecedent  to  birth  there  was  sub- 
acute inflammation  of  this  surface,  and  hence  the  eff"usion. 

The  bones  of  the  face  are  ordinarily  less  developed  than  in  healthy  chil- 
dren of  the  same  age,  so  that  the  disproportion  between  the  head  and  face 
becomes  a  marked  peculiarity.  The  shape  of  the  forehead  and  face  is  nearly 
triangular. 

The  foregoing  remarks  in  reference  to  the  anatomical  characters  of  con- 
genital hydrocephalus  refer  in  the  main  to  cases  which  have  continued  for  a 
considerable  time,  so  that  their  characteristic  features  are  well  marked.  In 
very  young  infants,  in  whom  the  disease  is  still  recent,  similar  anatomical 
characters  are  present,  but  in  less  degree. 

Congenital  hydrocephalus  is  often  associated  with  other  vices  of  confor- 
mation, especially  with  spina  bifida.  The  two,  when  coexisting,  are  only 
parts  of  the  same  disease,  the  large  quantity  of  cerebro-spinal  fluid  prevent- 
ing the  spinal  canal  from  closing  during  foetal  development. 

The  fluid  in  congenital  hydrocephalus  consists  largely  of  water,  in  the  pro- 
portion even  of  99  parts  in  100.  In  addition  to  this  element  there  are  traces 
of  albumen,  chloride  of  sodium,  phosphate  and  carbonate  of  sodium,  and 
osmazome. 

I  have  had  an  opportunity  to  witness  only  one  post-mortem  examination 
in  a  case  of  congenital  hydrocephalus  in  which  the  liquid  was  exterior  to  the 
brain.  This  case  was  under  observation  in  the  children's  service  of  Charity 
Hospital  in  1866.  Full  notes  and  measurements  of  the  head  were  taken, 
which,  unfortunately,  were  mislaid  or  lost.  The  infant  had  congenital  syph- 
ilis and  had  a  pallid,  strumous  appearance.  The  shape  and  relative  size  of 
the  head  are  seen  in  the  woodcut  (Fig.  35),  from  a  photograph.  While 
the  whole  head  was  enlarged,  there  was  a  relative  excess  of  development  in 
the  part  between  and  above  the  ears.     The  axis  of  the  eyes  was  not  at  all 


ETIOLOG  Y— SYMPTOMS. 


545 


Fig.  35. 


changed,  and  the  vision  was  good.  Tlio  appearance  corresponded  so  closely 
with  descriptions  of  hypertrophy  of  the  brain  tliat  this  was  supposed  to  be 
the  anatomical  state.  Antisyphilitic  treatment  was  employed,  and  the  syph- 
ilitic eruptions  had  nearly  disappeared  when  diarrhoea  supervened,  followed 
by  death.  At  the  autopsy  a  quantity  of  trans- 
parent or  light  straw-colored  liquid,  estimated  at 
six  or  seven  ounces,  was  found  exterior  to  the  brain 
in  the  great  cavity  of  the  arachnoid,  lying  mostly 
over  the  superior  surface  of  the  organ.  There  was 
no  excess  of  liquid  in  the  ventricles,  and  the  brain, 
though  of  good  size,  was  not  abnormally  large,  nor 
did  it  possess  the  firmness  which  is  present  in  true 
hypertrophy. 

All  cases  of  congenital  hydrocephalus  may  be 
embraced  in  two  groups — namely,  that  in  which 
the  li(|uid  is  in  the  interior  of  the  brain,  and  that 
in  which  it  lies  exterior  to  the  organ.  Liquid 
primarily  in  the  arachnoidean  cavity  permeates 
the  meshes  of  the  pia  mater,  and  lies  in  part  vm- 
derneath  it,  or  this  delicate  membrane  may  be  rup- 
tured. Four  of  the  groups,  therefore,  described  by  Breschet,  may  properly 
be  reduced  to  one — namely,  those  groups  in  which  the  liquid  lies  under, 
between,  or  external  to  the  meninges.  It  is  probable  that  some  of  the  cases 
which  led  to  Breschet's  classification  were  examples  of  acquired  cii'cumscribed 
hydrocephalus,  the  result  of  extravasation  of  blood.  In  this  form  of  hydro- 
cephalus, as  is  stated  elsewhere,  an  adventitious  membrane  forms  external 
to  the  liquid,  becoming  in  time  thin  and  delicate  and  often  bearing  a  close 
resemblance  to  the  normal  membrane  (especially  the  arachnoid),  for  which 
it  is  sometimes  mistaken. 

Etiology. — The  constitutional  vice  which  gives  rise  to  this  disease  is 
probably  different  in  different  cases.  I  have  been  able,  I  think,  to  attribute 
correctly  a  considerable  proportion  of  cases  which  I  have  observed  to  con- 
genital syphilis,  but  in  other  instances  from  the  character  of  the  parents  I 
could  not  assign  this  cause. 

Sy.mpto.ms. — If  there  be  a  considerable  amount  of  hydrocephalic  fluid 
prior  to  the  birth  of  the  child,  so  that  the  head  is  abnormally  large,  partu- 
rition is  seriously  interfered  with.  The  scalp  and  meninges  may  become 
ruptured  by  the  severity  of  the  pains,  so  that  the  fluid  escapes.  If  this  do 
not  occur  the  labor  is  often  necessarily  instrumental.  Whether  the  liquid  be 
present  before  birth  or  accumulate  subsequentl}'  to  it,  the  tendency  is  to  an 
increase  of  the  quantity  and  a  corresponding  enlargement  of  the  head. 

The  digestive  function  in  this  disease  is  at  first  well  performed.  The 
infant  nurses  readily  and  has  its  evacuations  with  the  regularity  of  other 
children.  Not  many  weeks,  however,  elapse,  in  the  majority  of  cases,  before 
defective  nutrition  is  apparent. 

While  the  volume  of  the  head  increases  other  parts  are  imperfectly  nour- 
ished and  stunted  in  their  growth.  Emaciation  of  the  neck,  trunk,  and 
limbs  is  common,  associated  with  progressive  feebleness.  In  the  last  stages 
of  this  disease  there  is  more  or  less  vomiting,  with  constipation.  If  there 
were  previously  the  ability  to  support  the  head,  it  is  now  lost  and  the  erect 
position  is  no  longer  possible.  In  marked  cases,  when  there  is  great  dispro- 
portion between  the  head  and  the  rest  of  the  system,  there  is  frequently  not 
even  the  ability  to  rotate  the  head  on  the  pillow.  So  long  as  the  cranial 
bones  yield  readily  to  the  pressure  from  within  and  there  is  no  compression 
of  the  brain,  the  function  of  this  organ  is  not  seriously  impaired.  The  child 
35 


546  CONGENITAL  HYDROCEPHALUS. 

recognizes  its  mother  or  nurse,  and  it  can  be  amused  like  other  children, 
though  easily  fatigued.  The  state  of  the  senses  is  different  in  different  cases, 
and  sometimes  at  different  stages  of  the  same  case.  The  sight  and  hearing 
in  some  are  perfect,  in  others  impaired,  while  in  others  still  they  are  good  at 
first,  but  gradually  become  obscured  and  lost.  It  is  said  that  the  sense  of 
smell  may  be  perverted,  so  that  agreeable  odors  are  unpleasant,  and  vice  versa. 
Many,  reaching  the  age  at  which  children  begin  to  walk,  cannot  walk,  or  if 
they  do  it  is  with  a  tottering,  unsteady  gait. 

When  the  liquid  increases  to  that  extent — and  it  usually  does  sooner  or 
later — that  the  brain  begins  to  be  compressed,  dangerous  cerebral  symptoms 
arise.  The  child  becomes  drowsy  and  takes  less  notice  of  objects.  Spas- 
modic muscular  contractions,  and  finally  convulsions,  occur.  The  pupils  act 
feebly  or  irregularly  by  light,  or  one  is  more  dilated  than  the  other.  Strabis- 
mus also  occurs.  As  death  approaches,  eclampsia,  partial  or  general,  becomes 
more  frequent,  and  is  succeeded  by  stupor  from  which  the  patient  cannot  be 
aroused. 

The  following  case,  which  I  copy  from  my  note-book,  is  an  example  of 
the  common  form  of  congenital  hydrocephalus  ;  it  will  give  an  idea  of  the 
ordinary  course  of  this  disease,  and  show  the  difficulty  which  we  meet  with 
in  its  treatment :  Female,  born  November  9,  1859,  with  the  aid  of  forceps. 
At  birth  the  fontanels  were  unusually  large,  the  cranial  bones  separated,  and 
the  aspect  in  a  marked  degree  hydrocephalic.  She  nursed  at  first,  but,  the 
mother's  milk  failing,  she  was  afterward  bottle-fed.  At  the  age  of  four 
months  her  head,  which  had  increased  faster  than  her  general  growth,  meas- 
ured from  one  auditory  meatus  to  the  other,  over  the  vertex,  seventeen  inches  ; 
the  occipito-frontal  circumference,  twenty-three  inches.  At  this  time  she 
manifested  considerable  intelligence,  being  able  to  distinguish  her  mother 
from  other  persons,  though  the  head  was  so  large  that  it  was  necessary  to 
support  it  constantly  on  a  pillow.  From  the  age  of  four  to  six  months  the 
operation  of  tapping  was  performed  six  times  with  a  small  hydrocele  trocar 
by  Dr.  Stephen  Smith,  at  a  point  near  the  coronal  suture  and  from  one  inch 
to  one  inch  and  a  half  from  the  sagittal.  At  each  operation  an  amount  of  fluid 
varying  from  twelve  ounces  to  one  pint  was  removed,  and  the  head  then  cov- 
ered with  strips  of  adhesive  plaster,  so  as  to  form  a  complete  cap.  It  was 
necessary,  however,  within  the  twelve  hours  succeeding  each  operation  to  loosen 
the  dressing  on  account  of  either  the  occurrence  of  convulsions  or  symptoms 
premonitory  of  them.  The  head  within  a  week  subsequently  to  each  opera- 
tion regained  its  former  size,  and,  as  there  was  no  permanent  benefit,  this 
treatment  was  discontinued.  She  finally  died  of  entero-colitis  at  the  age  of 
ten  months  and  five  days. 

At  the  autopsy  the  distance  from  one  auditory  meatus  to  the  other  was 
twenty  and  a  quarter  inches  ;  the  occipito-frontal  circumference,  twenty-six 
and  a  quarter  inches.  The  anterior  fontanel  measured  antero-posteriorly 
four  and  three-fourths  inches ;  transversely,  seven  and  three-fourths  inches. 
The  parietal  bones  were  separated  from  each  other  to  the  distance  of  two  or 
three  inches,  and  they  measured  in  length  nine  and  a  half  inches. 

On  opening  the  cranial  cavity,  seven  pints,  by  measurement,  of  trans- 
parent fluid  escaped,  exposing  a  vast  open  space  at  the  bottom  of  which 
were  the  parts  which  constitute  the  floor  of  the  ventricles,  somewhat  changed 
in  shape,  and  from  them  on  either  side  the  hemisphere  was  spread  in  a 
lamina,  so  as  to  cover  the  internal  surface  of  the  cranial  bones.  The  laminae 
near  the  base  of  the  brain  measured  in  thickness  from  half  an  inch  to  one 
inch,  and  they  gradually  became  thinner  on  approaching  the  vertex,  at  which 
point  the  brain-substance  was  exceedingly  thin,  so  as  to  be  scarcely  demon- 
strable. 


DIAGNOSIS— TREATMENT.  547 

The  brain  had  its  normal  vascuhirity  and  consistence,  and  the  cerebellum, 
medulla  oblongata,  the  base  of  the  brain,  and  cranial  nerves  presented  their 
usual  appearance.  On  folding  tlie  brain  together  it  had  the  size,  shape,  and 
aspect  of  this  organ  in  its  ordinary  development.  Nothing  unusual  was 
observed  in  tlic  membranes  except  their  great  expansion.  The  above  case 
corresponds  in  its  general  features  with  most  cases  met  in  practice. 

Diagnosis. — The  ordinary  form  of  congenital  hydrocephalus,  that  in 
which  the  liquid  occupies  the  interior  of  the  brain,  can  in  most  cases  be 
readily  diagnosticated.  If  there  be  only  a  moderate  amount  of  liquid,  it 
may  be  confounded  with  hypertrophy  of  the  brain.  In  hydrocephalus  there 
are  commonly  more  rapid  growth  and  greater  expansion  of  the  head ;  more- 
over, the  enlargement  occurs  equally  on  all  sides,  while  in  hypertrophy, 
though  all  parts  of  the  cranial  vault  are  expanded,  the  enlargement  is  more 
at  the  vertex  than  elsewhere.  The  hydrocephalic  head  yields  more  readily 
to  pressure  than  the  hypertrophied,  and  often  communicates  a  fluctuating 
sensation.  Moreover,  in  the  ordinary  form  of  hydrocephalus  the  change  in 
the  axis  of  the  eyes  described  above  is  an  important  diagnostic  sign.  In 
rachitis  the  volume  of  the  head  is  often  considerably  enlarged,  due  some- 
times, in  part  at  least,  to  a  deposit  of  calcareous  matter  on  the  exterior  of 
the  cranial  bones.  The  differential  diagnosis  is  based  on  the  shape  of  the 
head,  round  in  one,  square  or  with  prominences  in  the  other,  on  palpation, 
direction  of  the  eyes,  etc.  The  smaller  the  amount  of  liquid,  the  greater  the 
liability  to  error  of  diagnosis ;  but  if  the  amount  be  inconsiderable  and  not 
increasing,  little  treatment  is  required  except  hygienic  and  tonic,  which  is 
also  proper  in  both  hypertrophy  and  rachitis.  If  the  liquid  be  exterior  to 
the  brain,  as  in  the  case  represented  in  Fig.  35,  diagnosis  may  be  difficult,  but 
such  cases  are  infrequent. 

Prognosis. — In  the  majority  of  cases  this  is  unfavorable,  since  the  secre- 
tion of  liquid  usually  continues.  The  most  favorable  result  is  no  increase,  or 
but  slight,  in  the  cjuantity,  while  the  natural  growth  of  the  infant  increases, 
and  thus  the  disproportion  between  the  head  and  the  rest  of  the  system 
gradually  disappears.  Such  patients  may  live  to  maturity  and  have  tolerable 
health,  and  may  engage  in  occupations.  But  ordinarily  in  cases  left  to 
themselves,  and  even  in  a  large  proportion  of  those  having  the  best  treatment, 
the  body  and  limbs  gradually  waste  from  defective  nutrition,  and  the  patient, 
if  not  cut  oif  by  an  intercurrent  disease,  finally  succumbs  with  cerebral  symp- 
toms produced  by  pressure  of  the  liquid.  Probably  more  than  half  of  the 
hydrocephalic  patients  die  before  the  close  of  the  second  year. 

Treatment. — We  may  attempt  to  diminish  the  quantity  of  fluid  by  the 
use  of  diuretics.  Digitalis,  squills,  nitrate  and  acetate  of  potassium  have 
been  used.  The  most  efficient  diuretic  in  these  cases,  however,  is  the  iodide 
of  potassium.  This  may  be  given  in  doses  of  one  to  two  grains  every  two 
hours  to  an  infant  of  three  months.  Constipation,  if  present,  should  be 
relieved  by  an  occasional  purgative.  If  it  be  tolerated,  we  may  partially 
prevent  the  expansion  of  the  head  by  a  close-fitting  cap.  For  this  purpose 
strips  of  adhesive  plaster  about  one-third  of  an  inch  in  width  should  be  applied 
so  as  to  cover  the  entire  head.  The  proper  way  of  applying  these  is  as  fol- 
lows :  First,  one  strip  from  each  mastoid  process  to  the  outer  part  of  the  orbit 
on  the  opposite  side  ;  secondly,  from  the  back  of  the  neck,  along  the  longi- 
tudinal sinus,  to  the  root  of  the  nose ;  thirdly,  over  the  whole  head,  so  that 
the  diff'erent  strips  will  cross  each  other  at  the  vertex  ;  and,  lastly,  a  strip 
long  enough  to  pass  three  times  around  the  head  should  be  applied,  passing 
above  the  eyebrows,  the  ears,  and  below  the  occipital  protuberance.  Too 
tight  an  application  should  be  avoided,  as  it  may  give  rise  to  convulsions  or 
other  cerebral  symptoms.     If  the  cap  can  be  tolerated  and  the  general  health 


648  ACQUIRED  HYDROCEPHALUS. 

be  good,  the  prospect  is  more  favorable  ;  but  usually,  from  the  increase  in  the 
quantity  of  fluid,  it  is  necessary  in  a  few  days  to  remove  or  loosen  the  strips 
in  order  to  prevent  convulsions,  or,  which  is  preferable,  to  diminish  the  size 
of  the  head  and  relieve  the  pressure  by  tapping.  In  56  cases  collected  by 
Dr.  West  in  which  tapping  was  employed,  4  recovered.  The  operation  is 
simple,  easily  performed,  devoid  of  danger,  and  it  frequently  gives  temporary 
relief.  It  should  therefore  be  recommended  to  the  parents,  even  if  it  do  not 
effect  a  cure.  It  should  be  performed  by  a  very  small  trocar,  which  should 
be  introduced  in  the  coronal  suture,  about  an  inch  external  to  the  anterior 
fontanel.  A  few  ounces  should  be  removed,  and  strips  of  adhesive  plaster  or 
an  elastic  skull-cap  applied.  In  a  few  days  the  operation  should  be  repeated 
as  the  liquid  increases.  It  is  important  to  maintain  compression  of  the  skull 
before  and  after  the  operation  (Treves).  Sometimes  a  dozen  or  more  tap- 
pings are  required  at  intervals  of  a  few  days  or  weeks,  when  the  secretion 
may  come  to  a  standstill.  In  the  Med. -Chir.  Trans.  (1864)  a  case  is  related 
in  which  two  tappings  effected  a  cure,  but  so  good  a  result  is  exceptional. 
Iodine  injections  in  connection  with  tapping  have  so  far  not  produced  any 
satisfactory  result.  Sir  James  Paget ^  relates  a  case  in  which  he  injected  ten 
grains  of  iodine  and  twenty  grains  of  iodide  of  potassium  in  one  ounce  of 
water,  but  the  child  died  of  convulsions  after  the  second  injection.  No  appre- 
ciable good  result  has  followed  the  use  of  irritating  or  sorbefacient  applica- 
tions to  the  head.  Nutritious  diet  and  attention  to  the  general  health  are 
requisite. 


CHAPTER  VII. 

ACQUIEED    HYDROCEPHALUS. 

Hydrocephalus,  or  dropsy  of  the  brain,  may  also  occur  in  those  who  at 
birth  are  well  formed  and  free  from  disease.  Pathologists  call  this  acquired 
hydrocephalus.  It  is  in  nearly  all  cases  the  result  of  disease,  which  is  located 
sometimes  within  the  cranium,  but  often  in  other  parts  of  the  system. 

Causes. — The  diseases  within  the  cranium  which  most  frequently  produce 
serous  effusion  are  the  meningeal  inflammations,  both  simple  and  tubercular, 
tumors  or  other  causes  which  obstruct  the  venous  circulation,  and  hemor- 
rhagic eff"usion  ending  in  the  formation  of  cysts.  Prolonged  passive  con- 
gestion often  ends  in  transudation  of  serum  through  the  coats  of  the  capil- 
laries. Therefore,  all  causes  of  congestion,  except  such  as  have  a  transient 
or  momentary  eff'ect,  may  be  regarded  as  causes  of  serous  eff'usion.  In  rare 
instances  chronic  hydrocephalus  results  from  cerebro-spinal  fever  (meningitis), 
as  has  been  stated  in  my  remarks  on  the  latter  disease. 

Among  the  diseases  external  to  the  cranium  which  produce  serous  effusion 
within  or  upon  the  brain  may  be  mentioned  retropharyngeal  abscess,  tuber- 
culization or  inflammation  of  the  bronchial  glands,  scarlet  fever,  and  certain 
afi'ections  of  an  exhausting  nature,  especially  protracted  diarrhoeal  maladies. 
In  at  least  five  cases  which  have  fallen  under  my  notice,  and  in  which  post- 
mortem examinations  were  made,  the  cause  was  enlarged  tubercular  bronchial 
glands,  which,  by  pressure  on  the  venae  innominatae,  so  retarded  the  flow  of 
blood  from  the  brain  as  to  cause  congestion  and  eff'usion.  The  causal  relation 
of  these  glands  to  cerebral  congestion  is  described  in  our  remarks  in  reference 
to  this  disease. 

^  Medical  Times  and  Gazette,  1860. 


ANATOMICAL   CHARACTERS— SYMPTOMS.  549 

Dropsy  of  the  brain  is  common  in  protracted  infantile  diarrhoea ;  as,  for 
example,  in  advanced  cases  of  intestinal  catarrh  of  the  summer  months  in 
the  cities.  It  is  preceded  and  accompanied  by  passive  congestion  of  the  cere- 
bral veins  and  sinuses,  due  in  part  to  feebleness  of  circulation  in  consequence 
of  the  exhausted  state  of  the  patient,  and  in  part  to  wasting  of  the  brain, 
which  always  give  rise  to  more  or  less  passive  congestion,  unless  in  young 
infants,  in  whom  the  cranial  bones  become  depressed  and  override  each  other. 
Dropsy  of  the  brain,  resulting  from  scarlet  fever,  and  that  peculiar  circum- 
scribed dropsy  which  results  from  hemorrhagic  effusions,  are  described  else- 
where. 

A  few  cases  have  been  related  by  different  observers,  Abercrombie  among 
others,  in  which  dropsy  of  the  brain  seemed  to  be  essential.  Nothing  abnor- 
mal was  observed,  with  the  exception  of  serous  effusion.  But  the  reports  of 
such  cases  are,  for  the  most  part,  meagre,  and,  as  Barrier  has  well  said,  we 
are  not  to  accept  such  cases  as  examples  of  essential  dropsy  of  the  brain 
unless  the  post-mortem  inspection  be  so  complete  as  to  render  it  certain  that 
there  was  no  pathological  state  which  might  cause  the  dropsy. 

Anatomical  Characters. — Acquired  hydrocephalus  usually  occurs 
after  the  cranial  bones  are  firmly  united,  and  therefore  the  shape  of  the 
head  is  not  materially  altered.  If  it  occur  at  any  early  age,  before  there  is 
free  union,  there  may  be  expansion  of  the  cranial  arch,  as  we  sometimes 
observe  in  the  circumscribed  hydrocephalus  resulting  from  hemorrhage. 
The  effusion  in  acquired  hydrocephalus  occurs  over  the  surface  of  the  brain, 
in  the  subarachnoid  space,  or  in  the  lateral  ventricles.  In  the  dropsy  of  pro- 
tracted diarrhoeal  maladies  I  have  rarely  failed  to  find  the  liquid  over  the 
whole  superior  surface  of  the  brain  as  well  as  at  its  base. 

The  quantity  of  fluid  in  this  disease  is  not  large.  In  the  majority  of 
cases  it  does  not  exc^eed  four  ounces,  and  is  often  much  less.  It  is  transpar- 
ent or  it  has  a  slightly  yellowish  tinge.  The  membranes  of  the  brain  some- 
times present  their  normal  appearance,  but  in  other  cases  they  are  injected. 
The  brain  itself  in  some  instances  has  an  injected  appearance  from  passive 
congestion  of  the  veins  and  capillaries ;  but  in  others,  when  there  has  been 
more  or  less  compression  of  the  brain,  there  is  no  more  than  the  ordinary,  or 
even  less  than  the  ordinary,  vascularity,  and  the  convolutions  are  somewhat 
flattened. 

Symptoms. — The  symptoms  of  the  pathological  state  which  gives  rise  to 
the  dropsy  precede  and  accompany  those  which  are  referable  to  the  dropsy 
itself.  The  dropsy  declares  itself  by  symptoms  which  ai'e  alarming  from 
the  first. 

In  children  old  enough  to  speak  or  manifest  intelligence  there  may  be  at 
first  complaint  of  headache.  The  child  is  irritable,  its  mind  confused  or  wan- 
dering at  times,  or  there  is  actual  delirium.  After  a  time  drowsiness  occurs. 
The  head  seems  too  heavy  for  the  body  and  is  buried  in  the  pillow.  In  fatal 
cases  the  features  become  pallid,  the  pupils  sluggish,  and  perception  and 
consciousness  are  gradually  lost.  The  child  lies  in  profound  sleep,  which 
increases.  There  are  now  often  convulsive  movements,  partial  or  general, 
and  these  soon  end  in  coma,  in  which  the  patient  dies. 

The  following  was  an  interesting  case  of  acquired  hydrocephalus  which 
seemed  to  result  from  subacute  meningitis.  The  patient  was  seen  by  several 
physicians,  and  the  diagnosis  was  for  a  long  time  doubtful : 

Harry  R.  L ,  of  healthy  parentage,  was  well  till  the  summer  of  1876, 

when  he  was  nearly  at  the  close  of  his  third  year.  At  this  time  he  was 
observed  to  be  feverish  and  fretful  and  his  features  were  flushed  at  times. 
He  also  complained  almost  daily  of  pain  in  the  top  of  his  head,  which  pain 
was  intermittent,  and  these  attacks  of  headache  occurred  during  at  least  six 


550  ACQUIRED  HYDROCEPHALUS. 

months,  perhaps  longer.  There  had  been  no  backwardness  in  dentition  and 
no  symptoms  of  rachitis  or  struma,  and  his  nutrition  was  good  even  after 
the  commencement  of  the  present  malady. 

In  February  or  March,  1877,  his  stomach  became  irritable,  so  that  he 
vomited  often  during  the  following  months,  and  about  the  same  time  he 
began  to  lose  the  use  of  both  legs — a  progressive  paralysis — and  his  bowels 
became  constipated.  Both  urination  and  defecation  were  sluggishly  per- 
formed. In  July,  1877,  he  ceased  to  walk,  and  he  has  not  been  able  to 
stand  since. 

On  March  29,  1878,  the  following  records  were  made:  No  improvement, 
but  gradual  increase  of  most  of  the  symptoms ;  lies  constantly ;  moves  his 
limbs  slowly  and   infrequently,  but    completely,  and    sensation   appears   to 
remain  in  all  of  them  ;  his  eyes  are  clear  and  his  pupils  moderately  dilated, 
but  without  vision — how  long  his  sight  is  lost   is 
Fig.  36.  not  known  ;     axis  of   eyes  not  depressed  or  other- 

wise changed,  and  parallelism  retained  ;  the  cranium, 
which  during  the  first  year  of  his  sickness  under- 
went little  change,  has  expanded  rapidly  during  the 
last  six  months ;  the  enlargement  is  most  marked 
above  the  ears ;  the  occipito-frontal  circumference 
is  represented  in  the  accompanying  diagram ;  this 
circumference  measures  twenty-one  and  a  half  inches, 
of  which  nine  and  three-quarters  are  in  front  of  ears, 
and  eleven  and  one-third  inches  posterior  to  ears ; 
distance  over  vertex  from  one  auditory  meatus  to 
the  other,  fifteen  and  a  quarter  inches.  The  anterior  fontanel  is  observed  to 
be  open,  though  small,  the  diameter  being  about  one-fourth  or  one-third  of 
an  inch ;  it  is  not  elevated  and  the  surrounding  edge  of  bone  is  flexible. 

This  patient  lived  till  near  the  close  of  1880  without  material  change  in 
symptoms,  and  with  moderate  progressive  increase  in  the  size  of  the  head. 
At  the  autopsy  measurements  were  again  made,  but  they  have  been  mislaid. 
The  enlargement  was  found  to  be  due  to  the  presence  of  about  three  pints 
of  straw-colored  serum  in  the  lateral  ventricles,  which  had  been  changed  into 
a  large  cavity.  There  was  nothing  to  indicate  any  other  disease.  From  the 
history  and  appearances  we  inferred  that  the  hydrocephalus  had  been  due  to 
a  mild  meningitis  occurring  in  the  third  year.  The  appearance  and  state  of 
the  encephalon  were  precisely  like  those  in  ordinary  congenital  hydrocephalus. 
In  January,  1890,  I  exhibited  to  the  New  York  Paediatric  Society  a  child 
with  acquired  hydrocephalus  which  dated  back  to  an  attack  of  cerebro-spinal 
fever  of  mild  type  which  occurred  a  few  months  previously.  It  seems  to  me 
that  the  case  detailed  above  resulted  from  the  same  disease. 

Prognosis. — Acquired  hydi'ocephalus  commonly  ends  unfavorably.  The 
prognosis  depends  not  only  on  the  quantity  of  liquid,  but  on  the  nature  of 
the  cause.  If  the  cause  be  venous  obstruction  within  the  cranium  or  thorax, 
death  is  inevitable,  since  we  have  no  means  of  removing  it.  If  it  be  an  exhaust- 
ing disease,  as  entero-colitis  or  scarlet  fever,  although  the  case  is  not  abso- 
lutely hopeless,  the  prospect  is  still  unfavorable.  It  is  only  favorable  when 
the  quantity  of  eifused  fluid  is  small,  the  system  not  much  reduced,  and  the 
primary  disease  mild.  When  acquired  hydrocephalus  arises  from  meningeal 
apoplexy,  the  case  is  usually  chronic.  The  symptoms  and  termination  of 
this  form  of  the  disease  are  very  similar  to  those  in  congenital  hydro- 
cephalus. 

Treatment. — The  treatment  in  acquired  hydrocephalus  must  vary  some- 
what in  different  cases,  according  to  the  nature  of  the  disease  on  which  it 
depends.     I  shall  indicate  the  treatment,  in  part  at  least,  in  the  description 


MENINGITIS.  551 

of  these  diseases.  Occasionally  the  condition  of  the  patient  is  such  that 
there  is  little  to  encourage  us  in  the  employment  of  any  remedial  measures. 
Tn  vigorous  children,  if  acquired  hydrocephalus  occur  in  connection  with 
syni])tonis  which  indicate  too  active  a  circulation,  moderate  abstraction  of 
blood  from  the  temples  at  an  early  period  may  be  useful,  but  cases  requiring 
such  do{)letory  measures  are  rare.  These  cases  require  cold  applications  to 
the  head ;  the  bowels  should  be  opened,  and  derivatives  should  be  applied  to 
the  feet  and  back  of  the  neck. 

If  the  congestion  be  of  a  passive  character,  as  when  the  circulation  is 
obstructed  by  tumors  or  otherwise,  benefit  may  still  be  derived  from  cold 
applications  to  the  head  and  derivatives  to  other  parts.  In  most  cases  of 
suspected  dropsy  of  the  brain,  unless  the  patient  be  in  such  a  hopeless  state 
that  all  treatment  is  obviously  futile,  vesication  should  be  produced  behind 
the  ears.  I  prefer  cantharidal  collodion  for  this  purpose.  In  addition  to  this 
treatment,  diuretics  should  be  employed,  unless  there  be  too  great  prostration 
or  the  course  of  the  disease  be  so  rapid  that  no  benefit  can  result  in  conse- 
quence of  the  tardy  action  of  these  agents.  The  best  diuretics  are  the 
acetate   of  potassium  and  iodide  of  potassium. 


CHAPTER   VIII. 

MENINGITIS  (TUBERCULAR  AND  NON-TUBERCULAR). 

The  most  interesting  and  important  disease  of  the  cerebro-spinal  system 
in  early  life  is  that  which  is  now  designated  meningitis.  It  is  not  infrequent. 
The  mortuary  statistics  of  this  city  show  that  it  is  the  cause  of  death  in  from 
1  in  25  to  1  in  50  of  the  entire  number  of  deaths,  the  proportion  varying 
somewhat  in  different  years. 

In  1768  the  attention  of  the  profession  was  particularly  called  to  this 
malady  by  Dr.  Whytt  of  Edinburgh.  This  observer  and  the  pathologists 
succeeding  him,  forming  their  opinion  of  meningitis  from  its  most  prominent 
anatomical  character — namely,  serous  effusion — believed  it  a  dropsy.  They 
accordingly  designated  it  acute  hj^drocephalus.  During  the  last  half  century 
the  profession  have  come  to  regard  the  disease  as  inflammatory,  and  hence 
the  name  by  which  it  is  now  known  and  which  is  believed  to  express  its  true 
pathological  character. 

Sometimes  meningeal  inflammation  in  children  occurs  without  tubercles. 
In  other  instances  it  results  from  the  presence  of  tubercles,  and  in  most  if 
not  in  all  such  patients  there  are  tubercles  in  or  under  the.  meninges,  which 
excite  the  inflammation  in  the  same  manner  as  in  the  lungs  they  cause  pneu- 
monitis or  pleuritis.  Therefore  two  forms  of  meningitis  are  recognized — 
to  wit,  tubercular  and  non-tubercular.  Meningitis  is  also,  as  we  have  seen, 
the  characteristic  anatomical  character  of  cerebro-spinal  fever,  but  as  this  is 
a  general  disease,  with  the  meningitis  as  a  local  manifestation,  we  have  treated 
of  it  at  length  among  the  constitutional  maladies. 

In  patients  over  the  age  of  eighteen  months,  although  the  proportion  of 
tubercular  to  non-tubercular  cases  is  larger  than  under  this  age,  the  excess  is 
not  so  great,  according  to  my  statistics,  as  the  remarks  of  some  observers  lead 
us  to  suppose.  There  can  be  no  accurate  statistics  of  tubercular  meningitis 
without  careful  post-mortem  examination  of  the  state  of  the  brain  and  other 
organs  in   each  supposed  case,  and  this   examination  sometimes  shows  the 


552  MENINGITIS. 

meningitis  to  be  non-tubercular  when  the  symptoms  and  signs  had  indi- 
cated its  tubercular  character.  As  an  example  may  be  mentioned  a  case 
which  occurred  in  the  children's  service  of  Charity  Hospital  in  March,  1868. 
The  infant  died  at  the  age  of  twenty  months,  having  had  a  cough  of  mod- 
erate severity  at  least  three  weeks  before  death,  and  symptoms  of  meningitis 
about  four  days.  It  was  considerably  wasted,  and  was  supposed  to  have 
tuberculosis.  At  the  autopsy  no  tubercles  were  found  in  any  part  of  the 
body,  but  portions  of  both  lungs  were  hepatized.  A  fibrinous  deposit,  vary- 
ing in  thickness,  was  found  over  the  pons  Varolii,  the  optic  commissure,  along 
the  fissures  of  Sylvius,  over  the  superior  surface  of  the  anterior  half,  and  also 
upon  the  superior  lobe  of  each  cerebral  hemisphere.  As  the  examination 
failed  to  discover  any  tubercles,  the  meningitis  was  considered  non-tubercular. 
Those  who  make  these  examinations,  failing  to  find  tubercles  in  the  lungs  and 
other  organs  in  which  they  usually  occur,  should  examine  the  lymphatic 
glands,  since  cheesy  glands  may  be  the  cause  of  the  formation  of  tubercles 
in  the  meninges,  while  the  organs  of  the  trunk  remain  unafi'ected.  The 
presence  of  cheesy  glands  in  the  absence  of  visceral  tubercles,  and  with 
granulations  upon  the  meninges,  small,  covered  with  fibrin,  and  of  a  doubt- 
ful character,  goes  far  toward  establishing  the  tubercular  nature  of  the 
meningitis.  Since  the  cases  embraced  in  the  following  statistics  were 
observed,  now  more  than  twenty  years,  I  have  been  led  by  a  more  extended 
experience,  and  especially  by  the  observations  of  cases  in  the  New  York 
Foundling  Asylum,  where  there  is  ample  material,  to  regard  not  only  the 
presence  or  absence  of  tubercles,  but  also  of  caseous  substance,  as  the  proper 
test  of  the  form  of  meningitis.  Not  a  few  that  seem  at  first  to  have  non- 
tubercular  meningitis  will  be  found,  on  more  thorough  examination,  to  have 
caseous  substance  in  some  part,  the  result  of  a  pre-existing  inflammation  ;  and 
if  we  regard  the  inflammation  of  the  meninges  occurring  under  such  circum- 
stances as  tubercular,  the  relative  proportion  of  tubercular  cases  will  be  con- 
siderably augmented.  The  following  is  an  example :  When  on  duty  in  the 
asylum  in  August,  1881,  an  infant  one  year  old  died  of  meningitis.  No 
tubercles  were  observed  in  the  fibrin  at  the  base  of  the  brain  and  along  the 
fissures  of  Sylvius,  but  one  inflammatory  nodule  (cerebritis)  as  large  as  a 
chestnut,  with  sixppuration  inside,  was  found  at  the  summit  of  one  hemisphere. 
No  tubercles  could  be  detected  in  any  of  the  organs  of  the  trunk,  unless  a  few 
whitish  spots  in  the  spleen  were  of  this  nature,  but  the  bronchial  glands  were 
cheesy  and  softened,  and  the  middle  lobe  of  the  right  lung  also  contained 
cheesy  substance.  It  seemed  to  me  probable  that  some  of  this  degenerated 
product  taken  up  by  the  vessels  had  lodged  in  the  meninges  and  produced 
the  tubercular  neoplasm  there  which  was  hidden  under  the  fibrin.  (See 
chapter   on  Tuberculosis.) 

Age. — The  following  table  gives  the  age  in  meningitis,  tubercular  and 
non-tubercular,  in  forty-two  cases  in  my  collection,  which  of  course  is  only 
a  small  proportion  of  those  which  I  have  observed ;  but  these  are  the  only 
cases  of  which  I  have  preserved  notes  which  are  now  accessible : 

Cases.  Age. 

1 2\  weeks  (autopsy). 

2 3  months. 

20 From  3  to  12  months. 

10 From  1  year  to  2  years. 

5 From  2  years  to  5  years. 

4 Over  5  years. 

42 
Rilliet  and  Barthez  have  also  published  statistics  of  the  age  in  meningitis. 


PATHOLOGICAL  ANATOMY.  553 

Their  cases  were  observed  chiefly  in  hospital  practice,  and  the  result  is  some- 
what different.  In  32  cases  of  non-tubercular  meningitis  observed  by  these 
authors,  8  were  under  the  age  of  one  year,  G  from  two  years  to  five,  and  18 
over  the  age  of  five  years.  In  98  cases  of  tubercular  meningitis,  2  were 
under  the  age  of  one  year,  -51  between  the  ages  of  one  year  and  five,  ;->8 
between  the  ages  of  five  years  and  ten,  and  7  betweeti  ten  and  fifteen 
years.  Gowers  states  that  the  age  at  which  meningitis  is  most  frequent  is 
between  the  first  and  tenth  years. 

Pathological  Anato.my. — Thi.s  differs  considerably  in  different  cases. 
The  dura  mater  is  usually  unaffected  or  is  affected  secondarily.  In  many 
cases  it  retains  its  normal  appearance,  its  internal  surface  remaining  smooth 
and  polished,  while  in  others  it  is  more  or  less  injected  and  its  internal  surface 
dim  or  lustreless.  The  free  surface  of  the  pia  mater,  formerly  designated 
the  visceral  arachnoid,  is  in  a  great  part  of  its  extent  unchanged,  but  is  often 
hyperffimic  or  dry  and  cloudy  or  opaque  over  the  seat  of  inflammation. 
Exudation  does  not  occur  upon  the  free  surface  of  the  pia  mater,  how- 
ever intense  the  inflammation. 

In  meningitis,  tubercular  and  non-tubercular,  the  inflammatory  action 
occurs  in  the  pia  mater.  In  its  meshes  or  underneath  them  those  lesions 
result  which  characterize  the  disease,  and  to  which  other  lesions  are  second- 
ary. Tubercular  meningitis  is  most  frequently  basilar,  or  is  basilar  chiefly 
and  primarily,  although  the  inflammation  may  extend  along  the  sides  of  the 
hemispheres.  The  meningitis  is  ordinarily  most  intense  around  the  pons 
Varolii,  in  the  subarachnoid  space,  and  along  the  fissures  of  Sylvius,  for  the 
tubercular  neoplasm  occurs  chiefly  at  the  base  of  the  brain  and  along  the 
vessels.  In  non-tubercular  meningitis  the  inflammation  may  also  occur  at 
the  base.  It  may  in  young  infants  be  quite  diffuse,  and  of  little  intensity  in 
any  one  place,  producing,  in  addition  to  hyperaemia  of  the  pia  mater,  slight 
cloudiness  and  a  moderate  or  slight  escape  of  leucocytes  from  the  blood, 
these  (pus-cells)  being  perhaps  visible  only  under  the  microscope.  In  men- 
ingitis due  to  extension  of  inflammation  from  an  otitis  media  the  inflamma- 
tory action  is  intense,  confined  to  the  portion  of  the  meninges  nearest  the  ear, 
and  is  often  attended  by  inflammation  of  the  adjoining  brain-substance,  with 
perhaps  the  formation  of  an  abscess.  If  the  cause  be  exposure  to  the  sun's 
rays  or  traumatism,  the  meningitis  is  usually  at  the  summit  of  the  brain. 

The  exudation  of  fibrin  is  greatest  along  the  course  of  the  vessels  and  in 
the  depressions  between  the  convolutions,  and  the  opacity  is  most  marked  in 
these  situations.  Pus,  when  present,  is  often  semi-solid,  from  the  small  pro- 
portion of  liquor  puris  which  it  contains,  even  in  recent  cases.  If  the  dis- 
ease have  continued  several  days,  the  liquor  puris  may  be  mostly  absorbed, 
and  the  pus-cell,  becoming  shrivelled,  irregular,  and  aggravated,  may  resem- 
ble closely  the  cheesy  ti'ansformation  of  tubercle-cells. 

The  fibrinous  exudation  presents  features  of  interest.  It  does  not 
usually  attain  much  thickness,  but  by  its  opacity  it  conceals  from  view  the 
brain  underneath.  If  it  occur  in  the  fissures  of  Sylvius,  the  anterior  and 
middle  lobes  are  united  by  it.  It  is  usually  infiltrated  through  the  substance 
of  the  pia  mater.  Sometimes  little  masses  of  variable  size,  often  not  as  large 
as  a  pin's  head,  appear  at  the  point  of  inflammation.  These  masses  are  firm, 
of  a  whitish  color  or  a  light  yellow,  and  their  number  varies  in  different 
cases.  They  consist  of  a  firm,  homogeneous  substance  containing  granular 
matter  and  cells  which  often  bear  a  close  resemblance  to  tubercle-corpuscles, 
but  are  distinct.  These  corpuscular  bodies  are  plastic  nuclei  or  plastic  cells, 
often  shrunken.  It  is  seen,  then,  that  there  are  two  morbid  products  which 
may  be  mistaken  for  tubercle — one,  pus  which  has  been  in  great  measure 
deprived  of  its   liquid   element,  and  which   may  resemble   cheesy  tubercular 


554  MENINOITIS. 

matter  ;  the  other,  plastic  nuclei  collected  in  little  bodies,  so  as  to  resemble  the 
ordinary  form  of  crude  tubercle.  I  once  carried  to  one  of  ,the  best  micro- 
scopists  and  pathologists  of  this  city  some  of  the  exudation  from  a  case  of 
meningitis,  the  cellular  element  in  which  could  not  readily  be  distinguished 
from  shrunken  tubercle-corpuscles.  The  exudation  was  from  a  child  two 
years  and  eight  months  old,  with  good  health  previously  to  the  meningitis, 
without  tubercles  in  any  part  of  the  body,  with  parents  healthy,  and  with  no 
predisposition  to  tubercular  disease.  The  microscopist,  not  knowing  the 
history  of  the  case  or  character  of  the  family,  and  ignorant,  like  all  of  us  at 
that  time,  of  the  true  tubercle-cell,  pronounced  the  exudation  tubercular 
after  a  careful  examination  with  the  microscope.  Bouchut  says :  "  The 
whitish  miliary  granulations  which  are  observed  on  the  surface  of  the  pia 
mater  have  a  certain  consistency  and  tenacity  which  render  them  difficult  to 
tear  with  the  needles  used  for  the  preparation  for  the  microscope.  These 
bodies  are  formed — 1.  Of  fibro-plastic  elements,  whether  nuclei  or  fusiform 
fibres ;  oval-shaped  cells  are  generally  present,  but  not  always.  The  nuclei 
are  oval  or  spherical,  generally  very  small — that  is  to  say,  they  hardly  exceed 
in  diameter  0.008  mm.  to  0.009  mm.  The  presence  of  these  little  spherical 
nuclei  must  be  insisted  on,  because  with  a  less  power  than  550  diameters  it 
would  be  sometimes  impossible  to  establish  the  differences  which  separate 
them  from  the  elements  of  tubercles ;  the  fusiform  fibres  are  small  and  rare. 
2.  There  exists  a  considerable  quantity  of  amorphous  homogeneous  matter 
in  which  minute  granulations  are  scattered  ;  it  is  very  dense,  and  keeps  the 
other  elements  strongly  united  together,  so  that  it  is  difficult  to  isolate  them 
completely.  3.  Vessels  are  very  rarely  observed ;  the  fibres  of  connective 
tissue  are  also  rare  or  altogether  wanting." 

In  the  tuberculosis  of  young  children  I  have  found  in  a  large  proportion 
of  cases  in  which  I  have  had  an  opportunity  to  make  post-mortem  exami- 
nations miliary  tubercles  disseminated  through  the  lungs  and  perhaps  other 
organs  in  small  masses,  many  of  them  not  larger  than  a  pin's  head,  and  some 
occurring  as  mere  specks  scarcely  visible.  These  minute  tubercular  forma- 
tions have  ordinarily  been  semi-transparent,  and  sometimes  even  transparent 
like  minute  drops  of  water,  and  containing  the  true  and  unchanged  tubercle 
bacillus.  Now,  if  in  such  a  case  meningitis  occur,  we  may  find  the  tubercle- 
cell  in  or  with  the  fibrin  at  the  base  of  the  brain.  But  failure  to  find  it,  even 
with  protracted  microscopic  examination,  does  not  prove  its  absence  from  this 
locality,  for  I  consider  it  almost  impossible  to  discover  in  the  midst  of  the 
fibrinous  exudation  such  minute  points  of  tubercular  matter  as  are  seen  in 
the  lungs,  liver,  or  elsewhere. 

The  pia  mater  is  often  firmly  adherent  to  the  brain  at  the  seat  of  inflam- 
mation, so  that  on  raising  it  a  portion  of  the  brain  may  be  detached  and 
removed  with  it.  The  extent  of  the  inflammation  varies  much  in  different 
cases.  There  may  in  extreme  cases  be  pretty  general  inflammation  of  the 
pia  mater.  In  cases  of  such  extensive  meningitis  the  symptoms  are  usually 
severe  and  the  course  of  the  disease  rapid.  Thus,  in  the  month  of  April, 
1866,  a  girl  eleven  years  of  age,  in  the  Protestant  Episcopal  Orphan  Asylum 
of  this  city,  had  complained  occasionally  of  dizziness,  but  was  otherwise  in 
good  health,  cheerful,  and  with  excellent  appetite,  till  Thursday,  when  she 
was  effected  with  vertigo,  more  persistent  than  previously,  and  with  head- 
ache. At  2  P.  M.  on  the  following  day  she  was  seized  with  general  convul- 
sions, and  continued  insensible  or  nearly  so,  with  occasional  convulsive  move- 
ments, till  Monday,  when  she  died  comatose.  The  pia  mater  at  the  vertex, 
sides,  and  base  of  the  brain  had  a  cloudy  appearance,  and  underneath  it  in 
places  was  a  thick,  creamy  substance  in  small  quantity,  which,  examined  by 
the  microscope,  proved  to   be   pus,  the  largest   amount  being  near  the  pons 


PATHOLOGICAL  ANATOMY.  '  555 

Varolii.  Tliere  was  no  tubercle  under  the  meninges  or  elsewhere,  and  no 
iippreciable  fibrinous  exudation.  The  nieriingitis,  though  of  brief  duration, 
was  nearly  general.  The  only  additional  lesions  noticed  were  moderate  con- 
gestion of  the  brain  and  an  increase  in  the  quantity  of  the  ccrebro-spinal 
fluid. 

If  the  disease  be  protracted  three  or  four  weeks,  which  is  rare,  or  even 
less  time,  the  exuded  substance  may  undergo  further  changes,  such  as  occur 
in  simple  exudations  in  other  parts  of  the  system.  Thus,  on  the  80th  of 
April,  18(50,  we  made  the  post-mortem  examination  of  an  infant  at  the  Nurs- 
ery and  Child's  Hospital  who  had  symptoms  of  cerebral  disease,  it  was  stated, 
for  several  weeks,  but  the  exact  time  was  not  ascertained.  Prominent  among 
the  symptoms  referable  to  the  cerebro-spinal  system  toward  the  close  of  life 
were  the  hydrocephalic  cry  and  rigidity  of  the  neck.  The  appearance  at  the 
autopsy  was  remarkable.  The  anterior  half  of  the  brain  was  completely 
encased  in  a  deposit  which  had  nearly  the  appearance  of  lard.  It  filled  the 
fissures  of  Sylvius  and  appeared  slightly  on  the  anterior  aspect  of  the  cere- 
bellum. Examined  under  the  microscope,  this  substance  was  found  to  con- 
tain numerous  cells,  among  which  could  be  distinguished  some  resembling 
pus-cells,  but  nearly  all  had  undergone  more  or  less  fatty  degeneration. 
Here  and  there  was  seen  a  large  cell  containing  numerous  small  oil-glob- 
ules,  the   compound  granular  cell  of  pathologists. 

The  brain  itself  in  meningitis  is  usually  hypersemic.  On  making  an 
incision  through  it  red  points  are  seen  upon  the  cut  surface,  which  indi- 
cate the  seat  of  the  congested  vessels.  The  inflammation  rarely  extends  to 
the  walls  of  the  ventricles,  but  the  choroid  plexus  is  injected.  In  excep- 
tional instances  pus  or  fibrin  is  found  in  the  lateral  venticles.  In  the  infant 
two  and  a  half  weeks  old  whose  case  has  already  been  alluded  to  about  two 
ounces  of  purulent  fluid  escaped  on  opening  the  left  ventricle.  A  small 
amount  of  liquid  of  a  similar  character  was  contained  in  the  right  ventricle. 
The  distension  of  the  lateral  ventricles  with  serum  is  one  of  the  common 
results  of  meningitis.  This  fluid  is  clear  or  straw-colored,  or  it  is  turbid. 
The  quantity  does  not  exceed  two,  three,  or  four  ounces,  and  is  often  not 
more  than  one  ounce  or  an  ounce  and  a  half.  The  distension  of  the  two  ven- 
tricles is  ordinarily  uniform,  as  they  are  united  by  the  foramen  of  Monro, 
but  now  and  then  one  ventricle  is  found  more  distended  than  the  other.  If 
there  be  considerable  eff"usion,  the  brain  is  compressed  and  the  convolutions 
have  a  flattened  appeai'ance,  unless  the  cranial  bones  are  still  separated  so  as 
to  yield  to  the  pressure.  If  the  sutures  and  fontanels  be  open,  the  cranial 
arch  is  expanded,  sometimes  quite  perceptibly  to  the  eye.  From  the  same 
cause  the  anterior  fontanel,  if  open,  is  elevated.  The  foramen  of  Monro  is 
■enlarged  according  to  the  amount  of  effusion,  and  the  portions  of  the  brain 
which  separate  the  ventricles  are  sometimes  lacerated.  In  many  cases  the 
cerebral  substance  surrounding  the  lateral  ventricles  is  softened.  The  soft- 
ening is  found  in  all  degrees,  from  the  least  appreciable  deviation  from  the  nor- 
mal consistence  to  a  state  of  diffluence,  so  that  the  brain  substance  presents  the 
appearance  of  cream.  Hypotheses  have  been  advanced  to  explain  the  cause 
of  this  change  in  consistence  which  are  not  entirely  satisfactorj-.  Whatever 
the  explanation,  the  fact  is  attested  by  all  observers,  though  there  are  excep- 
tional cases.  Thus  Dr.  A\'"est  has  records  of  the  condition  of  the  brain  in  59 
cases,  in  37  of  which  there  was  considerable  softening,  and  in  the  remaining 
22  the  consistence  was  normal. 

Since  a  majority  of  the  cases  of  meningitis  in  children  are  basilar,  and 
portions  of  all  the  cerebral  nerves  lie  at  the  base  of  the  brain,  it  is  easy 
to  understand  why  the  functions  of  these  nerves  are  so  seriously  impaired  in 
this  disease.     Compression  of  these  nerves  or  extension  of  inflammation  to 


556  MENINGITIS. 

their  sheaths  affords  explanation  of  many  of  the  symptoms,  as  the  sighing 
respiration,  abnormalities   of  the  eye,  etc. 

Although  the  above  remarks  relating  to  the  anatomical  characters  of  men- 
ingitis are  applicable  to  a  large  majority  of  the  cases,  I  must  confess  that  I 
have  sometimes  been  disappointed  at  the  autopsies  of  young  infants  who  died 
with  all  the  symptoms  of  meningitis  in  not  finding  more  lesions.  Moderate- 
hypersemia  of  the  pia  mater,  its  slight  opacity  or  cloudiness  at  the  base  of  the 
brain  or  elsewhere,  with  the  presence  of  a  few  wandering  white  corpuscles, 
without  any  fibrinous  exudation,  with  no  increase  of  liquid  external  to  the- 
brain,  but  a  considerable  increase  of  it  in  the  lateral  ventricles,  and  hypersemia 
of  the  choroid  plexus,  with  nearly  natural  appearance  and  consistence  of  the 
brain,  have  in  some  instances  been  the  only  lesions  when  I  had  expected  to- 
find  marked  anatomical  changes. 

I  am  fully  convinced  from  my  observations  that  in  some  instances  phy- 
sicians who  supposed  that  they  were  treating  tubercular  meningitis,  and 
at  the  autopsies  discovered  within  the  cranium  tubercles,  without  any  inflam- 
matory lesion,  but  with  a  larger  increase  of  the  cerebro-spinal  liquid,  have 
been  treating  cases  in  which,  in  addition  to  the  meningeal  tubercles  which 
were  latent,  the  bronchial  glands  were  tubercular  and  cheesy,  so  that  by  their 
increased  size  they  compressed  the  venae  innominatae  within  the  thorax,  thus, 
preventing  the  free  flow  of  blood  from  the  brain,  and  causing,  as  I  have  else- 
where stated,  cerebral  and  meningeal  congestion,  with  more  or  less  transuda- 
tion of  serum,  but  with  no  meningitis.  In  tubercular  meningitis  the  ana- 
tomical characters  are  like  those  in  simple  meningitis,  with  the  addition  of 
tubercles,  which  at  first  are  minute  and  transparent,  and  are  most  easily 
detected  when  the  inflammation  has  been  slight.  Seated  in  the  pia  mater,, 
they  cause  some  prominence  of  the  arachnoid,  and  are  best  seen  when  so 
minute  by  an  oblique   light. 

Causes. — The  causes  of  non-tubercular  meningitis  are  not  fully  ascer- 
tained. Active  cerebral  congestion  frequently  occurring,  however  produced,, 
appears  to  be  one  of  the  common  causes  in  young  infants.  In  at  least  three 
instances  I  have  known  meningitis  to  occur  in  infants  between  the  ages  of 
four  and  eight  months  after  severe  and  protracted  bronchitis,  which  had  been 
attended  with  the  usual  heat  of  head.  The  disappearance  of  eruption  upon 
the  scalp  at  or  immediately  before  the  commencement  of  the  meningitis 
has  also  been  observed.  I  have  witnessed  it  at  the  commencement  of  non- 
tubercular  meningitis,  as  well  as  of  meningitis  which,  if  not  tubercular,, 
occurred  at  least  in  a  decidedly   scrofulous  state  of  system. 

The  direct  effect  of  the  solar  rays  upon  the  head  and  the  prolonged  action 
of  a  high  atmospheric  temperature,  even  without  direct  exposure  of  the  head 
to  the  sun,  are  common  causes  during  the  summer  months  in  New  York  City. 
I  once  attended  a  child  with  this  disease  who  had  been  much  exposed  bare- 
headed to  the  direct  rays  of  the  sun  in  August  and  September,  and  at  his 
death,  which  occurred  toward  the  close  of  the  hot  weather,  found  hyperaemia,. 
opacity,  and  fibrinous  exudation  in  the  pia  mater  at  the  summit  of  the  brain,, 
while  the  base  of  the  brain  seemed  nearly  or  quite  normal. 

Dr.  Soltmann^  of  Breslau  reports  three  cases  in  which  intense  cerebral 
hyperaemia,  and  probably  meningitis,  occurred  from  solar  heat.  In  all  three 
children  the  attack  was  sudden,  the  febrile  movement  and  heat  of  head  intense,, 
and  the  progress  rapid.  The  first  had  convulsions,  the  second  automatic 
movements,  and  the  third,  the  oldest,  aged  four  years,  when  able  to  speak 
complained  of  violent  headache. 

The  statistics  of  New  York  City  show  that  congestive  and  inflammatory 
maladies  of  the  brain  and  its  covering  are  more  common  during  July  and 

^  Jahrbuch  f.  Kinderkrank.,  for  October,  1875. 


PREMONITORY  STAGE.  557 

August,  which  are  the  months  of  maximum  atmospheric  heat,  than  in  other 
months  of  the  year.  For  example,  in  July  and  Au<i;ust,  1875,  1G7  died  of 
these  maladies,  or  1  in  every  it.<S  who  died  from  local  disease,  while  during 
the  entire  year  only  710  died  from  the  same,  or  1  in  every  15  who  perished 
from  local  diseases. 

July,  1876,  in  New  York  City  was  characterized  by  excessive  and  long- 
continued  atmospheric  heat,  the  temperature  of  the  Central  Park  Observatory 
in  the  shade  never  falling  below  61°,  though  never  above  98°,  and  having  a 
mean  of  82.9°.  There  was  also  unusual  dryness  of  the  atmosphere,  since 
•during  the  entire  month  prior  to  July  30th  there  were  only  fourteen  hours 
•of  rain  with  a  rainfall  of  0.77  of  an  inch,  and  the  average  atmospheric 
humidity  was  represented  by  65,  saturation  being  denoted  by  100.  During 
this  month  T  treated  in  my  private  practice  four  fatal  cases,  all  between  the 
ages  of  two  and  seven  years,  which  I  diagno.sticated  meningitis,  none  of 
them  presenting  any  symptoms  of  otitis  or  tuberculosis.  It  would  seem 
that  the  atmospheric  heat  had  much  to  do  with  the  development  of  the  dis- 
ease in  these  cases.  One  died  in  two  days,  but  in  the  others  there  was  the 
usual  duration.    Gowers  also  mentions  insolation  among  the  occasional  causes. 

A  not  infrequent  cause,  especially  among  the  strumous  families  of  cities, 
is  otitis  media  and  caries  of  the  petrous  portion  of  the  temporal  bone,  the 
inflammation  extending  to  the  meninges.  Any  suppurative  inflammation 
occurring  outside  the  dura  mater,  but  in  immediate  proximity  with  it,  may 
by  extension  cause  meningitis ;  but  the  most  common  cause  of  this  kind 
is  purulent  otitis.  The  external  discharge  of  pus  from  the  ear  usually 
ceases  when  the  meningitis  begins.  Gowers  states  that  several  cases  are 
on  record  of  meningitis  occurring  from  traumatic  inflammation  of  the  eye, 
the  inflammation  probably  passing  along  the  sheath  of  the  optic  nerve, 
(rowers  also  states  that  the  following  acute  diseases  occasionally  sustain  a 
causal  relation  to  meningitis :  measles,  scarlet  fever,  smallpox,  typhoid  fever, 
pneumonia,  and  acute  rheumatism.  But  the  meningitis  occui-ring  with  or 
from  pneumonia  is  probably  cerebro-spinal  fever,  and  meningitis  occurring 
from  the  acute  infectious  diseases  mentioned  by  Gowers  is  certainly  rare,  and 
perhaps  its  coexistence  with  them  is  in  at  least  some  instances  a  coincidence. 
Septic  processes  in  any  part  of  the  system  occasionally  cause  meningitis, 
probably  from  microbes,  which,  entering  the  circulation,  are  conveyed  to  the 
meninges.  Since  tubercular  meningitis  is  due  to  the  irritating  eff"ect  of  tuber- 
cles in  or  under  the  pia  mater,  it  usually  occurs  where  tubercles  are  most 
abundantly  developed  ;  that  is,  at  the  base  of  the  brain  and  along  the  course 
of  the  vessels  in  the  intergyral  spaces.  The  inflammation  is  commonly  excited 
when  they  are  still  small,  even  minute. 

Premonitory  Stage. — Meningitis  is  usually  preceded  by  symptoms 
which,  if  rightly  interpreted,  are  of  the  greatest  value.  In  most  cases  of 
this  malady  which  I  have  seen  there  was  a  prodromic  period  varying  from  a 
few  days  to  several  weeks.  The  symptoms  of  this  period  are  obscure,  and  are 
liable  to  be  mistaken  for  those  of  other  and  distinct  aff'ections. 

The  child  in  whom  meningitis  is  approaching  loses  his  accustomed  vivacity 
and  cheerfulness.  He  has  a  melancholy  and  subdued  appearance,  being  quiet 
a  few  minutes,  and  then  fretful,  without  apparent  cause.  He  can  some- 
times be  amused  by  his  playthings  or  companions  for  a  brief  period,  when  he 
turns  from  them  with  evident  displeasure.  Unexpected  and  loud  noises  and 
bright  lights  are  evidently  painful.  If  old  enough  to  desci'ibe  his  sensations, 
he  complains  of  transient  dizziness,  and  at  other  times  of  headache.  His  ill- 
humor,  if  his  wishes  are  not  immediately  gratified  or  if  they  are  denied,  is 
often  scarcely  endurable  on  the  part  of  friends  who  are  ignorant  of  the  cause. 
There  is  great  difl"erence,  however,  in  diff'erent  cases  as  regards  this  symptom. 


558  MENINGITIS. 

Some  are  inclined  to  be  taciturn  and  quiet,  while  others  are  almost  constantly- 
fretting.  The  appetite  is  capricious  ;  at  one  time  it  is  pretty  good,  at  another 
it  is  poor  or  even  entirely  lost.  The  patient  may  take  a  few  mouthfuls  of 
food,  or  if  an  infant  may  nurse  a  moment,  when  his  hunger  appears  satisfied 
and  he  will  take  nothing  more.  The  bowels  are  regular  or  inclined  to  con- 
stipation. The  pulse  is  natural  or  it  has  times  of  acceleration,  especially  in 
the  latter  part  of  the  day  and  toward  the  close  of  the  premonitory  stage. 
The  duration  of  this  stage  is  very  different  in  different  cases.  Upon  an 
average  it  is  perhaps  about  two  weeks,  but  is  often  longer.  In  tubercular 
meningitis  the  symptoms,  both  during  the  inflammation  and  previously,  are 
often  complicated  by  those  which  arise  from  tubercles  in  other  parts  of  the 
system. 

Unless  the  prodromic  period  be  of  short  duration  the  effect  of  imperfect 
nutrition  is  obvious  before  it  closes.  The  flesh  becomes  soft  and  flabby  or 
there  is  emaciation,  though  generally  slight.  The  patient  loses  his  strength,, 
becoming  less  able  to  stand  or  to  walk  and  more  easily  fatigued.  Occasionally,, 
especially  in  the  non-tubercular  form,  premonitory  symptoms  are  absent  or 
are  slight  and  of  short  duration. 

Symptoms. — Dr.  Whytt,  living  in  the  last  century,  when  the  tendency 
was  toward  refinement  rather  than  simplicity  in  classification,  divided  menin- 
gitis into  three  stages,  according  to  the  symptoms,  especially  the  pulse.  Many 
subsequent  writers,  following  Whytt's  example,  have  recognized  three  stages,, 
based  not  upon  the  anatomical  characters  of  the  disease,  but  upon  the  suc- 
cession of  symptoms.  Such  division  of  meningitis  is  in  great  measure  arbi- 
trai'y,  since  in  one  case  the  same  symptoms  occur  at  an  earlier  period  than  in 
another. 

When  the  premonitory  stage  has  passed  and  inflammation  is  developed,, 
some  of  the  symptoms  which  were  previously  present  remain  and  are  intensified,, 
and  other  new  and  more  characteristic  symptoms  appear.  There  are  now  fewer 
intervals  of  apparent  improvement.  The  child  is  quiet,  often  lying  with  his- 
eyes  shut.  If  aroused  he  has  a  wild  expression  of  the  face  and  is  irritated 
by  attempts  to  engage  his  attention  or  amuse  him.  He  rarely  smiles  or  takes 
his  playthings,  or  he  notices  them  for  a  moment,  when  he  turns  away  with 
disgust.  During  sleep  there  is  often  at  first  a  placid  expression  of  counte- 
nance, but  when  aroused  he  has  the  aspect  of  real  sickness  ;  the  eyebrows  are- 
sometimes  contracted,  as  if  from  headache  ;  the  features  wear  a  melancholy 
look,  and  are  turned  away  to  avoid  the  gaze  of  the  observer  or  to  shun  the- 
light.  If  the  anterior  fontanel  be  open,  it  is  observed  to  be  prominent  and 
pulsating  forcibly.  If  consciousness  be  not  lost  and  the  patient  be  of  sufficient 
age,  he  complains  of  headache  or  of  pain  in  some  part  of  the  body.  The 
tongue  is  moist  and  covered  with  a  light  fur ;  the  appetite  is  lost  or  poor ; 
there  is  seldom  much  thirst ;  more  or  less  nausea  and  constipation  are  pres- 
ent. As  the  inflammation  continues,  and  usually  within  three  or  four  days 
from  its  commencement,  symptoms  arise  which  dispel  all  doubts,  if  there  were- 
any,  as  to  the  nature  of  the  disease.  The  vital  powers  are  now  evidently 
beginning  to  yield.  The  surface  generally  is  more  pallid,  and  there  is  the 
curious  phenomenon  of  the  sudden  appearance — and  after  some  minutes  dis- 
appearance— of  spots  or  patches,  or  even  streaks,  of  active  congestion  upoa 
the  face,  forehead,  or  ears.  These,  having  a  bright-red  color,  contrast  strongly 
with  the  general  pallor.  Ordinarily  they  are  irregularly  circular  or  oval,  and 
from  one  inch  to  an  inch  and  a  half  in  diameter.  A  red  spot  or  streak  is  also- 
produced  if  the  finger  be  pressed  upon  the  surface  or  drawn  forcibly  across 
it.  It  continues  a  few  minutes,  and  then  gradually  fades.  Trousseau  calls 
attention  to  this  fact  as  a  diagnostic  sign.  It  is  known  as  the  tCiclie  cerehrale- 
of  Trousseau,  and  it  affords  important  aid  in  diagnosis. 


SYMPTOMS.  551) 

Another  curious  phenoincnnn  is  the  variation  in  temperature.  Tlie  face 
and  limbs  at  one  time  feel  (|uitc  cool,  and  after  some  minutes,  without  any 
excitement  or  other  appreciable  cause,  the  temperature  rises,  so  that  the  sur- 
face is  warm  to  the  touch. 

Consciousness  in  severe  cases  may  be  lost  at  an  early  period.  On  the 
other  hand,  I  have  known  it  in  a  case  of  moderate  severity  to  remain,  though 
partially  obscured,  till  within  twenty-four  or  thirty-six  hours  of  death.  The 
jiationt  will  usually  open  his  mouth  for  drinks  which  arc  placed  to  his  lips 
when  there  is  no  other  evidence  of  intelligence  and  when  sight  and  hearing 
are  evidently  lost. 

The  loss  of  the  senses  constitutes  an  interesting  but  melancholy  feature 
of  the  disease.  Among  the  first  unequivocal  signs,  and  fretjuently  the  very 
first,  are  such  as  pertain  to  the  eye.  This  organ  should  be  watched  from  day 
to  day  when  the  diagnosis  is  uncertain.  Deviation  from  its  normal  state  affords 
evidence  of  meningitis.  The  pupils  are  seen  to  dilate  or  contract  sluggishly 
by  variations  in  the  intensity  of  the  light,  or  they  are  not  of  the  same  size 
with  those  of  another  individual  to  whom  the  same  amount  of  light  is  admit- 
ted. Sometimes  the  first  perceptible  deviation  from  the  normal  state  is  an 
ine(|uality  in  the  size  of  the  pupils,  while  in  others  oscillation  of  the  iris  is 
observed.  Later,  when  convulsions  have  occurred,  the  parallelism  of  |.he 
eyes  is  lost.  After  effusion  has  taken  place  the  pupils  are  commonly  dilated. 
As  death  approaches  the  eyes  become  bleared  and  a  puriforra  secretion  col- 
lects in  the  inner  angle  of  the  eye  and  between  the  eyelids.  This  secretion  is 
not  abundant,  but  it  is  sometimes  sufficient  to  unite  the  lids.  The  sense  of 
hearing  is  probably  lost  as  soon,  or  nearly  as  soon,  as  that  of  sight,  but  the 
sense  of  touch  continues  longer.  The  tongue  is  covered  with  a  moist  fur, 
unless  near  the  close  of  life,  when  it  is  sometimes  dry.  The  appetite  is  grad- 
ually lost,  but  often  drinks  are  taken  with  apparent  relish,  even  when  there  is 
no  other  evidence  of  consciousness.  There  are  two  symptoms  pertaining  to 
the  digestive  system  which  are  rarely  absent,  and  which  possess  great  diag- 
nostic value  ;  one  is  vomiting,  the  other  constipation.  In  some  patients  irri- 
tability of  stomach  begins  at  so  early  a  period  that  it  is  really  prodromic ; 
it  is  rarely  absent.  Barrier  collected  the  records  of  80  patients  with  men- 
ingitis, and  in  75  of  these  this  symptom  was  present.  It  is  due  to  the 
intimate  relation  existing  between  the  stomach  and  brain  through  the  gan- 
glionic system  of  nerves.  The  vomiting  occurs  without  effort,  and  usually 
at  intervals  for  several  days.  It  is  a  sudden  ejection  of  the  contents  of 
the  stomach,  apparently  without  preceding  or  subsequent  nausea.  It  con- 
trasts, therefore,  with  the  vomiting  due  to  an  emetic,  which  is  attended  by 
distressing  symptoms.  With  some  it  occurs  frequently,  with  others  not  more 
than  two  or  three  times  daily.  Commencing  in  the  first  stages  of  meningitis 
or  even  prior  to  it,  it  occurs  less  often  as  the  drowsiness  becomes  more  pro- 
found, and  finally  ceases.  Constipation  is  also  present,  usually  from  the 
commencement  of  the  meningitis.  It  is  one  of  the  most  constant  and  per- 
sistent symptoms,  continuing  through  the  entire  sickness,  unless  relieved  by 
medicine  or  unless  there  be  a  coexisting  diarrhceal  affection.  Often,  when 
diarrhoea  precedes  the  meningitis,  it  ceases  the  moment  the  latter  commences. 
The  constipation  in  this  disease  is  easily  overcome  by  purgatives.  Several 
writers  speak  of  retraction  of  the  abdomen  as  a  sign  of  meningitis.  A  hol- 
low or  sunken  appearance  of  the  abdomen,  according  to  Golis,  aids  in  distin- 
guishing meningitis  from  fever.  The  anterior  abdominal  wall  approaches  the 
spine,  so  that  the  pulsations  of  the  abdominal  aorta  are  distinctly  felt.  Ril- 
liet  and  Barthez,  who  have  rarely  observed  this  retraction  except  in  cerebral 
diseases,  attribute  it  to  the  state  of  the  intestines  rather  than  to  the  action 
of  the  abdominal  muscles. 


560  MENINGITIS. 

The  pulse  in  the  first  stages  of  meningitis  is  accelerated,  or  it  is  nearly- 
natural  during  certain  hours  and  afterward  accelerated.  When  the  disease 
has  continued  a  few  days,  often  not  more  than  three  or  four,  the  pulse  under- 
goes a  marked  change.  It  becomes  slower  and  at  the  same  time  irregular. 
The  irregularity  usually  consists  in  an  intermittence  of  the  pulse  after  each 
six  or  eight  beats.  Sometimes  the  force  of  the  pulse  varies,  so  that  a  feeble 
pulsation  is  succeeded  by  one  of  greater  volume  and  strength.  The  decrease 
in  the  frequency  of  the  pulse  cannot  fail  to  arrest  attention.  From  110  or  120 
beats  per  minute  in  the  first  stage  of  the  inflammation  it  often  descends  to 
a  frequency  even  less  than  that  of  the  normal  adult  pulse.  At  an  advanced 
period,  as  death  approaches,  the  pulse  again  becomes  accelerated  and  feeble. 

The  change  in  respiration  is  as  marked  as  that  of  the  pulse.  In  the 
beginning  of  meningitis  the  breathing  is  in  some  patients  moderately  acceler- 
ated ;  in  others  it  is  natural.  When  the  disease  has  continued  a  few  days,  the 
time  usually  varying  from  three  or  four  days  to  more  than  a  week,  a  marked 
alteration  occurs  in  the  respiratory  movements.  Their  rhythm,  like  that  of  the 
pulse,  is  changed.  The  breathing  is  irregular,  intermittent,  and  accompanied 
by  sighs.  The  change  in  pulse  and  respiration  corresponds  with  the  loss  of 
consciousness,  and  shows  that  the  brain  is  becoming  seriously  involved. 

,  When  the  pulse  and  respiration  undergo  the  changes  which  have  been 
described,  another  prominent  and  grave  cerebral  symptom  is  sometimes  pres- 
ent— to  wit,  convulsions.  Its  occurrence  diminishes  greatly  the  prospect  of  a 
favorable  issue.  The  severity  and  extent  of  the  convulsive  movements  vary 
in  different  cases.  They  may  be  partial  or  general.  Their  duration  is  often 
brief,  but  they  recur  three  or  four  times  through  the  day.  They  are  pre- 
ceded by  cephalalgia  in  those  old  enough  to  express  their  sensations,  and 
often  by  drowsiness.  Each  convulsive  attack  ends  in  still  greater  drow- 
siness. 

With  this  group  of  symptoms  another  should  be  mentioned.  I  refer  to 
the  hydrocephalic  cry.  At  intervals  the  patient,  without  being  disturbed 
and  without  any  change  in  symptoms,  utters  a  scream  or  sharp  cry,  and 
immediately  relapses  into  his  former  state.  This  cry  is  more  common  in  the 
commencement  of  the  meningitis  than  subsequently,  and  in  many  it  is  absent 
or  is  not  a  marked  symptom.  The  glandular  system  participates  in  the  gen- 
eral loss  or  derangement  of  function.  Tears  are  seldom  shed  even  when  the 
child  is  much  irritated,  and  the  urinary  secretion  is  diminished.  The  small 
amount  of  urine  passed  sustains  an  important  relation  to  the  progress  of  the 
disease  and  the  therapeutics. 

The  patient  usually  lingers  several  days  after  the  pulse  and  respiration 
are  changed  in  the  manner  stated.  The  drowsiness  becomes  more  profound, 
the  vomiting  ceases  as  well  as  the  convulsive  attacks,  and  sensation  and  con- 
sciousness are  entirely  lost.  But  even  in  this  state,  if  nutriment  and  stimu- 
lants be  administered  with  regularity,  the  child  often  lives  several  days  longer 
than  appeared  possible.  At  length  increasing  feebleness  and  rapidity  of 
pulse  and  coldness  of  the  face  and  limbs  indicate  the  near  approach  of  death, 
which  occurs  in  a  state  of  coma. 

The  symptoms  described  above  are  such  as  we  observe  in  ordinary 
cases  of  meningitis  and  in  the  order  which  I  have  indicated.  But  he  will 
be  disappointed  who  expects  that  the  above  description  will  apply  to  all 
cases. 

Meningitis  may  be  so  violent  and  rapid  that  both  the  character  and  suc- 
cession of  symptoms  are  diff"erent  from  those  which  have  been  stated.  Thus, 
I  have  related  the  case  of  a  girl  who,  with  no  prodromic  symptoms  excepting 
occasional  dizziness  and  slight  headache,  was  taken  sick  on  Thursday,  had 
convulsions  on  Friday,  and  from  this  time  continued  either  in  convulsions  or 


SYMPTOMS.  561 

coma  till  her  death  on  Monday.  Again,  even  in  cases  of  the  usual  duration 
and  anatomical  character  some  of  the  most  prominent  symptoms  upon  which 
we  rely  for  diagnosis  may  he  lacking.     The  following  was  a  case  of  this  kind : 

Ca.se. — On  the  Sth  of  April,  18G2,  I  was  asked  to  see  a  boy  two  yeans  and 
eight  months  old,  of  liealtli'y  parentage,  who  during  the  preceding  year  had 
been  in  uniform  good  health,  but  ])reviously  had  had  two  or  three  .severe  attacks 
of  sickness.  His  head  was  unusually  large,  and  whenever  much  indisposed  he 
often  had  symptoms  premonitory  of  convulsions,  which  were  always,  however, 
j)rev('iit('d. 

One  night  in  the  latter  part  of  jNIarch  his  parents  noticed  that  his  sleep  was 
restless,  but  on  the  following  day  he  seemed  entirely  well,  and  the  restlessness  at 
night  was  attributed  to  a  late  and  hearty  supper.  On  succeeding  nights,  how- 
ever, he  was  restless,  and  when  questioned  complained  of  pain  in  the  abdomen. 
In  a  few  days  he  was  observed  to  be  drooping  in  the  day-time,  and  his  appetite 
was  not  quite  so  good  as  previously.  He  had  continued  in  this  way  about  a  week 
when  my  first  visit  was  made. 

The  abdominal  pain  had  at  this  time  become  more  constant,  but  was  never 
severe  or  accompanied  by  moaning.  When  asked  where  he  felt  sick,  he  placed 
his  hand  upon  the  epigastrium,  pressure  upon  which  was  sometimes  tolerated, 
but  at  other  times  painful.  The  following  symptoms  were  noted  :  tongue  slightly 
furred,  anorexia,  thirst,  constipation,  scantiness  of  urine,  no  headache  or  unusual 
heat  of  head  during  any  part  of  his  sickness.  He  vomited  at  intervals  from 
about  the  7th  to  the  10th  of  April,  when  the  irritability  of  stomach  ceased  and 
there  was  no  return  of  this  symptom. 

About  April  7th  the  respiration  was  first  observed  to  be  irregular  and  sighing 
and  the  pulse  intermittent.  These  symptoms,  so  tardily  developed,  were  the 
first  which  indicated  cerebral  disease.  He  now  lay  most  of  the  time  in  bed  with 
eyes  closed,  surface  commonly  pallid,  with  occasional  rose-colored  spots  or  patches 
upon  the  cheek  or  forehead.  The  pupils  responded  to  light  in  the  usual  manner 
till  near  the  close  of  life,  but  bright  lights  were  painful;  the  last  two  or  three 
days  of  his  life  the  left  pupil  was  more  dilated  than  the  right.  He  had  no  con- 
vulsions or  any  spasmodic  movement,  and  was  conscious  till  within  a  few  hours 
of  death  :  the  mother  states  that  there  was  unequivocal  evidence  of  his  recogni- 
tion of  her  on  the  last  day  of  his  life.  He  died  April  17th,  nearly  three  weeks 
after  the  commencement  of  the  disease  and  ten  days  after  the  commencement  of 
symptoms  which  were  clearly  referable  to  the  brain. 

Autopsy. — Abdominal  organs  healthy,  though  epigastric  pain  had  been  so 
constant  and  prominent  a  symptom  ;  brain  and  its  membrane  somewhat  injected. 
The  meninges  covering  the  base  of  the  brain  from  the  most  prominent  part  of 
the  pons  Varolii  to  the  first  pair  of  nerves  presented  evidences  of  inflammation. 
There  was  such  opacity  of  the  pia  mater  in  places  as  to  conceal  the  brain  from 
view.  The  anterior  and  middle  lobes  of  each  hemisphere  were  glued  together 
by  fibrinous  exudation,  and  on  the  left  side,  along  the  fissure  of  Sylvius,  was  a 
thick  deposit  of  the  same  character.  The  lateral  ventricles  contained  about  an 
ounce  of  clear  serum,  and  about  half  an  ounce  escaped  from  the  base  of  the 
brain.  The  foramen  of  Monro  was  considerably  enlarged,  and  the  brain-sub- 
stance surrounding  the  lateral  ventricles  was  softened. 

In  this  case  it  is  seen  that  the  prominent  symptoms — and.  indeed,  almost 
the  only  marked  symptom  in  the  first  stages  of  the  disease — was  pain  in  the 
abdomen,  and  yet  the  abdominal  organs  were  healthy.  At  the  very  moment 
when  it  was  highly  important  that  a  correct  diagnosis  should  be  made  the 
evidences  of  cerebral  disease  were  lacking.  This  case  is  therefore  interesting 
on  account  of  the  variation  in  symptoms  from  those  in  the  usual  form  of 
meningitis.  There  were  no  convulsions,  and  consciousness  was  retained,  as 
well  as  vision,  till  near  the  close  of  life,  and  yet  the  lesions  were  such  as  are 
commonly  present  in  meningeal  inflammation.  It  is  in  such  cases  that  a 
wrong  diagnosis  is  frequently  made,  to  the  injury  of  the  patient  and  the 
reputation  of  the  physician. 

Occasionally  meningitis  may  continue  so  long  as  almost  to  justify  its 
36 


562  MENINGITIS. 

being  called  clironic,  even  when  there  is  a  large  amount  of  exudation  upon 
the  pia  mater.  In  the  few  cases  which  end  favorably  the  symptoms  abate 
gradually.  I  shall  describe  more  fully  the  termination  in  speaking  of  Prog- 
nosis. 

Diagnosis. — It  is  of  the  utmost  importance  to  diagnosticate  meningitis 
in  its  first  stages,  since  treatment  to  be  successful  must  be  commenced 
early.  Certain  writers  describe  at  length  the  means  of  diagnosticating  the 
simple  from  the  tubercular  form  of  the  inflammation.  DiflFerential  diagnosis 
is  often  difiicult,  and  sometimes  impossible ;  but  it  matters  little,  practically, 
whether  the  form  of  the  disease  be  ascertained.  On  the  other  hand,  it  is 
very  important,  in  order  that  the  treatment  be  appropriate,  to  diagnosticate 
the  premonitory  or  initial  stage  of  meningitis  from  certain  other  aff"ections 
not  located  within  the  cranium.  Sometimes  remittent  or  continued  fever  or 
constitutional  disturbances  arising  from  irritation  in  the  digestive  system 
simulate  closely  incipient  meningeal  disease,  so  that  the  greatest  care  and  dis- 
crimination are  required  in  order  to  make  a  correct  diagnosis.  Within  a  com- 
paratively recent  period  I  have  known  in  three  different  instances  experienced 
physicians  of  this  city  to  mistake  commencing  meningitis  for  fevers,  not 
aware  of  the  serious  error  they  had  made  till  the  inflammation  had  reached  a 
stage  from  which  recovery  was  impossible.  In  order  to  avoid  error  in  the 
diagnosis  in  the  premonitory  or  initial  stage  of  meningitis,  the  physician 
should  take  time  to  observe  the  physiognomy  and  note  every  symptom. 
More  than  one  protracted  visit  is  often  required  to  remove  doubt  as  to  the 
exact  pathological  state. 

Meningitis  is  usually  preceded,  and  in  its  commencement  accompanied, 
by  greater  restlessness,  fretfulness,  intolerance  of  light,  and  a  greater  varia- 
tion of  symptoms,  than  most  other  maladies.  One  familiar  with  the  physiog- 
nomy of  infancy  and  childhood  will  discover  in  the  features  indication  of 
greater  sufi'ering,  of  more  serious  sickness,  than  is  commonly  present  in  other 
maladies  which  simulate  this. 

Sometimes  the  sudden  disappearance  of  a  chronic  eruption  upon  the  scalp 
will  aid  in  the  diagnosis.  This  is  a  sign  of  importance,  taken  in  connection 
with  the  symptoms.  Headache  and  vomiting,  symptoms  of  early  occurrence, 
should  especially  arrest  attention,  or  in  absence  of  headache  pain  of  a  neur- 
algic character  in  some  other  part.  But  we  may  repeat  that  familiarity 
with  the  symptoms  of  meningitis  will  not  protect  from  error  if  the  visits  of 
the  physician  are  hasty  and  his  examinations  imperfect.  When  the  eyes 
become  affected,  the  respiration  and  circulation  irregular,  and  especially  when 
convulsive  attacks  begin,  diagnosis  is  easy.  In  fact,  an  incorrect  diagnosis 
would  then  be  unpardonable ;  but,  unfortunately,  if  proper  treatment  have 
not  been  commenced  till  this  period  it  will  be  of  little  service. 

Prognosis. — Meningitis  is  one  of  the  most  fatal  maladies  of  early  life. 
Whether  the  form  be  tubercular  or  not,  if  the  initial  stage  have  passed  with- 
out proper  treatment  death  may  be  considered  inevitable.  Tubercular  men- 
ingitis, however  early  recognized,  is  rarely  amenable  to  treatment.  M.  G-uer- 
sant^  believes  that  recovery  from  the  first  stage  of  this  form  of  meningitis 
is  possible.  "  In  the  second  stage,"  says  he,  "  I  have  not  seen  one  child 
recover  out  of  a  hundred,  and  even  those  who  seemed  to  have  recovered 
have  either  sunk  afterward  under  a  return  of  the  same  disease  in  its  acute 
form  or  have  died  of  phthisis.  As  to  patients  in  whom  the  disease  has 
reached  its  third,  I  have  never  seen  them  improve  even  for  a  moment." 
The  very  few  reported  cases  which  resulted  favorably  may  have  been,  as 
M.  Guersant  has  intimated  in  the  context,  cases  of  the  non-tubercular 
form.     Rilliet  and  Barthez  believe  that  in  a  few  instances  tubercular  men- 

^  Diet,  med.,  t.  xix.  p.  403. 


TREATMENT.  563 

ingitis  has  been  cured  in  its  first  stage,  but  they  state  also  that  it  is  apt  to 
return 

The  prognosis  in  non-tubercular  meningitis  is  not  so  unfavorable,  pro- 
vided that  treatment  be  commenced  at  a  sufficiently  early  period.  It  is  now 
generally  admitted  that  it  may  not  infrequently  be  averted  when  threatening, 
and  even  arrested  in  its  incipiency.  In  many  such  cases  we  cannot,  from  the 
nature  of  the  disease,  be  certain  that  the  diagnosis  is  correct.  But  when  we 
see  children  relieved  who  present  precisely  those  premonitory  and  even  initial 
symptoms  which  occur  in  meningitis,  we  must  believe  that  at  least  some  of 
them  would  have  had  the  genuine  disease  if  not  relieved  by  the  measures 
employed.  That  in  its  commencement  recovery  is  possible  from  non-tuber- 
cular meningitis  is  also  obvious  from  the  fact  that  a  few  recover  even  in  the 
second  stage,  when   there  can  be  no  error  of  diagnosis. 

Although  a  considerable  proportion  of  patients  with  epidemic  cerebro- 
spinal meningitis  recover,  even  when  the  symptoms  have  been  most  grave, 
I  have  known  only  two  recoveries  from  sporadic  meningitis  when  it  had 
reached  that  stage  in  which  the  functions  of  the  brain  and  cranial  nerves 
were  impaired.  One  of  these  recovered  with  permanent  loss  of  sight,  the 
other  with  loss  of  hearing.  Both  seem  to  have  ordinary  intelligence. 
Another  case  has  been  communicated  to  me  in  which  the  patient,  a  little 
child,  recovered  completely,  but  for  several  months  after  the  attack  seemed 
nearly  idiotic. 

Sometimes,  even  in  the  second  stage  of  meningitis,  treatment  properly 
employed  is  attended  by  amelioration  of  symptoms.  Though  such  improve- 
ment may  serve  to  encourage  physician  and  friends,  it  should  not  be  the  basis 
for  a  favorable  prognosis  unless  it  continue  three  or  four  days. 

Apparent  improvement  during  a  few  hours  or  a  considerable  part  of  a 
day  is  not  unusual  in  those  who  finally  die.  Thus,  in  an  infant  whose  bow- 
els were  previously  confined  I  have  known  the  pulse  and  respiration  to  become 
more  regular  and  the  symptoms  generally  improve,  though  only  for  a  brief 
period,  by  the  action  of  a  purgative.  Dr.  Watson  says  of  the  advanced 
stage  of  this  disease,  it  is  "  often  attended  with  remissions,  sometimes  sud- 
den and  sometimes  gradual — deceitful  appearances  of  convalescence.  The 
child  regains  the  use  of  its  senses,  recognizes  those  about  it  again,  appears 
to  its  anxious  parents  to  be  recovering,  but  in  a  day  or  two  it  relapses  into 
a  state  of  deeper  coma  than  before.  And  these  fallacious  symptoms  of 
improvement   may  occur   more   than   once." 

Most  fatal  cases  of  meningitis  terminate  between  the  third  or  fourth  and 
the  twentieth  day,  the  duration  varying  according  to  the  extent  and  intensity 
of  the  inflammation  and  the  vigor  and  age  of  the  patient.  But  there  are 
cases  in  which  it  may  continue  much  longer.  It  is  surprising  sometimes 
how  long  the  patient  lives  when  the  symptoms  are  such  that  death  seems 
impending.  Sensation  and  consciousness  may  be  extinguished,  convulsions 
occur  at  intervals,  and  the  surface  have  acquired  almost  a  cadaveric  aspect, 
and  yet  the  patient  lives  on.  Rilliet  and  Barthez  say :  "  Often  have  we 
inscribed  upon  our  notes  death  imminent,  and  been  astonished  the  next  day 
to  find  still  alive  children  to  whom  we  had  scarcely  allowed  two  hours  of 
life."  The  symptom  which  I  have  found  to  be  the  most  reliable  prognostic 
of  the  near  approach  of  death  has  been  a  pulse  gradually  becoming  more 
frequent  and  feeble,  though  other  symptoms  remain  as  before.  This  change 
in  the  pulse  is  usually  very  apparent  durins;  the  last  twenty -four  hours  of 
life. 

Treatment. — Such  remedial  measures  should  be  prescribed  during  the 
premonitory  stage  as  are  calculated  to  relieve  the  fretfulness  or  irritability  of 
temper  and  quiet  the  action  of  the  brain,  and  at  the  same  time  produce  a 


564  MENINGITIS. 

derivative  effect  from  this  organ.  To  this  end  the  patient  should  be  kept 
from  all  causes  of  excitement,  and  the  bowels  should  be  opened  daily — if  not 
naturally,  by  the  use  of  proper  medicines.  A  mustard  foot-bath  at  night  and 
occasionally  through  the  day  is  useful,  as  it  produces  both  a  derivative  and 
soothing  effect.  It  will  commonly  produce  a  few  hours'  undisturbed  rest, 
while  other  measures  except  medicines  fail.  If  dentition  be  taking  place  and 
the  gums  are  swollen,  it  has  been  the  practice  to  employ  the  gum  lancet, 
and  still  is  with  some  physicians,  but  I  for  one  have  discarded  its  use  for 
this  purpose.  Restlessness  from  dentition  or  restlessness  premonitory  of 
meningitis  requires  large  doses  of  bromide  of  potassium,  which  will  relieve 
the  symptoms  more  effectually  than  the  lancet.  Three  grains  should  be 
given  to  a  child  of  six  months,  and  four  grains  to  one  of  ten  or  twelve 
months,  and  repeated  if  necessary  in  two  to  four  hours.  If  symptoms  indi- 
cate the  near  approach  of  meningitis  or  its  incipiency,  the  head  should  be 
kept  constantly  cool  by  a  cloth  wrung  out  of  ice-water — or,  better,  an  India- 
rubber  bag  containing  ice.  Some  physicians  have  recommended  vesication 
back  of  the  neck  or  ears,  but  it  is  a  measure  of  doubtful  benefit,  and  if 
employed  at  all  should  be  restricted  to  the  application  of  cantharidal  collodion 
behind  the  ears. 

Many  children  who  are  threatened  with  meningitis  are  scrofulous.  They 
have  already  shown  symptoms  of  tubercular  disease.  They  are  perhaps,  to 
a  certain  extent,  emaciated,  and  may  have  been  affected  with  a  cough.  If 
the  premonitory  symptoms  in  children  indicate  the  approach  of  the  tuber- 
cular form  of  meningitis,  a  more  sustaining  course  of  treatment  is  re- 
quired than  in  those  who  are  robust.  To  such  children  cod-liver  oil  may 
be  profitably  given  three  times  daily,  together  with  the  syrup  of  the  iodide 
of  iron  and  perhaps  the  bromide.  They  should  also  be  taken  into  the  open 
air  with  proper  precautions,  and  every  hygienic  measure  should  be  employed 
which  will  be  likely  to  invigorate  the  system  without  exciting  the  brain. 

Loss  of  blood  is  not,  in  general,  required  during  the  prodromic  period  nor 
in  the  disease.  Those  of  a  strumous  cachexia,  or  those,  whether  strumous  or 
not,  who  are  under  the  age  of  two  years,  do  not,  unless  in  very  rare  instances, 
require  depletion  by  leeches,  much  less  by  venesection.  There  is  one  class 
of  patients  in  whom  the  early  loss  of  blood  may  perhaps  be  of  service — 
namely,  those  who  in  a  state  of  robust  health  are  suddenly  seized  with 
inflammation,  especially  if  the  cause  be  insolation.  Leeches  may  then  be 
applied  to  the  head  of  the  patient  if  he  be  seen  at  an  early  period,  but  the 
majority  of  physicians  probably  wisely  recommend  the  ice-bag  in  preference 
to  leeching. 

Often,  notwithstanding  the  measures  employed,  the  patient  grows  worse ; 
the  symptoms  become  more  continuous,  others  more  alarming  arise,  and 
meningitis  declares  itself.  Whatever  the  cause  of  the  inflammation,  and 
whatever  modifications  of  treatment  were  required  in  the  premonitory  stage 
on  account  of  special  indications,  the  purpose  now  is  to  subdue  the  inflam- 
mation by  every  resource  in  our  art  which  does  not  injure  or  too  much  pros- 
trate the  system.  In  former  days  calomel  was  largely  employed  as  the  main 
remedy  in  this  disease,  but  when  administered  daily  it  has  a  very  depressing 
effect,  and  it  is  to  be  borne  in  mind  that  in  meningitis  the  vital  powers  pro- 
gressively fail  on  account  of  the  loss  of  appetite,  vomiting,  etc.  In  tuber- 
cular meningitis  depressing  treatment  is  of  course  strongly  contraindicated. 
erases  have  occurred  in  which  calomel  was  given  at  short  intervals  for 
several  successive  days,  so  as  to  produce  a  laxative  effect,  but,  though  the 
meningitis  seemed  to  be  controlled,  death  resulted  from  exhaustion  or  from 
some  intercurrent  affection  due  to  exhaustion.  Thus  in  one  case  for- 
merly related    to  his    class  by  a    distinguished    New  York    professor   fatal 


TREATMENT.  565 

gangrene  of  the  mouth  supervened  IVom  the  mercurial  treatment  after  the 
meningeal  inflammation  had  apparently  subsided.  Although  calomel  during 
these  last  years  has  been  properly  discarded  as  the  main  remedy  and  its  daily 
use  rejected,  nevertheless  it  is  very  useful  as  an  occasional  laxative  in  the 
more  robust  cases  if  not  given  too  near  the  iodide  of  potassium,  and  it  is 
especially  indicated  as  a  derivative  from  the  head  in  children  of  four  or  five 
years  who,  previously  hearty  and  strong,  have  become  suddenly  aifected  with 
meningitis,  as  from  exposure  to  the  sun's  rays  or  from  an  injury.  But  I 
repeat  the  belief  that  in  ordinary  ca.ses  calomel  should  never  be  employed, 
except  as  an  occasional  laxative. 

The  two  remedies  upon  which  we  must  chiefl}'  rely  are  the  iodide  of 
potassium  and  the  bromide  of  potassium  or  sodium.  While  the  bromide 
quiets  the  restlessness,  prevents  convulsions,  and  diminishes,  there  is  reason 
to  think,  to  a  certain  extent,  the  hypertemia,  the  iodide  is  useful  as  a  sorbe- 
facient,  and  it  probably  has  some  control  over  the  inflammation.  The  iodide 
or  bromide  can  be  given  together  or  separately. 

The  iodide  .should,  like  the  bromide,  be  given  early.  If  by  a  careful 
examination  the  absence  of  any  other  local  disease  or  constitutional  disease 
which  might  give  rise  to  the  symptoms  be  ascertained,  and  the  symptoms 
indicate  the  meningeal  disease,  the  iodide  should  be  immediately  prescribed. 
Obscurity  often  hangs  over  meningitis  at  this  early  stage,  but  it  is  better  to 
give  the  iodide,  even  if  the  diagnosis  be  wrong  and  no  inflammation  have 
commenced,  than  to  err  on  the  other  side,  and  withhold  it  in  the  initial  period 
of  the  true  disease  ;  for  it  is  not  an  injurious  remedy  like  calomel,  and  to 
exert  any  marked  effect  it  should  be  given  in  the  commencement  of  the 
inflammation.  An  infant  of  the  age  of  six  to  twelve  months  should  take 
two  grains  every  two  hours,  and  older  children  a  proportionate  dose.  At  the 
same  time  the  bromide  should  be  given  in  doses  twice  as  large  as  that  of  the 
iodide  if  the  indications  for  its  use  are  present — to  wit,  headache,  restless- 
ness, and  symptoms  which  threaten  eclampsia.  The  bromide  is  a  harmless 
remedy  given  frequently  for  a  limited  time.  With  the  regular  and  continued 
use  of  the  iodide  and  occasional  doses  of  bromide  the  quantity  of  urine  is  in 
most  cases  largely  increased.  If  the  patient's  condition  do  not  soon  begin  to 
improve  with  such  treatment,  there  is  no  remedy. 

If  convulsions  occur,  the  bromide  should  be  given  every  ten  or  fifteen 
minutes  till  they  cease.  If  they  be  not  controlled  by  the  bromide,  an  injec- 
tion, per  rectum,  of  three  to  five  grains  of  hydrate  of  chloral  in  a  teaspoonful 
of  water  should  be  used  in  addition.  Compresses  wrung  out  of  ice-water 
fre((uently  applied  to  the  head,  or  a  bladder  containing  pounded  ice  and  sep- 
arated by  one  thickness  of  muslin  from  the  head,  materially  aid  in  reducing 
the  meningeal  hyperjemia.  Ergot,  recommended  by  Brown-Sequard  for  its 
supposed  effect  in  diminishing  the  hypei'aemia  in  the  inflammatory  diseases 
of  the  nervous  centres,  may  also  be  employed  as  an  adjuvant  in  the  treat- 
ment of  this  disease. 

In  the  first  stage  of  simple  meningitis  the  diet  should  be  mild  and  in 
moderate  quantity,  but  in  the  tubercular  form  it  should  from  the  first  be  of 
the  most  nourishing  kind,  consisting  of  beef  tea,  milk  porridge,  etc.  At  a 
more  advanced  stage  in  both  forms  of  the  malady  the  most  nutritious  diet 
should  be  allowed,  but  alcoholic  stimulants  should  not  be  given  unless  near 
the  close  of  life,  when  the  vital  powers  are  failing.  The  apartment  should 
be  cool  and  quiet. 


566  SPURIOUS  HYDROCEPHALUS. 


CHAPTER  IX. 

SPUMOUS  HYDKOCEPHALUS. 

The  disease  known  as  spurious  hydrocephalus  might  with  more  propriety 
be  called  spurious  meningitis.  It  received  its  appellation  at  the  time  when 
meningitis  of  early  life  was  believed  to  be  essentially  a  hydrocephalus,  and 
was  so  called.  Attention  was  first  directed  to  it  by  London  physicians  of  the 
last  generation,  particularly  by  Drs.  Gooch,  Abercrombie,  and  Marshall  Hall, 
and  little  can  be  added  to  their  description  of  its  symptoms. 

Anatomical  Characters. — This  disease,  though  resembling  meningitis 
in  certain  of  its  phenomena,  is  not  in  its  nature  inflammatory,  nor  is  it 
primary.  It  is  the  result  of  some  malady  often  chronic,  but  occasionally 
acute,  which  has  produced  exhaustion,  especially  of  the  nervous  system. 
When  it  commences  there  is  usually  more  or  less  emaciation  and  the  symp- 
toms of  the  primary  disease  are  present.  To  this  disease  the  lesions  pertain 
which  are  found  in  other  organs  besides  the  brain. 

The  state  of  the  brain  in  spurious  hydrocephalus  is  not  the  same  in  all 
cases.  In  some  there  is  no  appreciable  anatomical  alteration  in  this  organ. 
There  is  no  apparent  difference,  either  in  the  meninges  or  the  brain  itself, 
from  the  condition  which  we  often  observe  in  those  who  have  died  of  diseases 
which  do  not  affect  the  cerebro-spinal  system.  In  such  cases  the  pathological 
state  is  simply  deficient  innervation,  or  if  there  be  a  structural  change  in  the 
minute  anatomy  of  the  brain,  pathologists  have  not  yet  discovered  it. 

The  following  case,  which  occurred  in  the  Child's  Hospital  of  this  city,  is 
an  example  of  this  form  of  spurious  hydrocephalus : 

Case. — A  female  infant,  six  months  old,  died  on  the  24th  day  of  April,  1862, 
with  the  following  history :  It  was  wet-nursed,  fleshy,  and  apparently  well  till 
six  days  before  death,  when  symptoms  of  gastro-intestinal  inflammation  were 
suddenly  developed.  The  vomiting  especially  was  severe,  continuing  forty-eight 
hours.  When  it  ceased  drowsiness  supervened  and  continued  till  the  close  of 
life.  The  face  during  the  four  days  of  stupor  was  pallid  and  cool ;  eyes  partly 
open,  pupils  sluggish,  but  of  equal  size ;  bowels  rather  torpid ;  anterior  fontanel 
depressed.  When  aroused  the  infant  noticed  objects  for  a  moment,  and  imme- 
diately relapsed  into  sleep ;  pulse  accelerated  and  not  intermittent,  the  day  before 
death  numbering  150  ;  respiration  accelerated,  without  sighing,  numbering  on  the 
same  day  30.  There  were  no  convulsions,  and  death  occurred  quietly.  The  brain 
weighed  twenty  and  a  half  ounces,  and  its  appearance  was  perfectly  healthy, 
both  as  regards  consistence  and  vascularity.  The  amount  of  cerebro-spinal  fluid 
in  the  ventricles  and  at  the  base  of  the  brain  was  not  notably  increased.  The 
stomach,  small  and  large  intestines,  were  vascular  in  streaks  and  patches. 

In  this  case  the  cerebral  symptoms  were  obviously  due  to  exhaustion 
occurring  at  an  early  period  in  consequence  of  the  severity  of  the  gastro- 
intestinal malady. 

In  a  majority  of  cases,  however,  of  spurious  hydrocephalus,  according  to 
my  observation,  there  is  an  anatomical  alteration  in  the  state  of  the  brain  and 
meninges.  This  consists  in  passive  congestion  of  the  veins,  often  with  tran- 
sudation of  serum.  At  the  same  time,  the  cranial  sinuses  are  congested,  and 
are  found  at  the  post-mortem  examination  to  contain  larger  and  more  numerous 
clots  than  are  present  in  those  who  die  of  diseases  which  do  not  affect  the 
encephalon.     Cases  might  be   cited  as  examples.     The  cause  of  this  con- 


SYMPTOMS.  567 

gestion  and  effusion  is  in  great  measure  feebleness  of  the  circulation  due  to 
the  general  exhaustion  of  the  patient.  But  there  is  another  cause.  In  pro- 
tracted diseases,  especially  those  of  a  diarrhoeal  character,  there  is  more  or 
less  wasting  of  the  brain  as  well  as  of  other  parts.  This  naturally,  by  way 
of  compensation,  gives  rise  to  congestion  of  the  cerebral  and  meningeal  veins 
and  capillaries  and  to  transudation  of  serum. 

The  transudation  commonly  occurs  in  this  malady  over  the  superior  surface 
of  the  brain  and  in  the  subarachnoidal  space,  perhaps  also  more  or  less  in  the 
lateral  ventricles.  So  common  is  it  in  the  last  stage  of  infantile  entero-colitis, 
the  summer  epidemic  of  cities,  that  this  stage,  which  is  really  spurious  hydro- 
cephalus, has  been  called  the  stage  of  effusion.  I  shall  relate  in  another 
place  examples  which  show  the  anatomical  characters  of  this  intestinal 
disease. 

Symptoms. — Spurious  hydrocephalus  most  frequently  results  from  pro- 
tracted diarrhoeal  complaints.  It  may,  however,  result  from  any  disease 
which  is  attended  by  great  prostration.  As  it  ordinarily  occurs,  the  patient 
has  for  days  or  weeks  been  gradually  losing  flesh  and  strength.  Finally, 
drowsiness  supervenes,  or  before  the  drowsiness  there  is  sometimes  a  period 
of  irritability. 

Marshall  Hall  describes  two  stages  of  spurious  hydrocephalus.  In  the 
first,  he  says,  "  the  infant  becomes  irritable,  restless,  and  feverish  ;  the  face 
flushed,  the  surface  hot,  and  the  pulse  frequent ;  there  is  an  undue  sensitive- 
ness of  the  nerves  of  feeling,  and  the  little  patient  starts  on  being  touched 
or  from  any  sudden  noise ;  there  are  sighing  and  moaning  during  sleep,  and 
screaming ;  the  bowels  are  flatulent  and  loose  and  the  evacuations  are  mu- 
cous and  disordered."  The  second  stage  he  describes  as  that  of  torpor.  The 
first  stage  often,  however,  does  not  present  those  prominent  symptoms  which 
have  been  described  by  Dr.  Hall,  and  this  stage  may  even  be  absent  or  not 
appreciable,  especially  in  young  infants. 

Whether  or  not  commencing  with  the  stage  of  irritability,  the  disease, 
if  not  checked,  gradually  increases.  The  child  soon  becomes  drowsy.  He 
may  be  aroused  for  a  moment,  but  unless  constantly  disturbed  immediately 
relapses  into  sleep.  He  is  sometimes  fretful  when  aroused,  but  in  other 
instances  is  quite  indifferent,  observing  without  apparent  interest  objects 
employed  for  the  purpose  of  amusing  him.  Often  there  are  indications  of 
cerebral  pain  or  distress,  as  contraction  of  the  eyebrows,  etc.,  but  many  of  those 
affected  are  too  young  to  make  known  their  sensations.  Convulsions  some- 
times occur  toward  the  close  of  life,  but  they  are  not  so  common  in  this  dis- 
ease as  in  meningitis.  When  they  do  occur  they  are  generally  partial  and 
often  slight.  The  pulse  is  accelerated  in  most  patients  prior  to  and  in  the 
commencement  of  spurious  hydrocephalus.  As  the  disease  advances  it 
becomes  irregular  and  intermittent,  and  toward  the  close  of  life  it  is  progress- 
ively more  frequent  and  feeble.  The  respiration  at  first  is  not  much  dis- 
turbed, but  at  length  it  becomes  irregular,  like  the  pulse.  It  is  feeble  and 
accompanied  by  sighs.  Occasionally,  there  is  slight  cough.  The  e3'elids  are 
partly  open,  the  pupils  no  longer  respond  to  light,  and  in  advanced  cases 
they  have  a  bleared  appearance.  The  diarrhoea,  which  in  most  instances 
precedes  and  causes  this  malady,  continues  till  the  stage  of  stupor  arrives, 
when  the  evacuations  become  less  frequent  or  cease  altogether.  In  infants 
the  stools  are  frequently  green,  in  older  children  brown  and  sometimes  slimy. 
The  febrile  heat  of  surface  which  preceded  the  disease,  and  which  was  pres- 
ent in  its  commencement,  disappears ;  the  face  and  hands  become  cool,  the 
features  pallid,  and  the  anterior  fontanel,  if  open,  is  depressed.  Death 
finally  occurs  in  a  state  of  coma,  or  if  the  disease  be  recognized  and  proper 
remedial   measures   employed  the  result  may  be  favorable,  even  when  the 


568  SPURIOUS  HYDROCEPHALUS. 

symptoms   are    such   that  if  meningeal   inflammation   were   the  malady  we 
would  consider  the  case  necessarily  fatal. 

The  following  case  is  an  example  of  spurious  meningitis  as  we  often  meet 
it  in  practice : 

Case. — On  the  13th  day  of  March,  1869,  I  was  asked  to  see  a  male  child 
twenty-two  months  old,  whose  history  was  as  follows : 

"  He  was  well  till  about  three  weeks  ago,  since  which  time  he  has  had  diar- 
rhoea, with  febrile  symptoms ;  pulse  162,  respiration  52 ;  has  a  slight  cough,  with  a 
few  mucous  rtles ;  resonance  on  percussion  of  chest  good ;  is  somewhat  emacia- 
ted, and  appears  languid ;  tongue  moist  and  slightly  furred.  Has  all  the  incisor 
and  three  anterior  molar  teeth,  and  the  gum  is  swollen  over  the  remaining  ante- 
rior molar  and  two  canine  teeth. 

"  From  the  14th  to  the  18th  there  was  no  material  alteration  in  his  symptoms, 
with  the  exception  that  the  diarrhoea  was  partially  restrained  by  Dover's  powder 
in  one-and-a-half-grain  doses.  On  these  five  days  the  stools  numbered  daily 
from  one  to  six.  The  pulse  was  uniformly  frequent,  varying  from  124  to  156, 
and  the  respiration  on  two  days,  when  its  frequency  was  ascertained,  numbered 
56  and  46. 

"March  19th,  pulse  124;  has  become  drowsy  since  yesterday,  and  when 
aroused  is  fretful.  Omit  Dover's  powder.  Treatment,  cold  applications  to  the 
head,  mustard  pediluvia. 

"  Evening  pulse,  136 ;  eyes  constantly  closed  and  head  reclining ;  surface 
generally  warm  ;  tongue  dry  and  furred ;  he  vomited  at  first,  but  has  not  in  three 
or  four  days.  Apply  cantharidal  collodion  behind  each  ear  and  continue  the 
local  treatment. 

"  20th,  pulse  130 ;  is  constantly  sleeping,  and  when  aroused  is  very  fretful 
and  soon  relapses  into  sleep;  no  unnatural  heat  of  head,  and  no  dejection  since 
yesterday.     Treatment,  a  dose  of  castor  oil,  nourishing  diet. 

"21st,  drowsiness  as  before;  cheeks  sometimes  flushed,  sometimes  pallid ; 
pupils  sensitive  to  light ;  margins  of  eyelids  covered  with  secretion.  The  bowels 
have  been  opened  by  the  oil." 

On  the  22d  and  23d  there  was  no  material  change  in  the  symptoms.  He  was 
constantly  sleeping,  except  for  a  moment  when  shaken.  More  active  stimula- 
tion was  now  employed.  Brandy  was  prescribed,  to  be  given  every  two  hours ; 
beef  tea  and  milk  porridge  frequently. 

On  the  following  day,  the  24th,  he  was  more  fretful  and  less  drowsy.  Brandy 
and  beef  tea  were  continued. 

On  the  25th,  with  the  same  treatment,  there  was  still  further  improvement ; 
drowsiness  nearly  gone  and  less  fretfulness  than  yesterday ;  rolls  the  head  occa- 
sionally and  does  not  appear  to  see  distinctly  ;  has  a  slight  cough  ;  stools  nearly 
regular ;  pulse  100 ;  respiration  natural ;  surface  warm,  and  no  unnatural  heat 
of  head.  The  same  treatment  was  continued,  and  he  rapidly  and  fully 
recovered. 

This  case  is  interesting  on  account  of  the  long  duration  of  marked  drow- 
siness, which  continued  five  days,  and  yet  the  patient  recovered  entirely  in 
the  space  of  two  or  three  days  under  the  use  of  brandy  and  beef  tea. 

In  May,  1860,  I  treated  a  similar  case.  A  child  twenty  months  old  had 
diarrhoea  for  two  weeks,  the  stools  being  of  a  dark-brown  color,  thin  and 
offensive.  He  was  at  first  very  irritable.  The  pulse  was  constantly  above 
1.30,  and  the  respiration  was  correspondingly  increased.  The  stage  of  drow- 
siness finally  supervened,  and  for  two  days  he  was  constantly  asleep  unless 
aroused  by  being  shaken.  During  the  somnolent  stage  the  pulse  numbered 
140,  respiration  36.  The  face  and  extremities  were  cool,  and  he  finally  had 
a  slight  convulsion.  By  stimulants  and  nutritious  diet  he  began  imme- 
diately to  improve,  and  was  soon  out  of  danger. 

In  the  following  case  the  result  was  unfavorable.  This  case  is  interest- 
ing on  account  of  the  anatomical  characters  of  the  disease  as  disclosed  by 
the  post-mortem  examination.     It  is  an  example  of  that  large  class  of  cases 


DIAGNOSIS— PROGNOSIS.  569 

in  which  spurious  hydrocephalus  is  associated  with  congestion  of  the  cere- 
bral vessels  and  serous  effusion.  It  is  exceptional,  however,  as  regards  the 
long  duration  of  drowsiness.  Ordinarily,  protracted  diarrhoeal  maladies 
which  end  in  passive  congestion  and  effusion  terminate  fatally  in  three  or 
four  days  after  the  drowsy  period  arrives : 

Case. — "  Dec.  13, 1861,  called  to-day  to  a  German  infant  eighteen  months  old. 
It  has  had  diarrhoea  four  weeks  without  regular  and  proper  medical  attendance ; 
stools  from  the  first  brown  and  thin ;  during  the  last  eight  or  nine  days  he  has 
been  drowsy  ;  when  aroused  opens  his  eyes  and  is  very  fretful,  but  immediately 
the  upper  eyelids  gradually  droop,  and  unless  disturbed  he  remains  asleep  with 
his  eyes  partially  open ;  forehead  warm,  face  cool  and  pallid,  and  limbs  also 
rather  cool ;  pulse  164,  respiration  32 ;  has  had  a  slight  cough  about  one  week, 
and  slight  dulness  on  percussion  over  the  left  infrascapular  region  ;  depression  of 
inframammary  region  on  inspiration.  Treatment:  Ammon.  carbonat.,  gr.  1 
every  two  hours ;  nourishing  diet. 

"  Dec.  20th,  has  continued  drowsy  since  the  last  record ;  pupils  moderately 
dilated  ;  a  thick  secretion  between  eyelids ;  right  pupil  considerably  larger  than 
the  left :  vision  apparently  lost  during  the  last  three  days ;  pulse  over  140 ; 
respiration  44  per  minute,  accompanied  by  sighing  since  the  18th  ;  moans  much 
when  awake ;  rolls  the  head  frequently ;  during  the  last  six  days  the  surface 
back  of  the  ears  has  been  constantly  sore  by  vesication ;  takes  the  most  nutritious 
diet  with  brandy.  The  stools  remain  thin  and  brown  and  number  three  or 
four  daily. 

"  From  this  date  the  diarrhoea  continued,  except  as  it  was  restrained  by  veg- 
etable astringents.  The  pulse  continued  frequent  and  a  slight  cough  remained. 
There  was  on  the  21st  and  22d  partial  abatement  of  the  drowsiness,  but  on  the 
23d  it  was  greater  than  ever.  The  body  was  somewhat  reduced  at  the  commence- 
ment of  the  cerebral  symptoms,  but  it  was  now  markedly  emaciated.  The  pros- 
tration increased  daily,  and  the  hands  were  observed  to  tremble.  The  face  and 
hands  became  more  cool,  while  the  head  was  warm.  On  the  24th  partial  con- 
vulsions occurred,  followed  by  coma  and  death. 

"  The  cerebral  veins  and  sinuses  were  generally  congested,  except  in  the 
anterior  portion  of  the  brain,  where  the  appearance  was  normal.  Between  the 
brain  and  its  membranous  covering,  chiefly  at  the  A'ertex  and  the  base,  was  an 
effusion  of  clear  serum.  The  whole  amount  of  this  fluid  was  estimated  at  two 
ounces.  On  slicing  the  brain  numerous  '  puncta  vasculosa '  were  seen,  both  in 
the  gray  and  white  portions.  With  the  exception  of  the  congestion  the  sub- 
stance of  the  brain  presented  its  normal  appearance.  No  inflammatory  lesions 
were  present.  We  were  not  permitted  to  examine  the  condition  of  the  intes- 
tines." 

Diagnosis. — The  only  disease  with  which  spurious  hydrocephalus  is 
liable  to  be  confounded  is  meningitis.  The  points  of  differential  diagnosis 
are  the  history  of  the  case,  especially  the  antecedent  diarrhoea  or  other 
exhausting  ailment,  evidence  of  prostration  when  the  cerebral  malady  com- 
menced, depression  of  the  anterior  fontanel  if  it  be  open,  and  the  cool  face 
and  extremities. 

Prognosis. — If  the  pathological  state  of  the  brain  be  simple  exhaustion, 
the  disease  can  often  be  arrested  by  judicious  treatment.  If  an  incorrect 
diagnosis  be  made  and  the  treatment  employed  be  that  appropriate  for 
meningitis,  which  it  so  closely  simulates,  death  is  almost  inevitable.  If 
transudation  of  serum  have  occurred,  unless  slight,  the  result  is  usually 
unfavorable  whatever  may  be  the  treatment.  This  disease  in  childhood  is 
more  easily  managed  than  in  infancy,  but  is  less  frequent.  The  prognosis  is 
better  in  the  cool  months  than  during  the  heat  of  summer.  It  is  more  favor- 
able if  the  child  be  over  than  if  under  the  age  of  one  year.  The  occurrence 
of  an  irregular  and  intermittent  pulse,  of  respiration  accompanied  by  sighs, 
of  inequality  in  the  pupils  or  their  sluggish  movements,  with  increasing 
stupor,   indicates  an   unfavorable  issue.     The  cure   of  the  primary  disease, 


570  ECLAMPSIA. 

with  the  pulse  and  respiration  still  natural  or  accelerated,  without  change  of 
rhythm,  pupils  sensitive  to  light,  drowsiness  from  which  the  patient  is  easily 
aroused  to  a  state  of  entire  consciousness,  render  recovery  probable  with 
proper  medication  and  alimentation. 

Treatment. — The  indications  of  treatment  are  twofold  :  first,  to  remove 
the  primary  pathological  state  which  is  the  cause  of  the  spui'ious  hydro- 
cephalus ;  and,  secondly,  to  cure  the  latter.  The  first  is  important,  since 
the  successful  treatment  of  a  disease  requires  the  removal  of  the  cause. 
The  measures  employed  for  this  purpose  are  pointed  out  in  our  description 
of  the  diarrhoeal  and  other  maladies  which  produce  spurious  hydrocephalus. 

We  may  here  say  that,  as  spurious  hydrocephalus  is  due  in  a  very  large 
proportion  of  cases  to  the  exhausting  effect  of  long-continued  diarrhoea, 
astringents,  especially  subnitrate  of  bismuth,  and  alkalies  are  required  in  a 
majority  of  cases  in  the  stage  of  irritability,  and  sometimes  also  opiates. 

Active  sustaining  measures  are  indicated.  Exhausted  nervous  power, 
as  well  as  passive  cerebral  congestion,  requires  these.  The  diet  should  be 
highly  nutritious,  comprising  such  substances  as  milk  and  beef  juice,  and 
should  be  given  frequently.  Brandy  is  required  at  short  intervals.  Dr. 
Gooch  was  in  the  habit  of  giving  the  aromatic  spirits  of  ammonia,  properly 
diluted,  as  a  quick  and  active  stimulant.  Six  or  eight  drops  may  be  given 
in  sweetened  water  to  a  child  one  year  old,  and  repeated  every  hour  in  cases 
of  urgency.  If  by  proper  treatment  of  the  cause  and  by  the  use  of  stimu- 
lants and  nutritious  food  the  patients  do  not  within  a  few  hours  become  less 
stupid  and  more  conscious,  there  is  that  degree  of  nervous  exhaustion  or  of 
serous  transudation  from  the  engorged  cerebral  veins  which  will  render 
death  probable.  In  some  cases  it  is  proper  to  produce  moderate  vesication 
behind  the  ears. 


CHAPTER    X. 

ECLAMPSIA. 

The  term  "  eclampsia  "  is  used  in  a  more  restricted  sense  by  some  writers 
than  by  others.  It  is  employed  in  the  following  pages  to  designate  those 
convulsive  seizures,  clonic  in  their  character,  sometimes  general,  sometimes 
partial,  which  aff"ect  the  external  muscles,  and  are  due  to  some  exciting  cause. 
It  consists  in  rapid,  forcible,  and  involuntary  muscular  contraction  alternating 
with  relaxation.  It  is  distinguished  from  chorea  in  the  fact  that  the  latter 
is  a  more  permanent  state,  and  is  characterized  by  muscular  movements  which 
are  partially  under  the  control  of  the  will  and  are  not  so  violent.  The  symp- 
toms of  eclampsia  closely  resemble  those  of  epilepsy,  but  these  diseases  are 
distinguished  from  each  other  by  characters  which  will  be  mentioned  here- 
after. 

Eclamp.sia  occurs  in  a  great  variety  of  diseases,  some  of  which  are  located 
in  the  cerebro-spinal  system,  some  in  other  parts  of  the  body,  and  some  are 
constitutional.  It  may  also  be  produced  by  temporary  derangements  of  sys- 
tem not  sufiiciently  severe  to  be  considered  diseases,  and  by  powerful  mental 
impressions,  those  of  an  emotional  nature  affecting  the  delicate  and  sensitive 
nervous  system  of  the  child.  Pathologists  recognize  three  different  forms  of 
eclampsia.  The  term  essential  or  idiopathic  is  used  when  the  convulsions 
have  no  appreciable  anatomical  character ;  that  is,  when  there  is  no  appa- 


CAUSES.  571 

rent  pathological  state  in  the  brain  or  elsewhere  which  gives  rise  to  the 
attack.  For  example,  if  a  child  die  in  convulsions  from  fright,  and  all  the 
organs,  including  the  brain,  are  found  in  their  normal  state,  the  eclampsia  is 
called  idiopathic  or  essential.  If  the  cause  be  disease  of  the  bi'ain  or  spinal 
cord,  it  is  termed  symptomatic.  If  eclampsia  arise  from  local  disease  else- 
where than  in  the  cerebro-spinal  axis,  as  from  pneumonia,  the  term  .sympa- 
thetic is  employed.  This  is  in  the  main  a  good  division,  but  eclampsia  may 
be  at  the  same  time  sympathetic  and  symptomatic,  as  when  it  occurs  in  con- 
sequence of  congestion  of  brain  which  is  induced  by  severe  and  frequent 
paroxysms   of  whooping   cough. 

Causes. — Eclampsia  occurs  at  any  period  of  infancy  and  childhood,  but 
it  is  much  more  rare  after  the  period  of  six  or  .seven  years  than  previously. 
Some  children  are  more  liable  to  it  than  others.  It  is  produced  in  one 
by  an  agency  which  in  another  has  no  appreciable  effect.  There  are  some, 
generally  those  of  an  impressible  nervous  system,  who  are  seized  with  con- 
vulsions whenever  there  is  any  slight  derangement  in  the  digestive  or  other 
organs.  Eclampsia  is  frequent  in  certain  families.  Thus,  Bouchut  mentions 
a  family  of  ten  persons  all  of  whom  had  convulsions  in  their  infancy.  One 
of  them  married  and  had  ten  children,  who,  with  one  exception,  had  con- 
vulsions. 

The  exciting  causes  of  eclampsia  are  too  numerous  to  be  mentioned  in 
full.  It  is  a  symptom  in  nearly  all  cerebral  diseases.  It  is  produced  in  the 
nursling  by  changes  in  the  milk  with  which  it  is  nourished.  These  changes 
are  usually  due  to  violent  emotions  of  the  mother,  as  anger,  fright,  and  gi'ief, 
to  the  use  of  acescent  or  indigestible  food,  or  to  derangement,  temporary  or 
permanent,  in  her  health.  Thus,  in  a  case  related  to  me  the  catamenia  so 
affected  the  milk  that  the  infant  was  seized  with  eclampsia  at  each  monthly 
period.  In  childhood  the  most  common  cause  of  clonic  convulsions  is  the 
presence  of  some  irritant  in  the  primge  viae.  All  kinds  of  fruit,  even  the 
mildest,  may  produce  eclampsia,  especially  when  eaten  unripe  or  taken  in 
undue  quantity.  I  have  known  an  infant  to  be  seized  with  convulsions  from 
eating  strawberries,  which  parents  usually  regard  as  harmless,  and  one  of 
the  most  violent  and  protracted  cases  of  eclampsia  which  I  have  witnessed 
occurred  in  a  child  over  the  age  of  six  years  from  swallowing,  in  considerable 
quantity,  the  parenchymatous  portion  of  an  orange.  Constipation,  worms, 
dysentery,  intussusception,  and  painful  dentition  are  also  causes  which  are 
located  in  the  digestive  apparatus.  Inflammation  in  some  part  of  the  respi- 
ratory apparatus  is  a  not  infrequent  cause.  Thus,  eclampsia  occurs  occasion- 
ally in  severe  coryza,  in  consequence,  according  to  some,  of  the  proximity  of 
the  inflamed  surface  to  the  brain  and  the  consequent  afflux  of  blood  to  this 
organ.  It  is  a  common  complication  also  of  pertussis  and  pneumonia.  It 
occurs  often  at  the  commencement  of  two  of  the  eruptive  fevers — namely, 
smallpox  and  scarlet  fever,  and  in  the  course  of  the  latter  disease. 

Violent  emotions  of  the  child  may  also  cause  eclampsia.  Bouchut  relates 
the  case  of  a  girl  five  years  old  who  was  corrected  before  her  companions, 
and  was  so  affected  by  anger  that  convulsions  ensued.  Residence  in  close 
and  overheated  apartments  or  in  streets  where  the  air  is  loaded  with  offensive 
vapors  and  is  stifling,  is  a  predisposing  cause,  so  that  there  is  a  larger  propor- 
tion of  deaths  from  convulsions  in  the  cities  than  in  the  country. 

In  young  children  burns,  even  when  not  very  severe,  are  liable  to  termi- 
nate suddenly  in  eclampsia,  succeeded  by  coma  and  death.  Urinary  calculi, 
both  renal  and  vesical,  may  produce  the  same  result. 

Such  ai'e  the  more  common  causes  of  eclampsia.  It  is  seen  that  they 
are  of  two  kinds,  predisposing  and  exciting.  An  excitable  or  impressible 
state  of  the  nervous  system  constitutes  the  chief  predisposition  to  the  dis- 


572  ECLAMPSIA. 

ease.  Plethora,  or  its  opposite  state  ansemia,  increases  the  liability  to  an 
attack. 

Premonitory  Stage. — In  the  majority  of  cases  there  are  prodromic 
symptoms  which  the  experienced  and  careful  physician  can  detect  so  as  to 
forewarn  friends.  The  child  is  perhaps  more  or  less  drowsy,  and,  when  dis- 
turbed, fretful.  The  eyes  often  have  a  wild  or  unnatural  appearance ;  occa- 
sionally they  are  fixed  for  a  moment  on  an  object,  and  yet  apparently  with- 
out noticing  it.  The  sleep  is  disturbed ;  in  some  there  is  unusual  heat  of 
head,  and,  if  old  enough,  complaint  of  headache.  At  times,  especially  if  the 
primary  disease  be  febrile  or  inflammatory,  there  is  incoherence  of  thought 
or  expression,  or  even  actual  delirium.  In  some  children  when  eclampsia  is 
threatening  the  thumbs  are  seen  to  be  carried  across  the  palms.  I  have 
observed  this  especially  during  the  convulsive  cough  of  pertussis.  A  very 
important  prognostic  symptom  is  sudden  starting  or  twitching  of  the  limbs. 
This  shows  that  the  nervous  system  is  profoundly  impressed,  and  but  slight 
additional  excitation  is  required  to  develop  eclampsia.  This  sudden  starting 
not  infrequently  precedes  the  attack  several  hours  and  gives  sufficient  fore- 
warning. 

The  prodromic  symptoms  are  often  disregarded  by  friends  who  do  not 
understand  their  significance.  Even  physicians,  in  the  haste  of  their  visits, 
in  many  instances  do  not  notice  them.  The  symptoms  which  precede  symp- 
tomatic and  sympathetic  eclampsia  are,  moreover,  blended  with  those  of  the 
primary  affection,  and  hence  another  reason  why  they  are  frequently  over- 
looked. When  the  convulsions  are  about  to  commence  the  child  generally 
lies  quiet ;  the  eyes  are  open  and  fixed.  If  spoken  to  or  shaken  he  takes  no 
notice  and  does  not  speak.  The  direction  of  the  eyes  is  then  changed ;  often 
they  are  turned  up  ;  occasionally  there  is  strabismus.  The  face  may  be  pale 
or  flushed,  and  sometimes,  especially  in  cerebral  diseases,  the  features  present 
patches  or  streaks  of  a  flushed  appearance,  while  around  them  the  natural 
color  is  preserved.  Immediately  before  the  spasmodic  movements  the  child 
sometimes  utters  a  piercing  scream,  which  is  probably  involuntary,  though  it 
seems  like  a  supplication  for  help.  The  duration  of  the  prodromic  stage  is 
very  diiferent  in  difi'erent  cases.  It  may  last  from  a  few  minutes  to  several 
hours,  or  even  more  than  a  day. 

Symptoms. — Eclampsia  is  general  or  partial.  If  general,  the  muscles  of 
the  face,  eyes,  eyelids,  and  of  all  the  limbs  are  in  a  state  of  rapid  involuntary 
contraction,  alternating  with  relaxation.  The  features  lose  their  natural 
expression  and  are  distorted ;  the  mouth  is  drawn  out  of  shape,  often  to  one 
side,  by  the  violent  muscular  action ;  the  teeth  are  pressed  together  by  tonic 
contraction  of  the  masseters,  and  may  be  violently  struck  together,  so  as  to 
lacerate  the  tongue  if  it  protrude,  or  are  ground  upon  each  other.  Unless 
the  attack  be  of  short  duration,  frothy  saliva,  perhaps  tinged  with  blood  from 
the  injured  tongue,  collects  between  the  lips.  The  eyelids  are  usually  open, 
and  in  severe  cases  the  eyes  are  turned  so  that  the  pupils  are  lost  under  the 
upper  eyelids,  or  the  muscles  of  the  eyes  are  involved  in  the  spasmodic  move- 
ment so  that  the  eyeballs  are  forcibly  drawn  from  side  to  side.  Occasionally 
strabismus  occurs.  While  the  features  are  thus  distorted  the  head  is  strongly 
retracted  or  is  turned  to  one  side ;  the  forearms  are  alternately  pronated  and 
supinated  ;  the  thumbs  and  fingers  are  convulsively  flexed,  so  that  the  thumbs 
lie  across  the  palms  and  are  covered  by  the  fingers ;  the  great  toe  is  adducted, 
the  other  toes  flexed  ;  and  the  toes,  as  well  as  legs,  participate  more  or  less  in 
the  spasmodic  movements. 

In  general  convulsions,  consciousness  is  usually  lost.  The  head  is  hot 
previously  to  and  during  the  attack — at  least  in  the  first  part  of  it — and  the 
face  flushed.     In  exceptional  cases,  especially  in  sympathetic  eclampsia,  the 


SYMPTOMS.  573 

head  is  cool  and  the  face  pallid.  The  pulse  is  somewhat  accelerated,  as  well 
as  the  respiration,  and  the  latter  is  rendered  irregular  if  the  respiratory  mus- 
cles, especially  those  of  the  larynx,  are  involved,  as  they  generally  are.  The 
sphincters  are  relaxed  during  the  convulsive  attack,  so  that  in  many  ca.ses  the 
urine  and  stools  are  passed  involuntarily. 

Partial  eclampsia  is  more  common  than  the  general  form  ;  it  occurs  in 
the  muscles  of  the  face,  including  those  of  the  eye,  of  the  face  and  of  one 
■or  both  upper  extremities,  or  of  the  face  and  the  extremities  on  one  side. 
The  spasmodic  movements  may  be  even  limited  to  the  muscles  of  the  eye, 
and  they  often  occur  only  in  these  muscles  and  those  of  the  face.  Rarely, 
if  ever,  does  eclampsia  affect  the  legs  without  afiecting  also  the  muscles  of 
the  arms  and  face.  In  partial  convulsive  attacks  sensation  and  consciousness 
are  in  some  patients  not  entirely  lost,  but  in  others  they  are  not  manifested 
if  present. 

The  duration  of  an  attack  of  eclampsia  varies  in  different  cases  from  a 
few  minutes  to  several  hours,  with  an  average  of  not  more  than  from  five  to 
fifteen  minutes.  The  movements  do  not  often  continue  longer  than  three  or 
four  hours  in  the  severest  cases.  They  are  sometimes  said  to  last  a  much 
longer  time,  even  for  days,  but  in  these  cases  there  are  intermissions.  Violent 
attacks  are  usually  short. 

When  the  convulsion  ends  favorably  the  spasmodic  movements  become 
less  and  less  strong,  and  finally  cease.  The  child  then  takes  a  deep  inspira- 
tion, after  which  it  lies  quiet,  and  the  respiration  remains  regular  or  mod- 
■erately  accelerated.  Some  fully  recover  in  a  few  minutes  if  the  eclampsia 
have  been  light  and  the  cause  transient,  and  seem  to  experience  no  incon- 
venience except  soreness  of  the  muscles  and  fatigue.  Others  soon  recover 
consciousness,  and  their  temperature,  respii-ation,  and  circulation  become 
natural,  but  they  remain  dull  for  a  time,  their  minds  are  bewildered,  and 
they  are  perhaps  unable  to  speak.  In  a  few  hours  these  untoward  symptoms 
pass  away.  In  essential,  and  in  a  large  proportion  of  cases  of  sympathetic, 
eclampsia,  if  properly  treated  and  if  the  cause  be  recognized  and  removed, 
there  is  no  recurrence  of  the  convulsion  ;  with  others  it  is  different.  In  many 
cases,  especially  of  symptomatic  eclampsia,  and  of  sympathetic  in  which  the 
cause  is  grave  and  persistent,  the  convulsions  return  after  a  variable  period 
of  a  few  minutes  or  a  few  hours.  Six  or  eight  or  moi-e  convulsions  may 
occur  within  twenty-four  hours.  Rarely  they  occur  several  times  daily  for 
several  con.secutive  days,  but  severe  convulsions,  repeated  at  shoi't  intervals 
for  twenty-four  or  forty-eight  hours,  usually  end  in  fatal  congestion  of  the 
brain  or  serous  effusion.  I  once  attended  an  infant  about  six  months  old 
who  had  from  four  to  twelve  convulsions  daily  for  eleven  days,  caused  prob- 
ably by  a  vesical  calculus,  as  there  was  dysuria  and  at  times  bloody  urine. 
Some  days  after  the  convulsions  were  controlled,  while  we  were  deferring 
exploration  of  the  bladder,  death  occurred  suddenly,  and  an  autopsy  was  not 
permitted.  This  case  will  be  detailed  elsewhere.  Bouchut  has  witnessed  a 
■case  of  whooping  cough  in  which  there  were  daily  convulsions  for  eighteen  days. 

In  severe  eclampsia  the  respiration  is  so  embarrassed  and  circulation  so 
retarded  that  congestion  of  various  oi'gans  results.  This  passive  congestion 
in  the  respiratory  organs  is  indicated  by  moist  rales  in  the  larynx  and  bron- 
chial tubes ;  occurring  in  the  brain,  it  is  indicated  by  profound  stupor.  It 
has  already  been  stated  that  death  may  occur  from  the  cerebral  congestion, 
which,  continuing,  is  apt  to  end  in  effusion  of  serum  or  extravasation  of  blood. 
In  these  cases  the  convulsive  movements  cease,  but  there  is  no  return  of  con- 
sciousness. The  child  lies  quiet,  as  if  in  sleep,  with  pupils  not  readily  acted 
on  by  light,  and  often  somewhat  dilated  ;  gradually  the  limbs  grow  cool  and 
the  pulse  feeble,  and  fatal  coma  supervenes. 


574  ECLAMPSIA. 

Death  does  not  ordinarily  occur  from  one  attack.  There  are  several  at 
intervals,  during  which  the  stupor  is  gradually  becoming  more  and  more  pro- 
found, till  finally  total  loss  of  consciousness  and  sensation  results,  terminating 
in  death.  Apnoea  may  occur  in  the  first  attack,  ending  life  abruptly  and 
unexpectedly,  but  in  other  instances  it  does  not  result  till  after  several  seiz- 
ures, when  at  length  one  more  violent  than  the  others  interrupts  the  respira- 
tory function  and  causes  death. 

Occasionally  when  life  is  preserved  there  is  some  permanent  ill-eifect  of 
eclampsia.  Bouchut  says :  "  The  origin  of  certain  permanent  contractions 
which  bring  on  deviation  of  the  head  or  other  parts,  retraction  of  the  limb, 
paralysis,  etc.,  must  be  referred  to  the  convulsions  of  the  muscles.  I  have 
seen  several  children  in  whom  torticollis  had  no  other  cause.  The  drooping 
of  the  upper  eyelid,  strabismus,  irregularity  of  the  mouth,  severe  contractions 
of  the  limbs,  often  depend  on  this  influence.  These  accidents  are  consequences 
of  essential  as  well  as  of  symptomatic  convulsions." 

Anatomical  Characters. — The  morbid  anatomy  pertaining  to  eclamp- 
sia is  in  most  cases  twofold :  first,  the  pathological  states  which  precede  and 
cause  the  convulsive  movements ;  secondly,  those  which  result  from  them. 
We  have  seen  that  in  sympathetic  eclampsia  the  diseases  which  sustain  a 
causal  relation  are  very  numerous :  some  are  constitutional,  others  local, 
and  the  latter  may  have  their  seat  in  almost  any  part  of  the  economy  distinct 
from  the  cerebro-spinal  axis.  In  some  cases  of  sympathetic  eclampsia  the 
immediate  cause  is  too  active  a  circulation,  a  state  of  hypersemia  of  the  cere- 
bral vessels. 

It  has  already  been  stated  that  this  hyperaemia  may  be  diagnosticated  in 
young  infants  in  whom  the  anterior  fontanel  is  open.  Such  infants,  seized 
with  acute  inflammation  of  one  of  the  mucous  surfaces,  often  present  a  full 
and  rapid  pulse  and  a  convex  and  forcibly  pulsating  fontanel  before  the 
eclampsia  begins.  In  other  cases  of  sympathetic  eclampsia  the  primary 
disease  induces  passive  congestion  of  the  brain,  and  this  in  turn  gives  rise  tO' 
convulsions.  Eclampsia  occurring  during  the  paroxysms  of  whooping  cough 
aff"ords  an  example. 

In  some  cases  of  sympathetic  eclampsia  the  convulsive  movements  are  pro- 
duced by  the  primary  disease  acting  directly  on  the  nervous  system  through 
the  medium  of  the  nerves,  without  causing  any  appreciable  alteration  in  the 
state  of  the  cerebro-spinal  axis.  Thus,  Barrier  relates  three  fatal  cases  of 
convulsions  occurring  in  pneumonia,  in  none  of  which  was  there  anything 
abnormal  in  the  condition  of  the  brain  or  its  membranes. 

The  pathological  state  preceding  symptomatic  eclampsia  difi'ers  in  difi"er- 
ent  cases,  since  convulsions  occur  in  almost  every  disease  of  the  brain  and 
its  membranes.  The  immediate  cause  of  this  form  of  eclampsia  may  be: 
active  or  passive  cerebral  congestion,  with  or  without  eff"usion  :  it  may  be 
compression  of  the  brain  from  various  causes ;  it  may  be  a  deficiency  as  well 
as  excess  of  the  cerebro-spinal  fluid. 

The  congestion  resulting  from  eclampsia  may  give  rise  to  extravasation, 
of  blood  and  the  formation  of  a  clot.  If  this  accident  occur,  there  is  often 
paralysis  aff"ecting  more  or  less  of  one  side  permanently,  or  gradually  dis- 
appearing. 

It  may  be  difiicult  to  decide  whether  the  cerebral  congestion  precedes  the 
eclampsia  or  is  its  result ;  but  in  those  cases  in  which  it  precedes  and  ope- 
rates as  a  cause  it  is  no  doubt  increased  during  the  convulsive  period.  The 
spasmodic  muscular  action,  by  rendering  respiration  irregular  and  imperfect, 
also  leads  to  congestion  of  the  lungs,  and  sometimes  of  other  organs. 

Diagnosis. — The  only  disease  which  resembles  eclampsia  is  epilepsy,  but 
the   diagnosis  can  ordinarily  be  made  by  recollecting  the   following  facts:. 


PROGNOSIS.  575 

Kclampsia  is  most  common  in  infuney.  If  it  occur  after  the  age  of  three 
years  there  is  some  manifest  excitiii<r  cause  which  renders  the  child  seriously 
sick  independently  of  the  convulsions,  and  prior  also  to  their  occurrence. 
But  in  epilepsy  first  attacks  are  very  often  mild,  the  prh't  nutl  of  writers:  in 
other  cases  they  are  tolerably  severe  from  the  first ;  but,  whether  mild  or 
severe,  they  occur  with  no  previous  or  coexisting  sickness  and  with  little  or 
no  warning. 

The  symptoms  in  eclampsia  and  epilepsy  are  identical,  except  as  the  causes 
of  eclampsia  produce  certain  concomitant  symptoms,  and  there  is  every  reason 
to  believe  that  the  spasmodic  muscular  movements  proceed  from  an  irritation 
of  the  same  portion  of  the  cerebro-spinal  axis — to  wit,  the  medulla  oblongata. 
Writers  like  Niemeyer  have  given  reasons  for  the  belief  that  spasmodic 
muscular  movements  are  produced  by  functional  disturbance  of  this  part  of 
the  nervous  centre.  I  may  state  the  following,  to  which  I  am  not  aware  that 
any  one  has  alluded :  If  the  exposed  medulla  of  an  acephalous  monster  be 
pressed  or  pinched  convulsions  like  those  of  eclampsia  and  epilepsy  result. 
These  two  diseases,  therefore,  have  a  close  resemblance  anatomically  and 
clinically,  but  by  attention  to  the  above  facts  they  can  ordinarily  be  dis- 
tinguished from  each  other. 

In  most  cases  of  eclampsia  the  child  has  fever  or  other  pronounced  symp- 
toms of  the  primary  disease,  which  suffice  for  diagnosis  :  but  we  have  fre- 
quently examined  epileptics  in  the  Bureau  for  the  Relief  of  the  Out-door 
Poor  whose  first  attacks  were  evidently  produced  by  some  exciting  cause, 
and  were  eclamptic.  One  attack  of  clonic  convulsions  predisposes  to 
another,  and  therefore  eclampsia,  if  the  attack  be  repeated  a  few  times,  not 
infrequently  ends  in  epilepsy.  The  convulsions,  which  at  first  are  produced  by 
an  obvious  cause,  now  occur  without  apparent  cause. 

It  is  often  difficult  to  ascertain  the  form  of  eclampsia,  whether  essential, 
symptomatic,  or  sympathetic — in  other  words,  to  determine  the  cause — till 
after  the  convulsions  cease.  This  is  especially  true  when,  as  is  frequently 
the  case,  the  physician  is  not  summoned  till  the  convulsive  movements  begin, 
and  it  is  necessary  that  he  should  act  promptly,  with  but  little  knowledge  of 
the  child's  previous  history.  If  there  be  an  obvious  antecedent  disease,  as 
whooping  cough  or  meningitis,  the  cause  is  apparent ;  but  if  the  previous 
health  have  been  good  or  but  slightly  disturbed,  it  may  be  necessary  to  make 
more  than  one  visit  or  examination  in  order  to  ascertain  the  seat  and  charac- 
ter of  the  cause.  In  the  majority  of  cases  of  convulsions  occurring  suddenly 
in  a  state  of  previous  good  health  the  cause  is  seated  in  the  intestines,  but 
sudden  and  unexpected  attacks  may  be  due  to  the  commencement  of  some 
inflammatory  affection,  as  pneumonia,  or  of  a  febrile  disease,  as  smallpox. 
Unless  the  eclampsia  be  speedily  fatal,  the  physician,  if  he  examine  carefully, 
will  in  most  cases  soon  be  able  to  ascertain  the  nature  of  the  cause  and  diag- 
nosticate the  form  of  the  disease. 

Prognosis. — Symptomatic  eclampsia  is  always  serious.  If  it  occur  in 
the  course  of  a  cerebral  disease,  it  indicates  the  approach  of  death,  but  if  at 
its  commencement  the  patient  may  recover.  Its  recurrence,  whatever  the 
cerebral  disease,  is  usually  prognostic  of  death. 

In  idiopathic  or  essential  convulsions  the  prognosis  depends  on  the  sever- 
ity of  the  attack  and  on  the  age,  strength,  and  previous  condition  of  the 
child.  If  there  be  predisposing  or  co-operating  causes,  as  a  nervous  or  excit- 
able temperament  or  dentition,  the  prognosis  is  less  favorable  than  when  such 
causes  are  absent. 

In  sympathetic  eclampsia  the  prognosis  varies  greatly,  according  to  the 
nature  of  the  primary  disease  and  often  according  to  the  stage  of  that  disease. 
If  convulsions  occur  at  the  commencement  of  an  eruptive  fever,  they  gener- 


576  ECLAMPSIA. 

ally  subside  without  untoward  symptoms  and  the  fever  pursues  a  favorable 
course.  Eclampsia  after  the  appearance  of  the  eruption  is  premonitory  of  a 
fatal  result.  I  have  not  yet  known  a  patient  with  scarlet  fever  recover  who 
had  convulsions  after  the  rash  had  covered  the  body,  and  experienced  physi- 
cians of  this  city  tell  me  that  their  observations  correspond  with  mine.  Dr. 
J.  F.  Meigs,  however,  relates  one  favorable  case.  If  the  cause  of  the  eclampsia 
be  located  in  or  upon  the  mucous  surfaces,  a  majority  recover  with  judicious 
treatment.  In  convulsions  consequent  on  pneumonia  or  a  burn  more  die  than 
recover. 

The  prognosis  in  eclampsia  is  more  favorable  if  the  parallelism  of  the  eyes 
be  retained,  the  pupils  remain  sensitive  to  light,  and  consciousness  soon  return. 
A  fatal  termination  may  be  predicted  if,  after  the  convulsion,  the  child  remain 
stupid,  without  any  evidence  of  returning  consciousness,  and  the  pupils  do 
not  respond  to  light. 

Treatment. — Fortunately,  inasmuch  as  the  physician  is  often  required 
to  treat  eclampsia  in  ignorance  of  the  cause,  the  same  measures  are  demanded 
to  a  considerable  extent  in  all  cases,  whether  the  form  be  essential,  symp- 
tomatic, or  sympathetic.  As  early  as  possible  in  the  attack  the  feet  should 
be  placed  in  hot  water  to  which  mustard  is  added,  or  if  it  can  be  procured 
with  little  delay  a  general  warm  bath  may  be  used  in  its  place.  This  has  a 
soothing  eiFect  upon  the  nervous  system  and  promotes  muscular  relaxation, 
while  it  also  produces  derivation  of  blood  from  the  cerebro-spinal  axis.  It  is 
therefore  useful,  especially  in  those  cases  in  which  active  or  passive  conges- 
tion precedes  the  eclampsia ;  it  is  also  useful  as  a  preventive  of  passive  con- 
gestion and  consequent  oedema  of  the  brain,  lungs,  and  other  organs,  which 
are  the  most  serious  results  of  eclampsia.  It  should  be  continued  from  six 
to  fifteen  or  twenty  minutes,  according  to  the  severity  and  duration  of  the 
attack  ;  at  the  same  time  cold  applications  should  be  made  to  the  head  until 
its  temperature,  which  is  usually  increased,  is  reduced.  The  application  of 
cloths  placed  upon  ice  or  frequently  wrung  out  of  cold  water  is  the  most 
convenient  and  ready  mode  of  employing  this  agent.  Cold  thus  employed 
acts  promptly  in  contracting  the  vessels  of  the  brain  and  meninges  and  dimin- 
ishing the  cerebral  congestion.  It  tends,  therefore,  to  remove  one  of  the 
chief  dangers. 

Cold  applications  are  also  useful  for  reducing  an  elevated  temperature 
if  it  be  present.  In  most  cases  of  eclampsia,  if  the  temperature  reach  103°, 
the  necessity  for  its  reduction  is  urgent,  and  the  cold  cloths  or  India-rubber 
bag  containing  ice  should  be  applied  not  only  upon  the  head,  but  also  along 
the  sides  of  the  face,  and  sometimes  over  the  great  vessels  of  the  neck. 

Since  a  large  proportion  of  convulsive  attacks  originate  in  the  condition  of 
the  intestines,  either  solely  or  in  part,  it  is  advisable  to  prescribe  an  aperient 
unless  there  be  previous  diarrhoea. 

The  common  enema  of  soap  and  water  will  usually  produce  a  free  and 
speedy  evacuation,  and  will  sometimes  disclose  the  cause  of  the  eclampsia  in 
the  expulsion  of  seeds  or  other  indigestible  substances  or  scybala.  A  cathartic 
is  also  often  required,  es-pecially  if  the  enema  fail  to  produce  sufficient  evacu- 
ations. In  those  that  are  robust,  and  especially  in  those  beyond  the  age  of 
two  or  three  years,  calomel  is  an  excellent  purgative,  is  easily  given,  and  is 
prompt  in  its  action.  If  the  symptoms  indicate  intestinal  inflammation,  the 
milder  purgatives,  as  castor  oil,  are  preferable,  as  they  also  are  in  young  or 
feeble  children.  If  the  recent  ingesta  of  the  patient  consisted  of  fruit  or  of 
substances  of  an  indigestible  character,  an  emetic  is  appropriate ;  a  teaspoon- 
ful  of  the  syrup  of  ipecacuanha,  repeated  if  necessary  in  fifteen  or  twenty 
minutes,  may  be  given  to  a  young  child,  or  this  syrup  mixed  with  the  syrup, 
scillae  compositus  to  one  older  and  more  robust.     Aside  from  the  ejection  of 


TREATMENT.  bll 

the  offending  substance  which  it  produces,  an  emetic  has  some  effect  in  con- 
trolling the  convulsive  movements.  But  the  cases  are  rare  in  which  emetics 
are  indicated. 

In  addition  to  the  local  measures  mentioned  above,  and  measures  calcu- 
lated tu  relieve  the  digestive  canal  of  any  offending  substance,  a  safe  medici- 
nal agent  which  will  act  promptly  in  relieving  the  convulsions  is  urgently 
demanded,  since  eclampsia,  if  severe  and  protracted,  involves  great  danger. 
Fortunately,  such  agents  have  been  lately  introduced  into  therapeutics — 
namely,  the  bromide  of  potassium  or  sodium  and  hydrate  of  chloral.  These 
agents,  while  they  are  effectual,  are  safe,  and  therefore  their  use  has  sup- 
planted that  of  the  antispasmodics,  asafoetida,  valerian,  lavender,  and  chloro- 
form, formerly  employed  ;  not  one  of  which,  except  chloroform,  exerts  any 
direct  controlling  influence  over  the  convulsions,  and  chloroform  is  a  danger- 
ous remedy  unless  used  sparingly. 

The  bromide  of  potassium,  which  I  prefer,  should  be  given  every  ten 
minutes,  dissolved  in  cold  water,  till  the  convulsions  cease,  in  doses  of  four 
grains  to  a  child  of  one  year,  and  of  five  to  eight  grains  to  a  child  of  two  or 
three  years.  When  the  convulsions  cease  the  interval  between  the  doses 
should  be  lengthened.  In  one  instance  in  my  practice  an  infant  of  eighteen 
months  was  suddenly  seized  with  eclampsia,  and  the  mother,  in  her  fright 
mistaking  the  directions,  gave  thirty  grains  of  bromide  at  one  dose.  Two 
hours  afterward,  when  I  was  able  to  attend,  I  found  that  the  convulsions  had 
ceased  at  once  and  that  the  patient  was  playful.  Such  cases  show  the  innoc- 
uousness  of  a  large  dose  of  the  bromide  and  the  safety  in  administering  the 
medicinal  dose  often. 

In  severe  cases  the  bromide  does  not  always  act  with  sufficient  prompt- 
ness and  power.  The  hydrate  of  chloral  should  then  be  employed,  given  by 
the  mouth  or  dissolved  in  two  or  three  drachms  of  water,  and  given  with 
a  small  glass  or  gutta-percha  syringe  per  rectum.  If  used  in  sufficient 
quantity  jier  rectum^  and  retained  by  pressure  with  a  napkin,  it  is  quickly 
absorbed,  and  will  usually  in  about  fifteen  or  twenty  minutes  control  the 
eclampsia.  For  a  child  of  one  year  I  employ  about  two  grains,  and  for  one 
of  four  years  four  grains,  given  by  the  mouth,  or  double  this  quantity  given 
per  rectum.  With  the  use  of  the  measures  indicated  above  eclampsia  is,  in 
my  practice,  much  more  amenable  to  treatment  than  in  former  years.  Unless 
the  cause  be  such  that  recovery  is  impossible  from  the  very  nature  of  the 
case,  the  convulsions  will  soon  cease  with  these  measures.  It  is  interesting 
to  observe  the  effect  of  the  chloral  enema.  In  from  five  to  ten  minutes 
the  convulsive  movements  cease  in  the  muscles  of  the  face,  a  moment  later 
in  those  of  the  arms,  and  lastly  in  those  of  the  lower  extremities. 

But  additional  treatment  may  be  required,  according  to  the  pathological 
state  which  has  brought  on  the  eclampsia.  If  it  be  an  eruptive  fever,  as 
scarlatina,  and  the  eruption  have  receded,  active  revulsive  measures,  as  hot 
mustard  baths,  are  required  ;  if  in  dysentery  or  other  internal  inflammation, 
the  flaxseed  and  mustard  poultice  should  be  applied  over  the  parts  affected. 

In  those  dangerous  cases  in  which  symptoms  of  cerebral  congestion  con- 
tinue after  the  eclampsia  ceases  additional  treatment  is  required.  The  child 
remains  drowsy,  does  not  speak  or  apparently  suffer  in  any  way,  and  the 
pupils  act  less  readily  than  in  health.  If  this  condition  remain  after  the 
lapse  of  a  few  hours  there  is  probably  serous  effusion.  All  attacks  of 
eclampsia,  unless  the  mildest,  are  followed  by  a  period  of  drowsiness,  but 
the  persistence  of  it,  with  symptoms  which  indicate  hyperaemia,  with  per- 
haps effusion  within  the  cranium,  calls  for  the  employment  of  additional 
measures.  Vesication  by  cantharidal  collodion  should  then  be  produced 
behind  the  ears,  mild  revulsives  be  applied  to  the  extremities,  the  head  kept 
37 


578  EPILEPSY. 

cool,  the  bowels  open,  and  in  certain  cases  a  diuretic  like  iodide  of  potassium 
may  be  advantageously  employed.  The  utmost  care  should  be  enjoined  in 
reference  to  the  hygienic  management  of  those  who  are  subject  to  eclampsia. 
The  diet  should  be  nutritious  but  bland,  and  all  causes  of  excitement  be 
studiously  avoided. 


CHAPTER  XI. 

EPILEPSY. 

Epilepsy  is  a  paroxysmal  disease.  The  paroxysms  are  manifested  by 
impairment  or  loss  of  consciousness,  and  in  fully-developed  and  typical  cases 
also  by  convulsive  movements  of  more  or  fewer  of  the  voluntary  muscles. 
Epilepsy  is  a  neurosis  or  functional  affection  of  the  nervous  system,  not  due, 
therefore,  to  any  appreciable  structural  change  in  the  brain  or  spine.  The 
convulsions  are  tonic  or  clonic,  or  most  frequently  both,  the  tonic  preceding 
the  clonic. 

Etiology. — In  a  large  proportion  of  cases  we  are  able  to  discover  both 
predisposing  and  exciting  causes  of  the  first  attack,  but  one  convulsion  pro- 
duces such  a  change  in  the  nervous  system  that  the  liability  to  another 
attack  is  increased.  Hence  after  the  epileptic  habit  is  established  after  one 
or  a  few  attacks,  convulsions  usually  occur  without  any  apparent  exciting 
cause;  and  if  such  a  cause  be  discovered,  it  is  evidently  insufficient  without 
the  presence  of  a  strong  predisposition. 

Predisposing  Causes. — Prominent  among  these  is  a  neurotic  inherit- 
ance. Echiverria,  whose  observations  were  made  in  the  epileptic  wards  on 
Blackwell's  Island,  states  that  28  per  cent,  of  the  300  epileptic  patients 
examined  by  himself  presented  evidences  of  inheritance.  In  Reynolds's 
cases  the  number  was  31  per  cent.,  and  in  1218  cases  examined  by  Gowers 
the  number  who  presented  evidences  of  an  inherited  predisposition  was  429, 
or  35  per  cent.  The  morbid  state  in  the  parent  which  gives  rise  to  an  inher- 
ited predisposition  to  epilepsy  in  the  child  is  most  frequently  epilepsy  or 
insanity.  Less  frequently,  according  to  Gowers,  the  parental  disease  is 
chorea,  hysteria,  or  a  spinal  malady.  Inherited  predisposition  is  said  to  be 
more  frequently  from  the  mother  than  from  the  father.  The  occurrence  of 
epilepsy  in  a  brother  or  sister  renders  it  probable  that  the  patient  has  inher- 
ited a  predisposition,  although  we  may  be  unable  to  trace  it  to  either  parent 
or  any  of  the  ancestry.  The  evidence  of  a  strong  inherited  predisposition  is 
sometimes  apparent  by  the  number  of  near  relatives  affected  by  the  same  dis- 
ease. Thus,  Gowers  states  that  in  one  instance  the  patient's  mother,  aunt, 
two  uncles,  and  a  cousin  were  epileptic,  and  in  another  instance  fourteen  near 
relatives  had  epilepsy. 

Age. — Statistics  relating  to  the  age  at  which  epilepsy  begins  have  been 
published  by  Haase,  Gowers,  and  others.  These  show  that  three-fourths  of 
the  cases  begin  under  the  age  of  twenty  years,  one-fourth  under  the  age  of 
ten  years,  and  about  one-eighth  under  the  age  of  three  years. 

Exciting  Causes. — Immediate  or  exciting  causes  of  epilepsy  are  usu- 
ally most  apparent  in  cases  which  begin  during  infancy  or  childhood.  The 
history  of  a  large  number  of  epileptic  children  has  been  ascertained  during 
the  last  twenty  years  in  the  children's  class  in  the  Out-door  Department  at 
Bellevue,  and  very  frequently  we  were  informed  that  at  the  first  attack  the 
child  was  feverish  or  constipated  or  had  some  acute  ailment,  which  served  as 


EXCITING  CAUSES.  579 

the  exciting  cause,  (^f'ten  the  first  convulsions  were  attributed  to  dentition, 
but  we  now  know  that  most  of  the  cases  which  are  attributed  by  the  parents 
to  teething  are  due  to  other  causes,  as  constipation,  diarrhoea,  the  presence  of 
indigestible  or  irritating  ingesta  in  the  intestines,  rachitis,  or  some  acute 
infectious  or  inflammatory  disease.  If  the  child  have  a  succession  of  dis- 
eases giving  rise  to  convulsions,  they  may  be  sufficient  to  establish  the  epi- 
leptic habit,  even  when  there  is  no  apparent  predisposition  to  epilepsy. 
Thus,  Gowers  relates  the  case  of  a  child  of  healthy  parentage  and  without 
any  inherited  predisposition,  that  had  a  fit  at  the  age  of  six  months,  attrib- 
uted to  teething ;  another  at  the  age  of  two  years,  from  scarlet  fever ; 
another  at  four  and  a  half  years,  from  measles  ;  and  another  at  sixteen  and 
a  half  years,  from  a  carbuncle.  These  repeated  convulsive  attacks  ended  in 
a  permanent  epilepsy. 

Mental  Emoditn. — Fright  or  great  excitement,  from  whatever  cause,  is  the 
most  common  and  potent  of  the  immediate  causes  of  epilepsy.  It  produced 
the  first  convulsive  attack  in  157  of  Gowei's's  cases,  or  in  more  than  one-third 
of  those  in  which  an  exciting  cause  was  assigned.  This  cause  is  operative 
chiefly  in  the  periods  of  childhood  and  youth,  when  the  emotions  are  strong, 
and  in  females  more  frequently  than  in  males.  Among  the  enumerated 
causes  of  the  mental  excitement,  authors  mention  fire-alarms,  burglaries,  thun- 
der-storms, and  pretended  ghosts.  Gowers  states  that  a  soldier  on  sentry-duty 
at  night  was  so  frightened  by  some  white  goats  that  appeared  suddenly  on  the 
wall  of  an  adjacent  cemetery  that  he  was  seized  with  convulsions  and  became 
an  epileptic.  Sudden  and  profound  emotion  has  sometimes  been  the  exciting 
cause  of  chorea,  and  in  other  instances  of  epilepsy,  in  cases  which  I  have 
observed,  in  one  instance  in  an  emotional  child,  the  sight  of  the  corpse  of  a 
favorite  uncle  producing  this  result.  In  another  instance  a  physician  of  my 
acquaintance,  in  treating  a  female  child  with  scarlatinous  nephritis,  ordered  a 
warm  bath.  The  next  day.  visiting  the  patient  and  learning  that  his  direc- 
tions had  not  been  heeded,  he  prepared  a  bath  and  in  a  rude  manner  plunged 
the  child  in  it.  She  was  much  frightened,  and  immediately  had  a  severe  con- 
vulsion. The  scarlatinous  uraemia  probably  predisposed  to  the  attack,  but 
the  fright  was  the  exciting  cause.  She  has  been  a  confirmed  epileptic  from 
that  day,  the  fits  being  frequent  and  severe.  Treatment  employed  at  inter- 
vals during  the  last  ten  or  twelve  years  has  had  but  little  eff'ect  in  controlling 
them.  Gowers  states  that  in  an  aggregate  of  76  cases  in  which  epilepsy 
resulted  from  fright  the  convulsion  occurred  immediately  in  28,  within  a  few 
hours  in  16  others,  after  the  first  day,  but  within  seven  days,  in  19,  and  at  a 
later  period  than  one  week  in  13. 

Protracted  cares  or  anxieties,  which  prevented  the  needed  mental  rest, 
have  also  in  some  instances  been  the  only  assignable  cause  of  epilepsy,  but 
this  cause  is  less  frequent  in   childhood   than   in   adult  life. 

Traumatism. — Usually  the  injury  received  is  upon  the  head,  either  from 
a  fall  or  a  blow,  by  which  the  patient  is  stunned  or  rendered  unconscious  for 
a  time.  The  convulsion  may  occur  immediately  or  not  until  the  lapse  of  a 
day  or  more.  Traumatism  is  ordinarily  attended  by  much  mental  excitement, 
and  this  has  its  influence  in  producing  the  convulsive  attack. 

Among  the  less  frequent  but  occasional  causes  of  epilepsy  in  infancy  and 
childhood  we  may  mention  inherited  syphilis,  intestinal  worms,  scarlet  fever, 
measles,  pneumonia,  rheumatism,  exposure  to  a  high  degree  of  heat,  especi- 
ally to  the  sun's  rays,  masturbation,  renal  disease,  and  peripheral  causes  hav- 
ing a  reflex  action,  as  phimosis,  cicatrices,  and  a  decayed  tooth.  When  these 
causes  are  removed,  the  clonic  convulsions  which  they  have  produced  may 
cease,  but  in  other  instances  they  continue,  the  epileptic  habit  having  been 
established. 


580  EPILEPSY. 

Symptoms. — Two  forms  of  epilepsy  have  long  been  recognized  and 
described  in  standard  treatises — the  mild  and  severe  forms,  the  epilepsia 
mitior  and  epilepsia  gravior ;  or,  in  the  French  language,  le  petit  mal  and 
le  grand  mal.  As  the  terms  imply,  this  classification  is  based  on  the  difier- 
ence  in  the  severity  of  the   attacks. 

Minor  AttacliS. — These  are  characterized  by  momentary  dizziness  and 
usually  loss  of  consciousness.  The  patient  has  a  bewildered  look ;  his 
speech  is  interrupted,  even  in  the  middle  of  a  sentence,  and  his  work, 
whatever  it  may  be,  is  also  interrupted,  so  that  whatever  he  is  holding 
drops  from  his  hands.  His  pallor,  bewildered  look,  and  strange  actions 
attract  attention,  but  in  a  moment  he  resumes  his  work  and  his  speech. 
When  the  attack  is  over  he  may  be  at  once  in  his  ordinary  mental  and 
physical  condition,  and  seem  quite  well,  but  he  does  not  have  a  clear  recol- 
lection of  what  has  happened.  Some  patients  after  the  attack  ceases 
remain  for  a  time  in  a  drowsy  state  and  without  full  perception,  or  their 
speech  and  acts  may  be  passionate  and  violent  until  they  regain  their  normal 
state. 

Major  Attacks. — These  begin  abruptly  with  strong  tonic  contraction  of 
the  muscles,  which  causes  rotation  of  the  head  to  one  side,  a  fixed  lateral, 
and  sometimes  upward,  deviation  of  the  eyes,  and  a  constrained  and  awk- 
ward position  of  the  extremities.  The  facial,  thoracic,  and  abdominal  mus- 
cles participate,  causing  distorted  features  and  embarrassment  of  respiration. 
The  face,  at  first  pallid,  soon  becomes  livid,  the  pupils  are  dilated,  the  con- 
junctiva insensitive,  and  the  eyes  are  in  some  patients  open,  but  in  others 
closed.  The  cyanosis  deepens  and  the  surface  becomes  very  livid.  In  a 
moment  the  muscles  begin  to  vibrate  and  undergo  alternate  relaxations  and 
contractions.  The  second  stage,  or  that  of  clonic  convulsions,  begins.  The 
head,  face,  body,  and  limbs  are  violently  jerked,  saliva  tinged  with  blood 
flows  from  the  mouth,  and  sometimes  the  urine  and  feces  are  expelled.  The 
patient  presents  a  striking  and  shocking  spectacle,  which  gave  rise  in  olden 
times  to  the  belief  of  demoniacal  possession.  Presently  the  muscular  relaxa- 
tions become  longer,  more  air  is  inhaled,  and  the  blueness,  which  was  intense, 
begins  to  abate.  The  muscular  contractions,  though  as  severe  as  at  first,  are 
less  frequent,  and  finally  cease,  and  the  patient,  weak  and  unconscious,  sleeps 
quietly  but  soundly.  Occasionally,  instead  of  a  simultaneous  commencement 
of  the  attack  in  all  parts  of  the  body,  it  begins  in  one  region  and  extends  to 
others  on  the  same  side,  and  then,  diminishing  on  this  side,  it  begins  on  the 
opposite  side.  In  this  form  of  epilepsy  the  patient  may  not  lose  conscious- 
ness until  late  in  the  attack,  so  that  he  at  first  is  aware  of  his  condition,  and 
the  convulsions  may  be  clonic  from  the  first. 

Aura. — Certain  patients  exhibit  symptoms  which  are  premonitory  of  the 
attack  some  hours  before  its  occurrence.  One  of  these  is  the  sudden  jerk- 
ing of  certain  muscles,  as  of  the  arms  or  legs.  This  usually  occurs  when 
the  patient  is  awake,  but  it  may  occur  when  he  is  asleep  or  is  falling  asleep. 
Another  occasional  premonitory  symptom  is  persistent  dizziness  preceding 
the  attack  some  hours  or  even  days.  A  ravenous  appetite,  a  stifling  sensa- 
tion in  the  chest,  as  if  from  want  of  air,  numbness,  cephalalgia,  impairment  of 
sight,  the  vision  of  red  fiery  sparks  (Aretaeus),  and  irritability  of  temper 
occasionally  precede  the  attacks,  so  as  to  forewarn  the  patient  and  friends. 
Bootius  in  1649  described  a  premonitory  symptom  which  was  observed  in 
rare  instances,  but  which  was  thought  to  justify  the  recognition  of  a  variety 
of  the  disease  that  was  designated  epilepsia  curaiva.  The  patient  ran  a  short 
distance  and  then  was  seized  with  the  convulsion.  Another  similar  precur- 
sory symptom  immediately  preceding  the  attack  is  mentioned  by  writers.  The 
patient,  if  walking,  even  if  entering  his  home,  turns  around,  retraces  his  steps, 


SYMPTOMS.  581 

and  falls  down  in  the  fit.  The  premonitory  symptoms  described  above,  which 
enable  the  epileptic,  with  the  aid  of  his  friends,  to  reach  a  place  of  safety 
before  the  attack   begins,   occur  in  a  small  proportion   of  cases. 

Many  epileptic  fits  begin  with  an  ain-a — a  term  first  employed  by  Pelops, 
the  predecessor  and  teacher  of  Galen,  to  indicate  a  sensation  which  com- 
mences in  some  part  away  from  the  brain  and  ascends  toward  it.  In  olden 
times  the  aura  was  supposed  to  be  a  vapor,  which  traversed  the  vessels  to  the 
brain  and  caused  the  attack.  It  is  now  known  that  it  ordinarily  has  a  cen- 
tral origin,  is  due  to  commencing  functional  disturbance  of  the  brain,  and  is 
a  part  of  the  tit.  It  is  true  that  the  immediate  application  of  a  ligature  or 
tight  band  above  the  aura,  which  arrests  its  ascension  to  the  brain,  will  often 
prevent  the  fit,  but  Odier,  Brown-Sequard,  and  Gowers  have  shown  that  this 
occurs  in  epilepsy  due  to  cerebral  tumors  even  more  frequently  than  in  epi- 
lepsy which  has  no  appreciable  anatomical  cause.  Therefore,  this  fact  of  the 
arrest  of  the  convulsion  by  ligation  above  the  aura  cannot  be  employed  as  an 
argument  in  support  of  the  theory  of  the  peripheral  origin  of  the  attacks. 

The  statistics  of  Romberg,  Sieveking,  and  Gowers  show  that  an  aura  occurs 
in  about  half  the  cases.  The  aura  may  begin  in  any  peripheral  portion  of 
the  system,  in  any  of  the  organs  of  the  special  senses,  and  in  many  of  the 
internal  organs.  By  knowing  from  what  portion  of  the  brain  the  nerve 
arises  which  supplies  the  part  that  is  the  seat  of  the  aura,  we  are  enabled  to 
state  which  of  the  divisions  of  the  brain  is  probably  so  aifected  as  to  produce 
epilepsy. 

The  aura  varies  greatly  in  its  character  as  well  as  location.  It  is  a  sen- 
sation of  pain,  numbness,  burning  or  tingling,  or  instead  of  being  sensory  it 
may  be  wholly  or  chiefly  motor,  as  cramps,  jerking,  twitching  of  a  certain  mus- 
cle or  group  of  muscles  occurring.  Sometimes  the  aura  is  at  the  same  time 
both  sensory  and  motor.  The  sensory  aura  commonly  ascends,  as  we  have 
already  stated,  toward  the  head,  but  it  occasionally  descends  a  limb,  and 
•when  it  reaches  a  certain  point  the  convulsion  begins.  The  aura  often  occurs 
in  one  side  of  the  face,  tongue,  or  trunk,  or  in  one  limb.  In  other  instances 
it  is  bilateral  or  general,  commencing  simultaneously  in  corresponding  limbs 
of  the  two  sides.  Aurfe  in  the  trunk,  and  not  in  the  viscera,  occur  almost 
entirely  in  the  back,  along  the  spine,  and  are  known  as  the  spinal  aurae. 
General  aurae  are  sometimes  characterized  by  faintness,  malaise,  or  power- 
lessness,  or  a  general  tremor  or  a  general  sensation  of  coldness  or  of  heat. 
Visceral  aurae  occur  for  the  most  part  in  viscera  supplied  by  the  pneumogas- 
tric.  The  most  common  of  these  aurae  is  the  epigastric,  a  pain  or  a  sensation 
in  the  epigastrium,  vaguely  described  as  a  "  heat,"  "  coldness,"  "  trembling," 
a  "  twisting  "  or  "  winding  up."  The  epigastric  aura  may  be  a  little  above 
or  below  or  to  the  left  of  the  epigastrium.  In  some  cases  the  aura  is  located 
in  the  chest  or  throat.  A  sensation  of  suflFocation  or  tingling  or  burning,  or 
an  indescribable  feeling,  is  experienced  in  the  chest  or  throat  immediately 
before  the  attack  begins.  The  patient  perhaps  presses  upon  his  chest  or 
throat  with  his  hands  and  immediately  becomes  convulsed.  The  heart  also 
derives  its  innervation  from  the  pneumogastric,  and  the  aura  is  sometimes 
referred  to  this  organ.  In  some  patients  the  cardiac  region  is  the  seat  of 
a  vague  sensation  variously  described,  or  the  aura  may  be  manifested  by 
increased  action  or  palpitation,  with  perhaps  more  or  less  dyspnoea.  Of  the 
cephalic  aurse,  vertigo  is  perhaps  the  most  common,  attended  in  some  by  rota- 
tion of  the  head  and  occasionally  of  the  body.  In  certain  epileptics  there  is 
the  sensation  of  rotation  without  actual  movement,  and  in  some  instances 
objects  seem  to  move.  Cephalic  aurte  in  a  considerable  number  of  instances 
consist  of  headache  or  a  sensation  in  the  head  described  as  heaviness,  pres- 
sure, coldness,  burning,  etc. 


582  EPILEPSY. 

In  certain  eases  the  auras  are  entirely  emotional,  having  usually  the  form 
of  fear,  which  is  sometimes  so  great  that  extreme  terror  is  depicted  on  the 
countenance,  and  yet  there  may  be  no  remembrance  of  it  after  the  convulsion 
is  over.  In  a  considerable  number  of  instances  the  aurae  are  manifested  in  the 
organs  of  the  special  senses,  and  consist  in  an  aberration  of  their  functions. 
The  olfactory  aura  is  usually  an  unpleasant  smell,  as  of  sulphur,  putrid  mat- 
ter, pus,  decaying  animal  substances.  The  gustatory  aura  is  a  bitter,  sour, 
metallic,  or  nauseous  taste.  The  ocular  aura  is  an  unusual  sensation  in  the 
eye — diplopia,  an  apparent  change  in  the  size  of  objects  viewed,  sudden 
blindness,  or  the  perception  of  unusual  or  striking  objects,  as  a  flash,  sparks, 
colored  lights,  or  persons  or  things  not  present,  sometimes  quiet,  sometimes 
in  motion.  The  auditory  sensations  occurring  as  aurae  are  sounds  of  many 
kinds — of  music,  of  bells,  thunder,  a  whistle,  the  wind,  an  explosion  or  any^ 
other  startling  sound.  It  is  seen  that  the  aurae,  although  having  a  central 
origin,  occur  in  almost  every  part  of  the  system,  remote  from  as  well  as  near 
the  brain,  and  are  of  many  different  kinds. 

In  some  epileptics  a  harsh  scream  or  groan  announces  the  commencement 
of  the  fit,  but  in  children,  according  to  my  observations,  it  rarely  occurs.  It 
is  apparently  produced  by  a  spasm  of  the  laryngeal  muscles,  which  causes 
narrowing  of  the  passage  through  the  larynx,  and  a  spasmodic  contraction 
of  the  thoracic  and  abdominal  muscles,  which  causes  a  rapid  and  forcible 
expiration.  The  patient  is  unconscious  of  the  scream,  or  he  may  be  conscious 
of  it,  but  unable  to  prevent  it. 

In  the  fit,  when  of  ordinary  severity,  consciousness  is  early  lost,  and  it 
does  not  return  until  the  somnolence  which  follows  the  attack  has  abated;  but 
in  the  mild  disease,  the  petit  mal,  the  patient,  though  confused,  often  retains 
consciousness  during  the  attack.  In  the  yrand  mal  the  attack  begins  with 
a  tonic  spasm  of  the  muscles,  causing  rotation  of  the  head  and  deviation  of 
the  eyes  to  one  side.  Sometimes  there  is  rotation  of  the  entii'e  body,  so  that 
the  patient  turns  around  one  or  more  times  before  he  falls.  The  position  of 
the  limbs  during  the  tonic  spasm  varies.  Commonly  the  arms  are  slightly 
abducted,  the  forearms  flexed  to  a  right  angle,  the  hands  flexed  at  the  wrists, 
the  fingers  flexed  on  the  hands,  but  extended  at  the  other  joints,  and  the 
thumb  is  pressed  upon  the  palm  or  fore  finger.  The  legs  are  ordinarily 
extended,  but  the  legs  as  well  as  arms  may  assume  different  positions. 

Clonic  convulsion,  or  the  second  stage  of  the  attack,  supervenes  in  a  few 
seconds  or  after  two  or  three  minutes.  The  tonic  spasm  relaxes  gradually, 
and  the  clonic  spasm  supervenes  gradually.  The  clonic  convulsion  or  alternate 
contraction  and  relaxation,  rapidly  succeeding  each  other,  occur  in  the  muscles 
of  the  face,  tongue,  palate,  and  larynx,  as  well  as  in  the  muscles  of  trunk 
and  extremities.  The  tongue  is  frequently  bitten,  both  in  the  tonic  and 
clonic  spasms,  so  that  the  blood  oozes,  and,  mixed  with  frothy  saliva,  exudes 
from  the  mouth.  The  pupils  are  dilated  during  the  attack,  and  they  do  not 
contract  by  light.  As  soon  as  consciousness  begins  to  return,  the  pupils 
begin  to  contract  and  respond  to  light.  Exceptionally,  at  the  close  of  the 
fit  the  pupils  alternately  contract  or  dilate  at  intervals  of  one  or  two  seconds, 
and,  as  already  stated,  the  conjunctiva  loses  its  sensitiveness,  so  that  it  can 
be  touched  without  producing  reflex  action  of  the  orbicularis.  Relaxation 
of  the  sphincters  also  often  occurs  during  the  fit,  so  that  fecal  and  urinary 
evacuations  take  place. 

The  pulse  may  be  normal  or  rather  feeble  in  the  beginning  of  the  attack, 
but  its  frequency,  and  sometimes  its  fulness,  increase  during  the  muscular 
spasms.  The  features,  usually  pallid,  but  sometimes  flushed  at  the  beginning 
of  the  attack,  become  congested  and  even  cyanotic  in  less  than  a  minute. 
The  congested  and  livid  features  present  an  alarming  appearance,  and  fre- 


ANATOMICAL   CHARACTERS.  583 

quently  tlie  general  surface  is  bathed  in  perspiration  before  the  attack  ends. 
Ophthahnoscopic  examination  of  the  eyes  during  the  convulsion  is  difficult, 
but  during  the  cyanotic  stage  the  retinal  vessels  have  been  seen  presenting 
an  engorged  and  dusky  appearance,  (iowers  states  that  in  one  instance,  in 
which  fits  occurred  in  rapid  succession  during  several  days,  he  observed  con- 
gestion of  the  discs  with  slight  cedenia,  which  disappeared  after  the  attacks 
ceased.  In  the  intervals  of  the  paroxysms  nothing  has  been  noticed  in  the 
appearance  of  the  eyes  which  throws  light  on  the  nature  of  the  disease. 
The  duration  of  the  second  stage  of  an  epileptic  fit  or  that  of  clonic  spasms 
varies  from  a  minute  or  two  to  a  considerably  longer  time.  When  it  ceases 
the  patient  passes  into  a  sleep  or  deep  stupor,  which  continues  a  quarter  of 
an  hour  or  longer.  If  aroused  from  the  stupor  he  complains  of  severe  head- 
ache, and  this  continues  often  for  hours  after  the  stupor  ceases. 

Languor  and  muscular  weakness  are  common  after  the  fit,  and  they  grad- 
ually pass  ofi".  When,  as  occasionally  happens,  paralysis  occurs  after  the  fit 
and  continues  for  weeks  or  permanently,  organic  cerebral  disease  is  present, 
either  preceding  and  causing  the  fit  or  resulting  from  it.  If  no  paralysis  or 
cerebral  symptoms  have  preceded  a  fit,  and  it  is  followed  by  paralysis  of  one 
or  more  of  the  extremities,  it  is  highly  probable  that  intracranial  hemorrhage 
has  occurred  during  the  attack.  Todd,  Hughlings  Jackson,  and  others 
attribute  the  muscular  weakness  following  an  epileptic  attack  "  to  exhaus- 
tion of  part  of  the  brain  by  the  excessive  action,"  but  protracted  or  per- 
manent loss  of  muscular  powe;"  in  an  epileptic  having  good  general  health 
indicates  organic  disease  in  the  brain. 

The  above  description  relates  to  epilepsy  as  it  ordinarily  occurs,  but  there 
are  many  cases  which  vary  from  the  typical  form.  Tonic  convulsions  may 
occur  without  the  clonic,  and  clonic  convulsions  without  the  tonic,  and  the 
convulsions,  instead  of  being  general,  may  be  limited  to  a  limb  or  to  one 
region  of  the  system.  Of  155  cases  of  minor  epilepsy,  Gowers  states  that 
in  45  the  disease  was  indicated  by  momentary  attacks  of  unconsciousness, 
faintness,  or  sleepiness ;  in  25  by  dizziness ;  in  17  by  sudden  jerking  of 
head,  trunk,  or  limbs;  in  17  by- loss  or  aberration  of  sight;  in  8  by  a  mental 
state,  as  sudden  and  extreme  fright ;  and  in  the  remaining  42  by  sensations 
of  various  kinds  or  momentary  rigidity  or  by  tremors  or  twitching  occurring 
in  some  part  of  the  system.  Automatic  movements  sometimes  occur  during 
the  stage  of  unconsciousness  which  succeeds  the  attack,  and  the  attack  may 
be  so  light  that  it  is  not  noticed  by  the  bystanders.  Gowers  relates  several 
such  instances.  Some  patients  begin  to  undress  themselves,  whatever  the 
surroundings ;  others  make  the  motions  of  walking  up  stairs,  although  no 
stairs  are  present;  some  put  in  their  pockets  any  near  object,  without  regard 
to  its  nature  or  ownership.  Trousseau  states  that  an  architect  during  the 
state  of  unconsciousness  ran  from  plank  to  plank  on  the  scaffold  where  he 
was  at  work,  shouting  his  own  name.  One  of  Gowers's  patients  during  the 
unconscious  state  laughed  and  sang ;  another  threw  her  infant  down  stairs  ; 
a  girl  of  twenty  kissed  every  object  within  her  reach  ;  and  a  man  struck  his 
friend  a  severe  blow.  Many  supposed  criminal  acts  have  been  perpetrated  by 
unconscious  epileptics,  for  which  they  have  been  severely  punished. 

Anatomical  Characters — No  information  has  been  obtained  in  regard 
to  the  etiology  and  nature  of  idiopathic  epilepsy  by  a  study  of  its  anatomical 
characters.  If  the  patient  have  died  in  the  attack,  intense  venous  congestion 
is  observed  of  the  cerebro-spinal  axis  as  well  as  of  other  parts,  but  in  i-ecent 
cases  nothing  else  abnormal  has  been  detected  in  the  brain  or  elsewhere.  The 
thickening  and  opacity  of  the  cerebral  meninges  sometimes  observed  in 
chronic  cases,  and  the  induration  of  the  pes  hippocampi  described  by 
Meynert,  are   now  believed  to  be  results  of  the  repeated   attacks,  and   not 


584  EPILEPSY. 

their  cause.  Structural  change  in  the  brain  in  idiopathic  epilepsy,  if  there 
be  such,  which  sustains  a  causal  relation  to  the  attacks,  has  thus  far  eluded 
detection  by  the  microscope. 

Pathology. — Epileptic  attacks  are  believed  by  neuropathists  to  be  due 
to  a  sudden  and  exaggerated  functional  activity  of  nerve-cells  in  some  part 
of  the  brain.  The  theory  at  present  accepted  is  that  these  cells  generate  a 
nerve-force  which,  transmitted  along  the  nerves,  stimulates  the  muscles  to 
spasmodic  contraction.  In  regard  to  the  part  of  the  brain  in  which  these 
overacting  cells  reside,  we  may  state  that  Brown-Sequard  and  Kussmaul 
demonstrated  that  convulsions  may  be  produced  by  irritating  the  pons  and 
medulla  when  every  other  part  of  the  encephalon  lying  above  these  is 
removed.  Convulsions  can  also  be  produced  in  acranial  monsters,  as  I  have 
stated  above,  by  irritating  the  exposed  medulla  and  pons.  Nothnagel  has  also 
shown  that  there  is  a  "  convulsive  centre  "  in  the  medulla  oblongata.  On 
the  other  hand,  injuries  of  the  convolutions  more  frequently  cause  convul- 
sions than  do  those  of  any  other  part  of  the  brain,  and  Wilks  and  others 
have  taught  that  in  ordinary  epilepsy  the  part  of  the  brain  which  is  most 
frequently  in  fault,  so  as  to  cause  convulsions,  is  the  superficial  portion  or 
the  convolutions.  Still,  the  exaggerated  production  of  nerve-force  which 
causes  the  convulsions  may  be  at  a  greater  depth  than  the  convolutions^ 
even  when  the  attacks  are  due  to  traumatism,  since,  as  Burdon-Sanderson  has 
shown,  nerve-cells  more  deeply  seated  than  the  convolutions  may  be  stim- 
ulated to  increased  functional  activity  by  injuries  of  the  superficial  regions. 
Therefore,  Nothnagel,  aware  of  the  fact  that  injuries  of  the  cortex  often 
cause  convulsions,  states  that  he  sees  no  reason  to  modify  his  opinion  that 
the  exaggerated  production  of  nerve-force  which  causes  the  convulsions  is  in 
the  "  convulsive  centre  in  the  medulla  oblongata."  The  above  observations 
seem  to  indicate  that  epileptic  attacks  do  in  some  instances  originate  in  the 
convolutions  or  hemispheres,  and  in  others  in  the  medulla. 

Recently,  Gowers  and  others  have  endeavored  to  determine  in  what  part 
of  the  brain  the  nerve-force  resides  which  causes  the  convulsions,  by  study- 
ing the  aurse.  Since  the  aurse  have  a  central  origin  and  are  the  first  mani- 
festation of  the  exaggerated  action  of  the  nerve-cells,  the  attempt  is  made  to 
determine  the  location  of  these  cells  by  observing  the  nature  and  the  seat 
of  the  aurae.  Gowers  says  that  one-fifth  of  the  aurae  pertain  to  the  special 
senses,  and  the  nerve-centres  of  these  senses  "  are  certainly  situated  within 
the  hemispheres,  above  the  pons."  Therefore,  the  inference  is  inevitable 
that  in  these  cases  the  discharge  of  nerve-force  which  stimulates  the  muscles 
to  spasmodic  action  is  in  the  hemispheres.  Moreover,  a  fit  that  is  preceded 
by  an  emotional  or  mental  aura,  we  infer,  originates  from  the  nerve-cells  of 
the  hemispheres  which  are  the  seat  of  the  mind.  The  theory  is  therefore 
plausible  and  apparently  sustained  by  clinical  observations,  that  in  at  least 
some  instances  the  epileptic  centre  in  the  brain  is  in  the  hemispheres,  though 
it  may  in  other  instances  be  at  the  base  of  the  brain — in  the  medulla  or 
pons. 

What  occurs  in  the  brain  to  produce  the  phenomena  of  epilepsy  ?  It 
is  the  belief  of  many  specialists  in  nervous  diseases  that  epilepsy  results 
from  suddenly  developed  cerebral  anaemia  produced  by  spasmodic  contraction 
of  the  arterioles.  It  is  also  the  belief  of  some  that  the  primary  discharge 
of  nerve-force  occurs  in  the  medulla  at  the  vaso-motor  centre,  and  that  this 
is  followed  by  spasm  of  the  arterioles  in  the  hemispheres,  by  which  conscious- 
ness is  lost.  That  cerebral  anaemia  is  present  is  inferred  from  the  fact  that 
the  features  are  usually  pallid  when  the  attack  commences.  But  in  many 
instances,  especially  in  epilepsy  of  a  mild  type,  no  pallor  or  other  sign  of 
peripheral  anaemia  is  present,  and  in  such  cases  there  is  no  evidence  what- 


DIA  GNOSIS.  585 

ever  of  cerebral  an;x!inia.  Besides,  as  Gowers  has  forcibly  stated,  pallor  of 
the  features  does  not  necessarily  indicate  cerebral  an;i;niia,  any  more  than 
flushing  of  the  face  indicates  cerebral  hypeneniia.  In  experiments  on  frojrs 
irritation  of  the  brain  causes  contraction  of  the  peripheral  arterioles.  Pro))- 
ably  in  the  same  manner,  says  Gowers.  the  contraction  of  the  peripheral 
arterioles  and  the  pallor  result  from  the  irritation  of  the  brain  occurring  in 
the  first  stage  of  the  fit.  That  cerebral  anasmia  occurs  in  the  attack,  and 
that  it  sustains  a  causal  relation  to  the  phenomena  of  epilepsy,  are  assump- 
tions destitute  of  proof. 

As  to  the  pathology  of  epilepsy,  we  have  said  or  have  intimated  that  it 
is  the  belief  of  the  majority  of  those  who  from  large  clinical  experience  are 
most  competent  to  express  an  opinion  that  the  epileptic  attacks  are  produced 
by  a  hyperactivity  of  nerve-cells  in  the  gray  matter  in  some  part  of  the 
brain,  and  an  increased  discharge  of  nerve-force,  which  stimulates  the  mus- 
cles to  spasmodic  action.  The  spinal  cord  and  the  nerves  are  implicated  as 
carriers  of  this  nerve-force.  Farther  than  this  we  are  unable  to  express  any 
theory  in  the  present  state  of  our  knowledge. 

Diagnosis. — In  a  considerable  number  of  instances  nocturnal  epilepsy 
is  entirely  overlooked.  Some  patients  awaken  at  the  beginning  of  the 
attack,  and  have  subsequently  a  vague  recollection  of  its  occurrence.  Others 
are  aware  of  the  fit  by  subsequent  signs  or  symptoms,  as  a  bitten  tongue, 
blood  on  the  bed-clothes,  a  swollen  and  ecchymotic  face,  conjunctival  extrav- 
asation, and  perhaps  evacuations  in  the  bed.  In  children  nocturnal  epi- 
lepsy is  more  likely  to  be  detected  than  in  adults,  since  they  are  more  closely 
watched.  Gowers  states  that  he  has  known  it  to  occur  twenty  years  with- 
out being  suspected.  In  mild  epilepsy  the  symptoms  may  escape  the  notice 
of  friends,  and  when  observed  by  the  patients  and  friends  their  import  is  often 
misunderstood.  Those  suffering  from  petit  mal  are  in  many  instances  sup- 
posed to  have  attacks  of  faintness.  The  differential  diagnosis  between  epileptic 
vertigo  and  syncopal  faintness  is  made  by  the  fact  that  in  the  latter  the  pre- 
vious health  has  usually  been  poor,  the  action  of  the  heart  feeble,  and  there 
is  some  exciting  cause  of  the  sudden  cardiac  weakness  ;  whereas  in  epileptic 
vertigo  such  conditions  do  not,  as  a  rule,  exist.  In  epileptic  vertigo  there  is 
no  premonition  except  the  aura,  which  is  momentary,  and  recovery  or  return 
to  the  normal  state  is  rapid.  Syncope,  on  the  other  hand,  begins  and  ends 
in  a  more  gradual  manner. 

The  symptoms  of  eclampsia  and  epilepsy  are  identical  as  regards  the 
convulsive  movements.  We  designate  by  the  term  ''  eclampsia "  those 
attacks  which  are  due  to  local  or  general  causes,  which  do  not  recur  when 
these  causes  are  removed,  and  the  occurrence  of  which,  whatever  the  causes, 
is  limited  to  a  brief  period.  But,  as  we  have  seen,  one  attack  of  convul- 
sions predisposes  to  another,  and  one  or  more  convulsive  fits  that  are  eclamp- 
tic frequently  establish  the  convulsive  habit,  so  that  epilepsy  results.  In  a 
large  proportion  of  the  cases  of  eclampsia  the  convulsions  have  a  reflex 
origin.  They  are  produced  by  causes  located  at  a  distance  from  the  brain 
and  affecting  the  nervous  centres,  causing  convulsions  through  the  medium 
of  the  nerves.  Painful  and  swollen  gums  in  dentition,  constipation,  irrita- 
ting ingesta,  intestinal  worms,  scarlet  fever,  nephritis  with  albuminuria,  are 
among  the  common  causes  of  eclamp.sia.  In  recent  convulsions,  when  such 
causes  are  present,  the  diagnosis  of  eclampsia  will  be  proper  in  the  great 
majority  of  instances,  and  the  attacks  will  cease  and  not  recur  when  the 
apparent  causes  are  removed.  Gowers  regards  rickets  as  a  common  cause  of 
eclampsia  in  young  children,  and  remarks  that  when  this  diathetic  state  is 
cured  by  "  cod-liver  oil  and  steel  wine  "  the  convulsions  no  longer  occur ; 
but  if  proper  treatment  be  not  employed,  if  the  rickets  continue,  and  with 


586  EPILEPSY. 

it  the  frequent  convulsive  attacks,  the  epileptic  habit  may  be  established  and 
epilepsy  continue  during  the  remainder  of  life. 

Prognosis. — Epilepsy  is  rarely  fatal,  although  the  symptoms  are  very 
appalling  to  one  who  has  not  previously  witnessed  an  attack.  Asphyxia  has 
occasionally  occurred  by  the  patients  falling  in  water  during  the  fit.  Even 
little  depth  of  water  with  the  face  downward  is  sufficient  to  cause  fatal 
obstruction  to  inspiration.  Therefore,  not  a  few  epileptics  die  by  drowning. 
If  the  patient  roll  upon  the  face  during  the  fit,  or  vomit,  he  may  be  asphyxia- 
ted by  the  bed-clothes  or  by  the  entrance  of  particles  of  food  in  the  larynx. 

The  spontaneous  cessation  of  the  epileptic  fits  and  spontaneous  cure  of 
epilepsy  rarely  occur,  since  each  attack  tends  more  strongly  to  establish  the 
epileptic  habit.  Fortunately,  since  the  therapeutic  uses  of  the  bromides  have 
become  known  epilepsy  has  frequently  been  cured.  In  infancy  and  childhood, 
in  the  majority  of  instances,  epilepsy  is  rendered  milder,  so  that  the  fits  occur 
at  longer  intervals,  even  if  entire  cure  be  not  effected.  Moreover,  the  pros- 
pect of  curing  epilepsy  is  better  in  children  than  in  adults,  in  accordance 
with  the  law  that  the  shorter  its  duration  and  the  fewer  the  attacks  which 
have  already  occurred  the  more  amenable  it  is  to  treatment.  Epilepsy  in 
which  several  days  intervene  between  the  attacks  is,  as  might  be  expected, 
more  likely  to  be  benefited  by  treatment  than  when  the  attacks  are  frequent. 
If  the  mind  be  not  perceptibly  impaired,  if  the  fits  are  uniformly  severe, 
instead  of  some  being  severe  and  others  mild,  if  they  occur  only  during 'sleep 
or'  only  during  wakefulness,  and  if  hemiplegia  be  absent,  the  prognosis  is 
better  than  when  the  reverse  is  the  case.  In  ordinary  cases  of  epilepsy  in 
childhood  the  attacks  immediately  become  less  frequent  by  the  bromide 
treatment.  If  a  sufficient  amount  of  the  bromide  be  administered  three 
times  daily,  months  often  elapse  before  a  recurrence  of  the  attack  ;  but  if 
the  remedy  be  discontinued  after  six  months  or  a  year  in  the  belief  that  the 
patient  is  cured,  a  recurrence  of  the  disease  is  probable.  A  patient  cannot 
be  pronounced  cured  until  three  years  have  elapsed  without  any  symptoms. 

Treatment. — No  mode  of  treating  epilepsy  which  will  effect  an  imme- 
diate cure  has  yet  been  discovered,  nor  is  it  probable  that  such  success  of 
treatment  will  ever  be  obtained.  Cure  is  effected  by  treatment  which  dimin- 
ishes the  hyperactivity  of  the  nerve-cells  that  are  in  fault,  and  prevents  the 
exaggerated  production  of  nerve-force.  Medicines  designed  to  effect  this 
object  must  be  given  daily  for  a  prolonged  period,  since  their  use  for  a  few 
days  or  weeks  does  not  suffice  to  produce  the  desired  change  in  the  nerve- 
centre. 

Since  the  bromides  have  come  into  general  use  in  the  treatment  of  nervous 
diseases,  the  first  place  is  universally  accorded  to  them  among  the  remedies 
for  epilepsy.  The  bromides  of  potassium,  sodium,  ammonium,  and  lithium 
have  probably  nearly  the  same  effect,  but  the  potassium  and  sodium  bromides 
are  usually  prescribed.  No  advantage  results  from  the  use  of  bromine  or 
hydrobromic  acid,  even  if  it  were  safe  and  convenient,  for  it  becomes  a 
bromide  as  soon  as  it  enters  the  alkaline  blood  (Gowers).  All  the  bromides 
produce  acne,  but  this  can  be  prevented  to  a  considerable  extent  by  the 
simultaneous  use  of  arsenic  in  small  doses.  The  bromide  should  be  given 
daily  for  weeks  or  months  in  the  smallest  dose  which  is  found  to  arrest  the 
fits  or,  if  it  do  not  entirely  arrest  them,  produces  the  most  decided  effect  upon 
them.  If  the  fit  occur  at  a  certain  hour,  one  daily  dose,  administered 
previously,  may  suffice  to  prevent  it,  but  usually  it  occurs  irregularly,  and  a 
morning  and  evening  dose  or  three  daily  doses  are  required.  Bromism, 
indicated  by  a  weak  pulse,  cold  extremities,  and  mental  and  physical  dulness, 
has  never,  according  to  my  observations,  seriously  interfered  with  the  treat- 
ment.    During  my  long  connection  with  the  children's  class  of  the  Bureau 


TREATMENT.  587 

for  the  Relief  of  the  Out-door  Poor  at  Bcllevue  almost  every  week  new  cases 
of  epilepsy  have  been  presented  for  treatment,  and  it  has  seldom  been  neces- 
sary to  discontinue  the  use  of  the  bromide  on  account  of  broniism.  A  girl 
liad  her  first  attack  of  clonic  convulsions  at  the  age  of  four  months.  When 
she  reached  the  age  of  three  years  and  a  few  months  she  began  to  have 
attacks  of  the  petit  ma/,  manifested  by  pallor  and  an  epigastric  aura,  followed 
by  sleep  lasting  one  or  two  hours.  These  attacks  occurred  at  irregular  inter- 
vals. In  her  fourth  year  she  had  measles  and  scarlet  fever.  In  her  seventh 
year  she  came  under  observation.  A  strict  milk  diet  was  ordered,  and  she 
took  one  teaspoonful  in  the  morning  and  two  at  night  of  the  following  mix- 
ture : 

R.  Sodii  bromidi,  .siiiss; 

Aqua;,  o^^j-     Misce. 

This  treatment  was  continued  with  scarcely  an  interruption  during  her 
seventh,  eighth,  and  ninth  yeai's,  with  complete  cure  of  the  disease  and  with 
bromism  only  on  one  occasion.  Gowers.  writing  of  adults,  remarks  that  few 
patients  can  take  more  than  one  and  a  half  drachms  of  the  bromide  daily 
without  bromism.  But,  according  to  my  observations,  children  can  take  lar- 
ger proportionate  doses  than  this  without  injury.  Although  prescribing  the 
bromide  of  potassium  daily  for  children  of  all  ages  during  many  years,  I 
have  seldom  observed  any  ill  effects  which  were  clearly  attributable  to  its  use 
except  the  occurrence  of  acne.  Bromism  soon  disappears  when  the  dose  of 
the  bromide  is  diminished  or  its  use  is  discontinued.  In  general,  this  medi- 
cine should  be  given  twice  or  three  times  daily  during  as  long  a  period  as 
two  years  after  the  last  paroxysm,  without  diminishing  the  dose  which  is 
found  sufficient  to  cure  the  disease ;  and,  to  make  sure  of  a  cure,  it  should 
be  employed  a  third  year  in  a  gradually  diminishing  dose.  In  the  case 
related  above  the  patient,  a  girl  then  at  the  age  of  nine  years,  had  taken  the 
bromide  of  sodium  two  years  in  two  doses  of  thirteen  and  twenty-six  grains 
with  complete  arrest  of  the  attacks,  when  she  had  symptoms  of  bromism. 
The  bromide  was  discontinued,  and  she  remained  well  for  some  weeks,  but 
finally  she  stated  that  the  furniture  at  times  seemed  to  move.  Half  the 
previous  dose  was  now  employed  for  a  month  or  two,  when  it  was  discon- 
tinued, and  she  has  remained  well  without  medicine  during  the  six  or  eight 
months  which  have  since  elapsed.  In  slight  bromism  during  the  first  and 
second  years  of  treatment  it  is  usually  better,  I  think,  to  diminish  the  dose 
of  the  bromide ;  but  not  to  discontinue  its  use,  and  at  the  same  time  to 
employ  a  vegetable  tonic  with  alcohol.  In  great  cerebral  depression  due  to 
the  bromide,  it  is  probably  better  to  entirely  discontinue  its  use  for  a  time, 
even  if  convulsions  occur. 

Occasionally,  the  bromide  employed  alone  does  not  cure  epilepsy.  It  may 
then  be  given  in  combination  with  another  drug  which  is  believed  to  exert 
some  controlling  influence  upon  the  disease,  as  digitalis,  belladonna,  cannabis 
indica,  or  zinc.  These  remedies  were  prescribed  with  apparent  benefit  in  at 
least  certain  instances  before  the  bromides  came  into  use.  Digitalis  has  been 
employed  as  a  remedy  for  epilepsy  since  Parkinson  recommended  it  in  1640. 
It  is  not  very  efficient  when  used  alone,  but  in  some  instances  when  given 
with  the  bromide  it  evidently  increases  the  curative  power  of  this  agent. 
■Gowers  says :  '•  In  many  cases  attacks  which  continued  on  bromide  only 
■ceased  entirely  on  bromide  and  digitalis."  He  observed  good  results  from 
the  use  of  this  combination,  especially  in  epileptics  who  had  cardiac  disease, 
as  dilatation,  valvular  insufficiency,  hypertrophy,  and  a  too  rapid  pulse. 
Benefit  also  occurred  in  some  instances  in  which  the  heart's  action  was  nor- 
mal, as  in  the  following  case :  Jesse ^,  aged  twelve  years,  was  when  an 


588  EPILEPSY. 

infant  racliitic,  backward  in  teething  and  the  use  of  his  limbs.  He  had  the 
first  epileptic  fit  at  the  age  of  sixteen  months.  The  attacks  occurred  at 
intervals  of  one  week,  and  were  preceded  by  a  visual  aura,  a  red  ball  of  fire, 
that  approached  the  eye.  Fifteen  grains  of  the  bromide  of  ammonium,  with 
five  minims  of  the  tincture  of  belladonna,  were  prescribed,  to  be  given  twice,, 
and  subsequently  three  times,  daily.  With  this  treatment  the  intervals 
between  the  fits  were  lengthened  to  one  month,  but  they  still  occurred  after 
six  months'  treatment.  Five  minims  of  the  tincture  of  digitalis  were  then 
substituted  for  the  belladonna,  and  no  fit  occurred  for  eleven  months.  On 
diminishing  the  dose  of  digitalis,  one  fit  occurred,  but  on  resuming  its  use  in 
five-minim  doses  seven  months  elapsed  without  an  attack.  A  girl  of  eighteen 
years  had  a  convulsion  at  the  age  of  two  years,  another  at  seven  years,  and 
confirmed  epilepsy  since  her  tenth  year.  The  attacks  occurred  about  every 
second  day,  without  an  aura.  The  bromide  alone  and  bromide  with  bella- 
donna were  employed,  with  slight  diminution  in  the  frequency  of  the  attacks. 
Digitalis  with  the  bromide  was  then  employed.  Immediately  the  fits  were 
reduced  to  four,  then  to  two,  in  the  month,  and  then  four  months  elapsed 
without  a  fit.  A  girl  aged  eleven  years,  greatly  frightened  by  a  thunder- 
storm, began  to  have  nocturnal  epileptic  attacks.  At  the  age  of  fourteen 
years,  when  treatment  was  commenced,  the  attacks  occurred  nearly  every 
night.  One  scruple  of  the  bromide  of  potassium  and  ten  minims  of  tincture 
of  belladonna  reduced  the  attacks  to  one  in  ten  days.  Then  the  treatment 
was  changed  to  two  scruples  of  bromide  of  ammonium  and  five  minims  of 
tincture  of  digitalis,  taken  once  daily  at  night,  and  two  months  passed  with- 
out an  attack,  when  she  was  lost  sight  of.  These  eases,  to  which  more  might 
be  added,  show  that  digitalis  combined  with  the  bromide  increases  the  efiicacy 
of  the  latter  in  certain  cases. 

Belladonna  has  been  employed  in  the  treatment  of  epilepsy  during  the 
last  two  centuries.  It  was  recommended  by  Mardorf  in  1691,  and  by  Hufe- 
land,  Stoll,  and  others  in  the  eighteenth  century.  Its  proper  use  is  in  com- 
bination with  one  of  the  bromides  when  the  latter  is  inadequate  to  arrest  the 
attacks.  Used  alone,  it  does  not  cure  epilepsy,  though  occasionally  it  renders 
the  attacks  less  frequent.  But  Growers  relates  cases  which  show  that  it 
increases  the  efficiency  of  the  bromides  in  certain  cases  when  combined  with 
them.  It  is  believed  to  first  stimulate  and  then  depress  the  functions  of  the 
nervous  system,  acting  not  upon  one  part  only,  but  upon  various  parts  of 
brain  and  spinal  cord,  affecting  their  functional  activity.  To  show  the  effect 
of  the  combination  of  belladonna  with  the  bromide,  Gowers  relates  the  case 
of  a  boy  in  whom  epilepsy  commenced  at  the  age  of  thirteen  years  without 
known  cause.  The  attacks  began  usually  in  the  morning  without  an  aura^ 
at  intervals  of  three  weeks.  Fifteen  grains  of  the  bromide  administered 
night  and  morning  reduced  the  attacks  to  one  a  month.  After  three  months 
of  treatment  twenty  grains  of  the  bromide  and  five  minims  of  tincture  of 
belladonna  were  given  three  times  daily,  and  two  months  elapsed  without  an 
attack,  when  two  occurred.  Subsequently,  he  took  the  same  medicine  four- 
teen months  without  an  attack,  when  treatment  was  discontinued.  Six  months 
later  he  was  still  well.  Other  cases  have  been  related  in  which  belladonna,, 
combined  with  the  bromide,  produced  a  more  decided  curative  action  than 
the  bromide  employed  alone  ;  but  in  some  instances,  as  we  have  seen,  when 
these  two  agents  fail  to  cure  this  result  is  accomplished  by  the  bromide  and 
digitalis.  The  liquor  atropise,  one  minim  of  which  contains  j-^-^-  of  a  grain 
of  atropine,  may  be  used  in  place  of  the  tincture  of  belladonna. 

Stramonium,  cannabis  indica,  and  gelsemium  sempervirens  have  been  pre- 
scribed with  some  apparent  benefit  in  certain  instances,  but  it  is  the  common 
belief  with  those  who  have  employed  them  that  they  are  no  more  efficacious 


TREATMENT.  589 

than  digitalis  and  belladonna,  and  they  seldom  if  ever  cure  the  disease  when 
used  alone.  When  employed  with  the  bromide,  good  results  have  followed, 
but  the  improvement  has  {)robably  been  due  almost  entirely  to  the  bromide. 

Zinc  has  been  recommended  in  the  treatment  of  epilepsy  for  more  than  a 
c'entury  by  good  observers.  In  experiments  on  animals  it  has  been  found  to 
diminish  reflex  action,  and  it  exerts  some  controlling  effect  on  the  functions 
of  the  hemispheres  and  the  medulla  oblongata.  It  diminishes  the  frequency 
of  the  epileptic  attacks  in  many  patients,  but  not  usually  so  certainly  as  the 
bromides,  or  to  such  an  extent.  In  exceptional  instances  zinc  prevents  the 
<ipileptic  attacks  to  a  greater  extent  than  the  bromide,  especially  when  they 
present  the  hysteroid  form.  The  oxide,  lactate,  and  citrate  are  commonly  pre- 
iscribed,  and  a  child  of  eight  years  can  take  from  one  to  two  grains  three  times 
daily.  It  should  be  given  after  the  meals,  since  it  sometimes  irritates  the 
stomach  and  causes  nausea.  It  is  believed  by  Gowers  to  be  slowly  converted 
into  the  chloride  in  the  stomach.  He  relates  the  case  of  an  adult  epileptic 
who  took  five  grains  of  the  oxide  of  zinc  morning  and  evening,  and  had  no 
attack  during  the  five  months  in  which  he  was  under  observation.  A  girl  of 
eight  years  having  inherited  epilepsy,  after  four  months  of  treatment  with 
the  bromide  was  still  having  two  fits  each  week.  Oxide  of  zinc  in  doses  of 
three  grains  was  ordered,  and  in  two  months  the  fits  ceased.  Nine  months 
■elapsed  with  only  one  attack,  when  the  patient  was  lost  sight  of.  Gowers 
also  relates  the  following  case,  showing  that  the  addition  of  the  zinc  to  the 
bromide  sometimes  plainly  increases  the  efficiency  of  the  latter:  A  boy  of 
eleven  months,  belonging  to  an  epileptic  family,  had  a  fit  at  the  age  of  eleven 
months.  At  the  age  of  fourteen  years,  when  he  was  presented  for  treatment, 
the  convulsions  occurred  every  two  weeks.  One  scruple  of  bromide  of 
ammonium  administered  three  times  daily  caused  some  improvement,  as  did 
the  bromide  with  digitalis,  but  the  disease  was  not  cured  until  the  zinc  was 
employed  with  the  bromide.  In  obstinate  cases,  therefore,  zinc  is  sometimes 
useful  as  an  adjuvant  to  the  bromide. 

Opium,  or  its  alkaloid  morphia,  has  been  long  employed  in  the  treatment 
of  epilepsy,  but  its  use  has  now  given  place,  for  the  most  part,  to  that  of 
other  remedies.  Occasionally,  especially  in  the  hysteroid  forms  of  epilepsy, 
morphia  given  at  the  commencement  of  the  warning  has  apparently  pre- 
vented the  fit. 

The  effiect  of  iron  in  epilepsy  is  equivocal  and  uncertain.  Brown- 
Sequard  and  Jackson  discountenance  its  use,  as  they  think  it  increases  the 
frequency  of  the  attacks.  Gowers  says  that  he  has  given  iron  to  several 
hundred  epileptics,  and  that  it  only  rarely  increases  the  severity  of  the  fits. 
In  most  instances  it  produces  no  ill  eff'ect,  and  it  sometimes  improves  the 
general  health.  He  states  that  occasionally  bromide  with  iron  arrests  the 
attacks  when  the  bromide  alone   has  little  eff'ect. 

A  considerable  number  of  remedies  which  we  have  not  mentioned  have 
been  employed,  but  they  have  been  for  the  most  part  discarded  by  recent 
observers,  either  because  they  have  been  found  to  be  inert  or  have  been  use- 
ful only  in  rare  cases,  and  less  useful  than  other  remedies. 

According  to  my  observation,  the  treatment  which  has  been  found  ade- 
quate to  arrest  the  fits  should  be  continued  at  least  two  years  after  the  last 
paroxysm,  being  omitted  for  a  few  days  or  its  quantity  reduced  if  symptoms 
of  bromism  occur.  Even  after  a  cure  for  two  years  occasional  symptoms  of 
the  petit  mal  may  occur,  so  that  it  will  be  necessarj^  to  resume  the  use  of  the 
medicine  in  smaller  doses. 

Hi/gienir  Treatment. — It  is  necessary  that  an  epileptic  child  should  lead  a 
quiet  and  regular  life,  free  from  excitement  and  all  perturbating  influences. 
The  diet  should  be  plain  and  easily  digested.     In  some  instances  a  diet  con- 


590  INTERNAL   CONVULSIONS. 

sisting  almost  entirely  of  milk  has  seemed  to  be  a  very  important  remedial 
measure. 


CHAPTER    XII. 

INTEENAL  CONVULSIONS   (SPASM   OF  THE  GLOTTIS;    LAEYN- 
GISMUS  STEIDULUS). 

Young  children  are  liable  to  temporary  suspension  of  respiration,  induced 
by  violent  emotions,  especially  by  anger.  In  the  midst  of  their  excitement, 
while  they  are  crying  or  screaming,  their  breath  is  suddenly  held,  as  if  from 
tonic  spasm  of  the  respiratory  muscles.  In  a  few  seconds  respiration  returns 
and  is  natural.  There  is  no  stridulous  inspiration  or  other  unusual  sound, 
and  there  is  no  apparent  ill-effect,  unless  occasionally  a  degree  of  languor. 
External  convulsions,  which  seem  to  be  threatening,  seldom  occur,  and  when 
they  do  are  ordinarily  mild.  Some  writers  consider  dentition  the  predispos- 
ing cause  of  this  arrest  of  respiration  by  inducing  a  sensitive  state  of  the 
nervous  system.  Such  an  effect  of  dentition  is  possible,  but  certainly  many 
infants  are  affected  in  this  manner  before  the  age  of  dentition. 

A  much  more  serious  state,  and  one  which  is  recognized  as  a  true  disease,, 
is  that  variously  designated  by  writers  as  internal  convulsions,  spasm  of  the 
glottis,  child-crowing,  laryngismus  stridulus,  etc.  Manifest  difficulties  attend 
the  investigation  of  the  pathological  state  in  this  disease.  There  can  be  little 
doubt  that  it  is  not  precisely  the  same  in  all  cases.  That  there  is,  during  the 
paroxysms,  tonic  or  clonic  spasm  of  more  or  fewer  of  the  respiratory  muscles- 
is  inferred  not  only  from  the  symptoms  pertaining  to  the  respiratory  appa- 
ratus, but  from  the  fact  that  in  severe  cases  spasms  of  the  external  muscles,, 
as  those  of  the  limbs  and  face,  often  occur.  Usually,  also,  the  movements 
of  the  eyeballs  indicate  spasmodic  contractions  of  the  motor  muscles  of  the 
eyes.  The  fact  of  spasmodic  muscular  action  in  parts  that  are  visible  justi- 
fies the  belief  that  it  occurs  in  other  parts  which  are  concealed  from  view, 
especially  as  the  characteristic  symptoms  cannot  be  readily  explained  except 
on  this  supposition.  Trousseau  says:  "Internal  convulsions  consist,  then,, 
principally  in  a  spasm  of  the  diaphragm  and  of  the  respiratory  muscles  of 
the  abdomen  and  chest ;  but  it  occurs  also  that  the  muscles  pertaining  to  the 
larynx  are  affected  with  spasm  at  the  same  time  with  these."  Rilliet  and 
Barthez  conclude  from  the  symptoms  that  the  "  heart  is  not  always  a  stran- 
ger to  this  internal  convulsion,  which  perhaps  prolongs  itself  even  to  the 
intestines."  The  muscles  of  the  pharynx  appear  to  be  involved  in  some 
cases,  as  well  as  those  of  respiration,  rendering  deglutition  difficult.  In  one 
form  of  internal  convulsions — namely,  that  which  is  principally  referred  to 
by  writers — there  is  not  complete  arrest  of  respiration,  but  the  inspirations 
during  the  paroxysms  are  difficult  and  are  attended  by  a  stridulous  noise. 
Again,  the  respiration  may  cease  entirely,  but  when  it  commences  it  is  strid- 
ulous and  difficult  during  a  few  inspirations.  In  still  another  form  of  the 
disease  respiration  ceases,  but  there  is  no  symptom  or  sign  indicative  of  glot- 
tic spasm  or  of  an  obstacle  to  the  ingress  of  air ;  the  inspirations  which  suc- 
ceed the  paroxysm  are  easy  and  noiseless.  It  has  been  suggested  that  in 
these  cases  there  is  paralysis  rather  than  spasmodic  contraction  of  the  respi- 
ratory muscles  ;  but  the  symptoms  may  be  explained  in  accordance  with  the 
commonly  accepted  opinion — namely,  that  there  is  spasm  of  the  diaphragm 
and  perhaps  of  certain  muscles  of  the  chest  and  abdomen,  while  the  laryn- 


CAUSES.  591 

j^eal  muscles  are  not  affected.  M.  Herard,  indeed,  wlio  lias  written  one  of 
the  best  monographs  on  internal  convulsions,  describes  three  forms  of  the 
disease  according  to  the  supposed  location  of  the  spasm — namely,  laryngeal, 
diaphragmatic,  and  another  which  consists  of  a  blending  of  the  two. 

Internal  convulsions  are  not  frequent  in  this  country  ;  they  are  rare  in 
France,  more  frequent  in  Germany,  and  quite  common  in  England.  They 
occur,  with  few  exceptions,  before  the  age  of  two  years.  Dr.  West  observed 
31  cases  under  the  age  of  two  years,  and  only  6  above  that  age. 

Causes. — The  causes  of  internal  convulsions  are  not  fully  ascertained. 
Most  observers  have  remarked  the  relative  frequency  of  the  disease  during 
the  period  of  dentition,  and  it  is  probable  that  dental  evolution  does  operate 
as  a  cause  by  rendering  the  nervous  system  more  impressible. 

Spasm  of  the  glottis  has  been  attributed  to  enlargement  of  the  thymus 
gland,  and  also  to  enlargement  of  the  cervical  and  bronchial  glands.  It  is 
presumed  that  this  effect  is  due  to  the  pressure  of  these  glands  on  the  par 
vagum  or  the  recurrent  laryngeal  nerve.  It  is  certain,  however,  that  there 
is  no  such  enlargement  of  the  thymus  gland  which  could  possibly  produce 
glottic  spasm  or  any  other  form  of  internal  convulsion  at  the  age  at  which 
these  convulsions  commonly  occur.  This  gland  is  largest  in  the  new-born, 
and,  having  no  function  after  birth,  it  gradually  becomes  atrophied.  If  an 
enlarged  thymus  could  produce  glottic  spasm,  it  would  certainly  occur  most 
frequently  in  the  new-born.  Abnormal  development  of  the  thymus  gland 
seemed  to  be  the  cause  of  atelectasis  in  two  infants  who  died  soon  after  birth 
in  my  practice,  but  I  have  not  seen  a  case  in  which  a  convulsive  attack  was 
referable  to  this  cause.  M.  Herard  examined  the  thymus  gland  in  6  children 
who  died  of  internal  convulsions  and  in  60  who  died  of  other  affections,  and 
was  not  able  to  discover  in  its  condition  any  causal  relation  to  this  disease. 
Indeed,  cases  have  been  reported  in  which  the  thymus  had  undergone  more 
than  its  usual  atrophy  at  the  time  when  the  convulsions  occurred  (Haase). 
Enlargement  of  the  lymphatic  glands  in  the  vicinity  of  the  pneumogastric  or 
recurrent  laryngeal  nerve  may  possibly  give  rise  to  glottic  spasm,  but  this  is 
doubtless  an  infrequent  cause,  if  it  be  a  cause  at  all,  since  these  glands  are 
often  greatly  enlarged  in  strumous  and  tubercular  diseases  without  such  a 
result.  According  to  Dr.  Jacobi : '  "  In  some  cases  described  by  Dr.  Fried- 
leben  a  congenital  hypertrophy  of  the  thyroid  gland  has  probably  been  the 
cause  of  laryngismus.  The  patients  were  new-born  infants  of  normal  devel- 
opment and  born  by  normal  labors.  There  were  no  constitutional  causes  of 
the  disease,  but  a  remarkable  vascular  swelling  of  the  thyroid  gland.  When- 
ever the  swelling  increased  the  veins  of  the  face  and  head  increased  in  size 
also,  the  face  grew  livid,  and  the  extremities  and  spinal  column  exhibited 
slight  tonic  convulsions.  The  recurrent  nerves  were  entirely  surrounded  by 
the  glandular  tissue,  their  neurilemma  looked  unusually  red,  and  their  func- 
tions were  probably  injured  during  the  occasional  swelling  taking  place  dur- 
ing lifetime"  (Jacobi). 

The  cause  is  occasionally  located  in  the  cerebro-spinal  axis.  Thus,  Dr. 
Coley  relates  a  case  in  which  an  exostosis  arising  from  the  internal  surface 
of  the  occipital  bone  pressed  upon  the  cerebellum,  while  nothing  abnormal 
was  discovered  in  other  organs.  Examples  are  also  related  in  which  the 
cause  was  located  in  the  spinal  cord.  Thus,  Marshall  Hall  relates  the  case 
of  a  child  with  spina  bifida  who  was  attacked  with  croup-like  convulsions 
whenever  it  lay  so  as  to  press  on  the  tumor. 

Internal  convulsions  are  also  frequent  in  rachitic  softening  and  absorp- 
tion of  the  calvarium,  since,  when   this  is  present,  undue  pressure  occurs 
upon  the  brain  by  the  weight  of  the  head  of  the  child  upon  the  pillow. 
^  M.  Y.  Jour,  of  Med.,  Jan.,  1860. 


592  INTERNAL   CONVULSIONS. 

In  some  patients  there  is  evidently  an  hereditary  predisposition  to  this 
disease,  those  aflfeeted  belonging  to  families  in  which  a  tendency  to  convul- 
sive maladies  is  manifested.  Thus,  Toogood  states  that  five  infants  of  the 
same  family  were  affected  with  spasm  of  the  glottis ;  and  Reid  relates,  on 
the  authority  of  Powel,  that  of  thirteen  infants  of  the  same  parents  only 
one  escaped  internal  convulsions. 

The  common  predisposing  cause  is  an  excitable  state  of  the  nervous  sys- 
tem, often  associated  with  impaired  general  health.  Hence  the  disease  is 
more  prevalent  in  cities,  where  antihygienic  conditions  abound,  than  in  the 
country.  Hence,  too,  the  frequent  improvement  when  the  patient  is  removed 
to  the  pure  and  bracing  air  of  the  country.  The  use  of  insufficient  food  or 
food  of  a  bad  quality  must  for  the  same  reason  be  considered  a  cause,  since 
it  leads  to  impoverishment  of  the  blood  and  renders  the  nervous  system  more 
impressible.  Facts  mentioned  by  Reid  and  others  show  conclusively  the  influ- 
ence of  premature  weaning  and  the  use  of  indigestible  or  otherwise  improper 
aliment  in  the  production  of  this  disease. 

The  causes  enumerated  above  are  for  the  most  part  predisposing ;  occa- 
sionally they  are  the  only  apparent  causes,  since  this  disease  sometimes  occurs 
when  the  child  is  tranquil,  even  in  the  midst  of  quiet  sleep  or  when  it  is  at 
rest  in  its  mother's  arms.  In  other  cases  and  more  frequently  there  is  an 
exciting  cause,  often  trivial.  Anything  that  requires  exertion  on  the  part 
of  the  infant  or  that  excites  strong  emotions  may  be  a  direct  cause,  as  anger 
or  any  of  the  violent  passions ;  so  may  even  coughing,  or,  in  rare  instances, 
attempts  to  swallow.  One  author  has  known  it  to  occur  from  excitement 
produced  by  examining  the  throat  with  a  spoon.  In  a  case  of  my  practice, 
hereafter  related,  it  occurred  whenever  the  infant  cried  violently.  It  appears 
from  the  above  facts  that  the  etiology  of  internal  convulsions  is  very  similar 
to  that  of  eclampsia.  The  same  spasmodic  muscular  contraction  may  occur 
from  a  variety  of  causes. 

Anatomical  Characters. — While,  therefore,  structural  changes  in 
various  parts  of  the  system  may  give  rise  to  internal  convulsions,  this  dis- 
ease, so  far  as  ascertained,  presents  no  anatomical  characters,  and  must  conse- 
quently be  considered  one  of  the  neuroses.  The  lesions  of  the  respiratory 
apparatus  which  are  seen  at  post-mortem  examinations  are  due  to  the  convul- 
sions or  are  coincidences.  Emphysema  has  sometimes  been  observed  as  a 
result,  it  is  believed,  of  the  spasmodic  and  irregular  respiration.  It  was  pres- 
ent in  all  of  Herard's  cases,  and  Rilliet  and  Barthez  consider  it  common  in 
those  who  die  of  this  affection,  although  they  did  not  observe  it  in  any  of 
their  cases.  Slight  emphysema  in  the  upper  lobes  is,  however,  a  common 
lesion  in  feeble  infants,  whatever  the  diseases  of  which  they  die.  Therefore 
its  occurrence  in  internal  convulsions  is  probably  due  more  to  molecular 
change  in  the  lungs,  since  these  patients  are  cachectic,  than  to  the  irregular 
breathing,  which  is  only  momentary. 

In  fatal  cases  of  internal  convulsions  the  blood  is  darker  than  usual,  from 
an  excess  of  carbonic  acid ;  and  in  some  cases  the  cavities  of  the  heart  and 
large  vessels  are  engorged  with  blood,  but  in  others  they  contain  no  more 
than  the  normal  amount.  More  or  less  passive  congestion  occurs  in  the  inter- 
nal organs  ;  and  congestion  of  the  cerebral  vessels  is  in  some  patients  so  great 
that  transudation  of  serum  occurs. 

Symptoms. — I  have  said  that  the  symptoms  vary  according  to  the  seat 
and  function  of  the  muscles  which  are  affected.  There  is  generally  previous 
ill-health.  The  child  is  drooping,  and  is  sometimes  restless,  for  days  before 
the  disease  appears.  Finally,  if  the  muscles  of  the  glottis  become  affected, 
the  peculiar  crowing  sound  is  heard  now  and  then  during  inspiration.  It 
is  observed  especially  when  the  child  is  crying  or  is  agitated.     It  may  be  loud 


SYMPTOMS.  593 

and  well  defined  from  the  first,  but  in  most  patients  it  comes  on  gradually, 
so  that  several  days  elapse  before  its  full  stridulous  character  is  developed. 
The  attacks  are  more  frequent  and  severe  at  night,  in  or  after  the  first  sleep, 
than  in  day-time. 

Under  favorable  hygienic  conditions  the  malady  may  pass  oiF  without 
becoming  more  serious.  In  other  cases  the  paroxysms  gradually  increase 
in  frequency  and  severity.  The  dyspna^a  in  the  attack  is  such  that  the  fea- 
tures are  livid,  the  head  forcibly  retracted,  and  death  seems  imminent  from 
apnoea.  In  these  severe  paroxysms  respiration  often  ceases  entirely  for  a 
moment.  When  the  spasm  ends  a  deep  stridulous  inspiration  occurs,  after 
which  the  breathing  is  natural.  I  have  stated  also  that  internal  convulsions 
are  often  associated  with  those — usually  tonic,  but  sometimes  clonic — of  the 
external  muscles.  In  the  tonic  form  the  thumbs  are  flexed  across  the  palms 
of  the  hands,  and  sometimes  are  grasped  by  the  fingers ;  the  great  toes  are 
addueted  and  the  other  toes  flexed.  In  severe  cases  the  hands,  forearms,  feet, 
and  legs  are  also  somewhat  flexed  and  rigid.  At  first  the  contraction  of  the 
external  muscles  is  temporary,  either  corresponding  with  the  internal  spasm, 
or  it  is  most  intense  at  the  time  of  the  spasm,  though  commencing  sooner  and 
subsiding  later.  After  a  while,  however,  if  the  disease  continue,  the  spas- 
modic action  of  the  external  muscles  becomes  more  persistent.  In  severe 
cases  nearly  every  inspiration  is  accompanied  by  the  whizzing  sound,  and  the 
paroxysms  of  dyspnoea  are  excited  by  trifling  causes.  Anything  that  sud- 
denly disturbs  the  mind  or  body  may  bring  on  the  attack,  as  anger,  the 
impression  of  cold,  or  currents  of  air.  Dr.  West  calls  attention  to  the  fact 
that  an  anasarcous  condition  is  sometimes  present,  accompanied  by  albumi- 
nuria. 

If  the  convulsions  afiect  other  muscles,  as  the  diaphragm  or  the  pectoral 
and  abdominal  muscles,  which  are  concerned  in  the  respiratory  function, 
while  those  of  the  larynx  escape,  respiration  is  irregular,  or  even  suspended 
for  a  moment,  but  the  stridulous  laryngeal  sound  is  absent,  as  there  is  no 
obstacle  in  the  larynx  to  the  entrance  of  air.  In  this  form  of  the  disease 
the  inframammary  region  may  be  strongly  retracted  during  the  paroxysm 
from  tonic  contraction  of  the  diaphragm.  In  severe  paroxysms,  whether  the 
spasm  be  laryngeal  or  diaphragmatic,  consciousness  is  nearly  or  quite  lost,  the 
features  may  be  pallid,  or,  if  respiration  be  suspended,  may  be  more  or  less 
livid.  Relaxation  of  the  sphincters  of  the  bowels  and  bladder,  with  invol- 
untary evacuations,  often  occurs  in  this  disease  during  the  attack. 

The  duration  of  the  paroxysm  may  be  a  quarter,  a  half,  or  even  a  whole 
minute.  Total  suspension  of  respiration  for  even  half  a  minute  involves 
danger.  In  mild  cases  there  may  be  but  few  paroxysms,  and  they  slight. 
In  other  instances  they  occur  in  a  severe  form  almost  daily  for  several  weeks 
or  even  months.  In  the  following  case  the  muscles  of  the  larynx  were  appa- 
rently not  involved.  The  patient  was  scrofulous,  and  has  since  had  scrofu- 
lous periostitis,  with  necrosis  and  exfoliation  of  the  surface  of  the  tibia.  At 
the  time  of  the  internal  convulsions  she  had,  as  seen  by  the  history,  a  scor- 
butic or  hemorrhagic  cachexia : 

Case.— On  the  28th  of  August,  1858,  a  German  female  infant,  fourteen 
months  old,  nursing  and  having  eight  teeth,  was  suddenly  seized  with  clonic 
convulsions.  Uniformly  delicate  and  pallid,  she  had  been  in  her  usual  health 
till  the  age  of  twelve  months,  when  she  had  a  single  convulsive  attack,  and  from 
that  date  had  remained  well  till  August  27th,  when,  without  any  premonitory 
symptom,  she  had  a  stool  consisting  of  almost  pure  blood,  black  and  offensive. 
On  the  morning  of  the  28th  a  similar  evacuation  occurred,  and  another  in  the 
afternoon  immediately  preceding  the  convulsion.  Pulse  128  after  the  convul- 
sion;  surface  cool  and  pallid;  flesh  soft,  but  no  emaciation.  Turpentine  was 
38 


594  INTERNAL   CONVULSIONS. 

prescribed  in  two-drop  doses  every  two  hours,  and  laudanum  in  one-and-a-half- 
drop  doses  repeated  sufficiently  often  to  ensure  quietude. 

On  the  29th  the  pulse  was  152.  At  1  p.  m.  she  had  a  general  convulsion, 
lasting  about  five  minutes ;  in  the  evening  she  had  an  evacuation  similar  to 
those  passed  on  the  preceding  day.  The  record  for  August  30th  states :  "  Pulse 
150  to  160 ;  up  to  this  time  has  been  playful,  but  is  now  drowsy,  and,  when  dis- 
turbed, fretful;  manifests  no  desire  for  solid  food,  as  before  her  sickness,  but  still 
nurses;  has  taken  up  to  this  time  thirty-two  drops  of  turpentine.  When  she 
cries  or  frets  she  has  a  spasmodic  attack."  This  was  the  commencement  of  inter- 
nal convulsions,  with  which  this  child  was  affected  for  several  months.  An  oppor- 
tunity was  afforded  of  observing  their  character,  for  her  excitement  when  she 
was  examined  was  usually  sufficient  to  produce  them.  After  a  succession  of 
short  expirations  respiration  ceased ;  for  a  moment  she  was  apparently  insensi- 
ble ;  eyes  closed ;  face  pallid ;  no  frothing  at  the  mouth.  The  return  of  conscious- 
ness and  respiration  was  without  any  laryngeal  rale,  and  after  the  attack  she 
seemed  as  well  as  before.  No  external  convulsion  and  no  evacuation  of  blood 
occurred  after  August  31st. 

There  was  gradual  improvement  in  her  health,  but  she  continued  for  many 
months  pallid  and  irritable  and  subject  to  attacks  of  internal  convulsions.  On 
the  11th  of  April,  1859,  when  twenty-two  months  old,  she  had  another  attack  of 
general  convulsions.  The  record  made  on  that  day  is:  "Has  had  internal  con- 
vulsions (one  or  more  paroxysms)  almost  every  day  since  last  August,  brought 
on  usually  by  crying  when  she  is  corrected  in  any  way  or  her  wishes  are  refused." 
Again,  on  December  1,  1859,  it  is  stated:  "Has  grown  considerably  since  the 
last  record,  and  appears  to  have  recovered,  except  that  at  long  intervals  the 
spasms  still  occur."  She  took  a  prei^aration  of  iron,  but  her  recovery  seemed  to 
be  due  more  to  the  growth  and  development  of  the  body  and  to  hygienic  than 
therapeutic  measures. 

The  general  health  in  internal  convulsions  is  more  or  less  impaired,  except 
in  mild  forms  of  the  disease,  in  which  the  convulsive  attacks  soon  cease. 
Pallor  or  a  sickly  and  cachectic  aspect,  irregular,  usually  constipated  bowels, 
poor  appetite,  and  moroseness  or  irritability  of  temper  are  common  symp- 
toms of  severe  and  protracted  cases. 

Diagnosis. — This  disease  is  easily  diagnosticated,  unless  when  its  symp- 
toms are  masked  by  those  of  external  convulsions  ;  it  may  then  escape  notice. 
Spasm  of  the  glottis  may  be  mistaken  for  spasmodic  laryngitis,  and  vice  versa. 
In  some  of  the  published  cases  this  mistake  appears  to  have  been  made. 
Spasmodic  laryngitis  is,  however,  so  different  not  only  in  its  nature,  but  in 
its  clinical  history,  that  a  differential  diagnosis  is  not  difficult.  It  is  an  inflam- 
matory disease,  and  is  attended  with  feeble  reaction  and  a  sonorous  cough  ; 
it  commences  at  night  after  the  first  sleep  and  from  exposure  to  cold — partic- 
ulars in  regard  to  which  it  contrasts  with  true  spasm  of  the  glottis,  which 
in  complicated  cases  is  not  attended  by  any  febrile  symptoms. 

Prognosis  ;  Modes  of  Death. — Statistics  show  great  mortality  in  this 
disease.  Dr.  Reid,  in  a  monograph  on  '•  Infantile  Laryngismus,"  states  that  of 
289  cases  which  he  collated,  115  died.  Rilliet  and  Barthez  met  with  1  favor- 
able case  in  9  unfavorable,  and  Herard  1  in  7.  If  the  paroxysms  be  mild, 
infrequent,  and  dependent  on  a  cause  which  can  be  easily  removed,  recovery 
is  probable  with  proper  treatment.  The  cause  may,  however,  be  such,  even 
when  the  spasm  is  mild,  that  the  case  is  necessarily  unfavorable,  as  when  it 
is  due  to  disease  of  the  cerebro-spinal  axis.  We  should  not,  however,  in  any 
case  consider  the  patient  entirely  safe,  since  grave  symptoms  may  suddenly 
arise,  so  as  to  change  entirely  the  prognosis.  Long  and  severe  paroxysms, 
with  lividity  of  face  and  symptoms  of  suffocation,  indicate  an  unfavorable 
result.  The  same  should  be  predicted  also  if  the  infant  gradually  lose  flesh 
and  strength,  especially  if  the  face  be  pallid,  the  pulse  feeble,  and  the  appetite 
poor. 

There  are  three  modes  of  death  in  internal  convulsions.     The  first  is  by 


TREATMENT.  595 

aptia'a.  The  infant  dies  suflocated  in  the  attack.  Ivcspiration  is  first  arrested, 
and  then  the  pulse  ceases,  and  at  the  autopsy  the  lungs  and  the  cavities  of 
the  heart  are  found  engorged  with  dark  blood.  Death  may  also  result  from 
the  state  of  the  brain.  In  such  cases  passive  congestion  of  the  brain  occurs 
from  obstruction  to  the  return  of  blood  from  this  organ  to  the  heart  and 
lungs ;  and  if  this  congestion  be  not  soon  relieved  serous  effusion  also  occurs. 
Death  results  from  the  congestion  and  consequent  asdema  or  dropsy. 

The  third  mode  of  death  is  from  exhaustion.  Kepeated  and  severe  attacks 
undermine  the  constitution  ;  the  infant  gradually  grows  pallid  and  thin,  and 
dies  of  inanition  or  of  some  disease  which  this  state  induces. 

TreaTiMENT. — The  treatment  of  internal  convulsions  has  varied  according 
to  the  theories  which  physicians  have  held  in  reference  to  its  cause.  Gland- 
ular enlargement  is  no  longer  regarded  as  a  common  cause,  and  therefore 
treatment  directed  to  its  removal  is  less  frequently  prescribed  than  formerly. 
The  causes  of  internal  convulsions  are  in  part  very  similar  to  those  of  eclamp- 
sia, and  the  remedies  employed  in  the  one  affection  are,  in  a  measure,  appro- 
priate in  the  other.  That  dentition  is  sometimes  a  cause  is  usually  admitted, 
and  two  cases,  one  of  Avhich  occurred  in  my  practice  and  the  other  was  reported 
to  me,  appeared  to  show  that  it  may  operate  as  a  cause.  The  effect  of 
dentition  is  especially  observed  in  weakly  infants  when  several  dental  fol- 
licles are  undergoing  active  evolution.  Thus,  in  one  of  the  cases  to  which  I 
refer  five  teeth  pierced  the  gums  in  the  course  of  two  weeks ;  after  which  no 
convulsive  attack  occurred.  If,  therefoi-e,  the  gums  are  swollen,  the  propriety 
of  scarification  should  be  considered,  especially  if  the  convulsions  be  so  severe 
as  to  endanger  life. 

In  all  cases  of  internal  convulsions  a  careful  examination  should  be  made 
in  order  to  detect  any  aberration  from  the  normal  state  which  might  cause 
nervous  excitation.  The  condition  of  the  digestive  organs  should  be  ascer- 
tained, and  evacuants  or  other  remedies  prescribed  if  there  be  evidence  of 
their  derangement. 

Sometimes  the  alimentation  of  the  infant  is  at  fault.  It  is  perhaps  bot- 
tle-fed and  the  stools  have  an  unhealthy  appearance.  Attention  should  be 
given  to  the  preparation  of  its  food  and  the  times  of  its  feeding,  or  if  it 
nurse  the  mother  or  wet-nurse  who  suckles  it  should  have  plain  but  nutri- 
tious diet,  live  with  regularity,  and  give  the  breast  to  the  infant  at  regular 
intervals.  If  there  be  a  torpid  state  of  the  intestines.  Dr.  Meigs  recommends 
"  castor  oil  and  aromatic  syrup  of  rhubarb  rubbed  up  together,  three  parts  of 
the  former  and  five  of  the  latter."  A  simple  enema  answers  well  in  such 
cases,  and  in  debilitated  infants  this  is  preferable  to  medicine  administered 
by  the  mouth.  If  diarrhoea  be  present,  and  it  persist  after  the  requisite 
changes  are  made  in  regard  to  the  diet,  remedies  calculated  to  relieve  it. 
which  are  mentioned  elsewhere,  should  be  employed.  Marshall  Hall  states 
that  he  has  ordinarily  succeeded  in  curing  the  disease  by  attending  to  the 
condition  of  the  gums  and  digestive  organs. 

Since  rachitis  is  a  not  uncommon  cause,  the  child  should  be  examined  in 
reference  to  rachitic  manifestations,  and  if  they  appear  the  treatment  appro- 
priate for  rachitis  is  i-equired. 

In  pallid  and  cachectic  infants  tonics  are  indicated.  The  elixir  of  cali- 
saya-bark  with  iron,  in  half-teaspoonful  doses  three  or  four  times  daily  to  an 
infant  of  two  years,  is  an  eligible  preparation.  The  pi'eparations  of  iron  are 
frequently  to  be  preferred  to  the  vegetable  tonics,  as  the  citrate  of  iron  and 
bismuth,  citrate  of  iron  and  quinia,  the  syrup  of  iodide  of  iron,  or  the  wine 
of  iron.  To  an  infant  of  one  year  the  syrup  may  be  given  in  doses  of  three 
drops,  the  citrates  in  one-grain  doses,  and  the  wine  in  doses  of  one  teaspoonful, 
every  four  hours,  or  the  liquor  forri  peptonati  may  be  employed. 


596  INTERNAL   CONVULSIONS. 

Antispasmodics,  as  asafoetida,  valerian,  and  oxide  of  zinc,  are  often  pre- 
scribed in  this  malady,  but  they  are  less  efficacious  than  the  general  tonic 
measures  which  I  have  mentioned.  The  salutary  effect  of  bromide  of  potas- 
sium in  eclampsia  and  epilepsy  certainly  justifies  the  trial  of  this  agent  in 
internal  convulsions  if  they  persist  after  the  employment  of  invigorating 
remedies. 

Hygienic  measures  are  of  the  utmost  importance.  The  infant  should 
reside  in  dry  and  airy  apartments,  and  should  be  kept  much  of  the  time 
through  the  day  in  the  open  air.  Remarkable  success  sometimes  attends 
this  simple  expedient  when  medicines  have  entirely  failed.  Mr.  Robertson  ^ 
of  3Ianchester  relates  five  severe  cases  in  which  this  disease  was  cured  by 
exposure  of  the  infants  several  hours  daily  to  a  cool  atmosphere.  These 
cases  were  treated  in  the  winter  months,  and  were  kept  outdoor  even  dur- 
ing strong  winds.  Mr.  Robertson  has  records  of  forty  cases,  all  occurring 
between  December  and  April,  while  he  has  seen  no  case  in  the  summer 
months.  As  the  result  of  such  extensive  experience  the  writer  recommends 
"  the  free  exposure  of  the  infant  out  of  doors  for  many  hours  daily  to  a  dry, 
cold  atmosphere,  and,  if  the  air  be  dry,  the  colder  the  better."  Dr.  Marshall 
Hall's  experience  was  similar.  Says  he  :  "  The  curative  influence  of  the  air, 
and  especially  of  the  sea-breezes,  is  not  less  marked  in  this  affection  than  in 
whooping  cough."  Mr.  Robertson  recommends  also,  as  part  of  the  tonic 
treatment,  "free  sponging  of  the  body  every  morning  with  cold  water."  In 
February,  1867,  I  attended  a  nursing  infant  five  months  old  with  internal  con- 
vulsions, the  paroxysms  being  attended  with  lividity  of  the  face  and  at  times 
tonic  convulsions  of  the  limbs.  Among  the  remedies  employed  was  bromide 
of  potassium,  but  more  benefit  obviously  accrued  from  keeping  the  infant 
much  of  the  time  in  the  open  air  than  from  the  medicines  employed.  The 
disease  passed  off  in  six  or  eight  weeks. 

Unless  the  cause  be  of  such  nature  that  it  cannot  be  removed,  the  above 
hygienic  and  therapeutic  measures  will,  in  a  large  proportion  of  cases,  be  fol- 
lowed by  a  satisfactory  result. 

The  mother  or  nurse  may  abridge  the  paroxysm  by  raising  the  infant, 
blowing  upon  it,  sprinkling  water  in  the  face,  or  gently  stroking  it.  Dr. 
Hall  recommends  tickling  the  nostrils  with  a  feather  to  produce  respiration, 
or  the  fauces  to  occasion  vomiting,  and  thereby  interrupt  the  paroxysm. 
Anything  which  causes  a  sudden  and  profound  effect  upon  the  system 
may  abridge  the  attack.  This  was  effected  in  one  case  in  the  practice  of 
Dr.  C.  C.  Meigs  by  applying  a  cloth  wrapped  around  ice  over  the  epigas- 
trium and  the  lower  pai't  of  the  sternum.  The  chief  danger  during  the 
attack  is  from  congestion  of  the  brain,  with  effusion  of  serum  or  extravasa- 
tion of  blood.  If  the  attack  be  severe  and  the  features  congested,  so  that 
there  is  evident  danger  of  such  a  result,  cold  applications  should  be  made  to 
the  head,  derivatives  applied  to  the  extremities — as  sinapisms  or  mustard 
foot-baths — and  the  bowels  should  be  speedily  opened  by  enemata. 

^  London  Med.  Gazette,  Jan.  14,  1865. 


TETANY.  597 


CHAPTER    XIII. 

TETANY. 

The  disease  known  as  tetany  has  probably  always  existed,  for  its  recoc^- 
nized  causes  are  of  common  oecuvrence,  but  the  attention  of  the  profession 
was  first  directed  to  it  by  a  memoir  bearing  the  title  "  Observations  sur  une 
Espece  de  Tetanos  intermittent,"  published  by  M.  Dance  in  the  Archivrs 
ffeneralcs  de  Mtdecine  in  1831.  lie  described  it  as  it  occurs  in  the  adult. 
In  the  following  year  (1832)  M.  Tonnele  published  in  the  Gazette  medlcale 
an  essay  on  tetany,  which  he  designated  a  new  convulsive  disease  of  child- 
hood. In  the  same  year  Constant  and  Murdoch  also  published  their  obser- 
vations on  this  malady  in  French  medical  journals,  the  former  designating  it 
"  contractures  essentielles,"  and  the  latter  "  retractions  musculaires  et  spas- 
modiques."  In  1835  the  memoir  of  De  la  Berge  on  tetany,  bearing  the 
title  "retractions  musculaires  de  courte  duree,"  was  published  in  the  Journal 
Hebdomadaite.  From  this  time  the  disease  was  fully  recognized  in  France, 
and  several  additional  monographs  relating  to  it  appeared  in  medical  journals 
prior  to  1850,  among  the  most  notable  of  which  was  the  thesis  of  Delpech 
in  18J:6.  The  term  tetany  (tetanic)  was  first  employed  by  Dr.  Lucien  Corvi- 
sart  in  an  interesting  and  instructive  paper  published  in  1851. 

The  term  tetany  is  applied  to  a  disease  which  is  characterized  by  tonic 
contraction  of  muscles,  commonly  those  of  the  extremities,  but  sometimes 
also  those  of  the  face  or  trunk,  produced  by  causes  external  to  the  nervous 
system,  and  usually  of  temporary  duration.  The  exception  to  this  definition 
might  be  as  regards  such  causes  as  are  psychical  or  emotional,  if  such  exist. 
Following  this  definition,  we  would  exclude  cases  of  tonic  muscular  contrac- 
tion, however  close  the  resemblance,  which  arise  from  disease  of  the  brain, 
spinal  cord,  or  their  meninges,  or  from  disease  of  the  nerve  supplying  the 
aifected  muscle.  The  contractions  in  these  cases  are  not  the  malady  itself, 
as  in  tetany,  but  are  mei'ely  symptoms  of  some  important  disease  located 
in  the  nervous  system  at  a  distance  from  the  affected  muscles. 

Causes. — Tetany  may  occur  at  any  age,  but  is  most  frequent  in  infancy, 
in  early  childhood,  and  in  early  adult  life.  Of  28  cases  observed  by  Rilliet  and 
Barthez,  1  was  at  the  age  of  nine  months,  13  between  the  ages  of  one  and 
two  years,  5  at  the  age  of  three  years,  and  the  remaining  9  between  the  ages 
of  three  and  fifteen  years.  Eustace  Smith  says  that  the  period  during  which 
the  largest  number  of  cases  occur  is  between  the  first  and  third  years.  In 
142  cases  collated  by  Gowers  the  ages  were  as  follows :  Between  one  and 
four  years,  34 ;  between  four  and  nine  years,  8 ;  between  nine  and  nineteen 
years,  36 ;  between  nineteen  and  twenty-nine  years,  24 ;  between  twenty- 
nine  and  thirty-nine  years,  23;  between  thirty-nine  and  forty-nine  years,  13; 
and  between  forty-nine  and  sixty-one  years,  4.  Erb  remarks  that  a  strong 
tendency  to  tetany  is  exhibited  in  early  childhood,  and  the  next  most  common 
period  of  its  occurrence  is  at  the  age  of  puberty  and  early  youth.  The 
statistics  of  different  observers  show  that  tetany  is  more  common  in  males 
than  females.  Of  Rilliet  and  Barthez's  28  cases,  20  were  boys.  Of  the 
142  cases  embraced  in  the  statistics  of  Gowers,  76  were  males  and  QQ 
females.  According  to  Gowers,  in  the  first  and  second  decades,  in  which  a 
large  majority  of  the  cases  occur,  more  males  are  aflfected  than  females, 
but  between  the  ages  of  twenty  and  fifty  years  females  preponderate,  while 


598  TETANY. 

above  the  age  of  fifty  years  all  the  recorded  cases  have  been  males.  It  is 
seldom  that  the  most  thorough  investigation  elicits  any  inherited  predisposi- 
tion in  cases  of  tetany  to  nervous  or  other  diseases.  Most  of  the  observed 
cases  have  occurred  singly  in  families,  and  in  families  vphich  exhibit  no  spe- 
cial tendency  to  nervous  or  other  ailments.  Rarely,  however,  multiple  cases 
have  occurred  in  families,  from  which  we  infer  that  there  may  be  an  inher- 
ited neui'opathic  tendency.  The  only  instances  of  this  sort  which  I  have 
been  able  to  find  in  the  literature  of  tetany  were  2  cases  observed  by  Mur- 
doch in  one  family,  and  cases  alluded  to  by  Abercrombie,  who  states  that 
at  different  times  4  cases  occurred  in  each  of  two  families,  and  2  cases  in 
another  family. 

Although  in  many  instances  difi"erent  causes  appear  to  act  simultaneously 
in  causing  tetany,  nearly  all  writers  who  have  contributed  to  the  literature  of 
this  malady  assign  the  most  important  place  in  the  causation  to  diseases  of 
the  digestive  apparatus.  Trousseau  states  that  in  the  cases  which  have 
fallen  under  his  observation  diarrhoea  has  been  commonly  present.  He  says 
that  in  1854  he  met  many  cases  following  cholera,  but  in  one  instance  occur- 
ring in  his  practice  the  cause  seemed  to  be  obstinate  constipation.  The 
patient  at  the  age  of  seventeen  years  was  suddenly  seized  when  travelling. 
His  fingers  were  bent  and  he  could  not  extend  or  use  them.  The  tetany 
subsided  in  two  or  three  hours,  but  it  recurred  every  day  for  three  months. 
He  was  treated  by  bleedings,  but  the  tetany  was  uniformly  worse  after  each 
loss  of  blood,  the  contractions  becoming  more  severe  and  also  more  general. 
Not  only  were  the  muscles  of  the  extremities  in  a  state  of  tetanic  contrac- 
tion, but  also  those  of  the  face  and  trunk,  so  that  respiration  and  speech  were 
embarrassed.  Although  the  contractions  were  aggravated  by  bleeding,  and 
were  never  so  bad  as  after  the  fourth  venesection,  they  ceased  entirely  for  a 
period  of  ten  months  after  cupping  along  the  spine.  Subsequently  they 
recurred  every  year  at  the  close  of  winter  and  continued  two  months.  The 
patient  was  habitually  constipated,  and  the  torpid  state  of  the  bowels  seemed 
to  be  the  chief  factor  in  producing  the  tetany.  In  the  following  case,  which 
I  have  recently  had  under  observation,  constipation  appears  also  to  have  been 

the  chief  cause  :  G-eorge  C ,  without  teeth  and  at  the  age  of  seven  months 

when  tetany  commenced,  was  taken  from  the  breast  at  the  age  of  two  months. 
He  lives  in  a  tenement-house,  and  from  the  time  of  weaning  has  been  fed  with 
condensed  milk,  one  heaped  teaspoonful  of  large  size  to  fifty  of  water.  Besides 
this,  he  has  taken  once  daily  a  tablespoonful  of  Nestle's  food  in  ten  of  water. 
With  this  diet  his  growth  has  been  about  like  the  average,  but  he  has  been 
habitually  very  constipated,  so  as  frequently  to  require  assistance  in  obtain- 
ing an  evacuation.  Eecently,  groups  of  muscles  in  all  the  extremities  have 
undergone  tonic  contraction,  producing  deformities,  as  shown  in  the  photo- 
graph (Fig.  37),  and  brief  attacks  of  laryngismus  stridulus.  These 
attacks  of  spasm  of  the  glottis  occur  both  by  day  and  by  night,  causing  for 
a  moment  the  characteristic  stridulous  respiration.  The  mother  states  that  at 
times  he  is  feverish,  probably  from  the  constipation,  but  usually  he  seems 
entirely  well,  except  as  regards  the  sluggish  state  of  the  bowels  and  the  con- 
tractions. Attempts  to  straighten  the  fingers  and  toes  elicit  cries  from  the 
pain.  The  mother  also  says  that  at  times  both  thighs  and  both  legs  are 
flexed,  and  he  resists  attempts  to  straighten  them  on  account  of  the  pain. 
The  treatment  employed  consisted  in  the  use  of  bromide  of  potassium  and 
measures  designed  to  I'elieve  the  constipation.  When  these  remedies  were 
perseveringly  employed,  the  contractions  gradually  diminished  and  ceased,  but 
they  returned  when  the  treatment  was  discontinued.  Four  months  have 
elapsed  since  the  commencement  of  the  disease,  and  it  is  only  in  the  last 
week   or  two   that  the   contractions   have   entirely   ceased.     The   important 


CA  USES. 


599 


factor  in  producing  the  tetany  in  this  case  appears  to  have  been  the 
habitual  constipation.  One  tooth  pierced  the  guru  during  the  four  months 
of  tetany. 

Fig.  37. 


Photograph  of  a  Child,  showing  Tonic  Contraction  of  Groups  of  Muscles  of  the  Extremities  as 

the  Result  of  Tetany. 


Erb  says  that  all  forms  of  intestinal  disease  may  cause  tetany,  but  it 
especially  occurs  after  '•  protracted  and  exhausting  diarrhoea."  Gowers  also 
remarks  that  the  most  common  cause  of  tetany  is  diarrhoea,  "  usually  long- 
continued  and  exhausting,  but  sometimes  acute  and  brief."  Among  the 
rarer  intestinal  causes  of  tetany  may  be  mentioned  the  presence  of  worms. 
I  have  not  found  in  the  literature  of  tetany  any  instance  in  which  lumbrici 
or  ascarides  caused  the  contractions,  but  Gowers  alludes  to  three  cases  in 
which  they  were  produced  by  the  tape-worm. 

From  the  nature  of  tetany,  and  from  the  important  part  long  assigned  to 
dentition  in  producing  nervous  ailments,  it  is  perhaps  remarkable  that  the 
teething  process  has  so  seldom  been  regarded  as  a  factor  in  causing  tetany  in 
young  children.  But,  so  far  as  I  have  been  able  to  learn  from  memoirs  and 
recorded  cases,  those  who  have  made  special  study  of  tetany  agree  for  the 
most  part  with  Trousseau,  who  says  that  in  nearly  all  instances  pathological 


600  TETANY. 

conditions  distinct  from  dentition  are  present,  "  on  which  tetany  would  seem 
rather  to  depend."  Nevertheless,  in  the  following  case  which  was  treated  by 
Professor  E.  G.  Janeway  and  myself,  after  repeated  and  thorough  examina- 
tions teething  was  regarded  by  both  of  us  as  the  chief  cause  of  the  con- 
tractions : 

Case. — B ,  aged  twenty  months,  well-nourished,  has  during  the  last  few 

days  been  unable  to  use  the  left  lower  extremity.  The  thigh  is  flexed  at  an 
angle  of  about  forty-five  degrees,  and  the  leg  at  about  the  same  angle,  and 
attempts  to  overcome  the  rigidity  of  the  flexors  and  straighten  the  limb  are 
resisted  and  are  painful.  The  muscles  in  the  other  extremities,  and  those  which 
move  the  foot  and  toes  of  the  affected  limb,  appear  to  have  their  normal  func- 
tional activity,  as  do  those  of  the  face,  neck,  and  trunk.  The  gums  were  swollen 
and  congested  over  the  crowns  of  five  advancing  teeth,  which  appeared  to  be  in 
nearly  the  same  stage  of  development,  and  were  evidently  soon  to  protrude.  It 
is  possible  that  a  rather  sluggish  state  of  the  bowels  may  have  been  a  factor  in 
causing  the  tetany,  but  the  chief  agent  was  apparently  the  cutting  of  so  many 
teeth.  There  was  not  at  any  time  any  notable  elevation  of  temperature,  loss  of 
appetite,  or  derangement  of  the  functions  of  important  organs,  but  the  contrac- 
tions continued  three  weeks,  when  all  or  nearly  all  the  imprisoned  teeth  escaped 
and  the  limb  was  quickly  restored  to  its  normal  state.  There  has  been  after  the 
lapse  of  two  years  no  return  of  the  tetany. 

Tetany  is  more  liable  to  occur  in  those  whose  systems  are  enervated  by 
pre-existing  disease  than  in  those  who  are  robust.  Killiet  and  Barthez  state 
that  in  cases  which  have  come  under  their  observation  the  patients  were  often 
in  poor  health,  resulting  from  disease  which  they  had  had,  as  pneumonia, 
bronchitis,  or  enteritis.  Bouchut  also  remarks  that  tetany  occurs  as  a  sequel 
of  various  enervating  maladies,  among  which  he  enumerates  cholera,  typhus 
and  typhoid  fevers,  and  dysentery.  Erb  mentions  the  following  diseases  which 
sustain  a  causal  relation  to  tetany  or  in  the  convalescence  from  which  tetany 
is  liable  to  occur :  typhoid  fever,  measles,  cholera,  Bright's  disease,  febris 
intermittens,  in  addition  to  the  diarrhoeal  maladies  which  have  been  alluded 
to  above.  Eustace  Smith  goes  farther,  and  states  that  tetany  is  rare  in 
robust  subjects — that  it  ordinarily  occurs  in  those  who  have  delicate  consti- 
tutions by  inheritance  or  disease  or  are  imperfectly  nourished.  Gowers, 
enumerating  the  maladies  which  are  followed  by  tetany,  mentions  "  typhoid 
fever,  cholera,  smallpox,  rheumatic  fever,  measles,  febricula,  catarrh,  and  pneu- 
monia ;"  and  he  states  also  that  in  young  children  the  indications  of  rachitis  are 
rarely  absent. 

Another  recognized  cause  of  tetany  is  taking  cold.  Exposure  to  wet  and 
cold  has  in  numerous  instances  been  followed  by  tetany.  From  this  mode  of 
origin  the  opinion  arose  that  tetany  is  a  rheumatic  affection.  Hence,  Eisen- 
mann  applied  to  it  the  term  brachiotonus  rheumaticus,  and  Benedict  desig- 
nated it  rheumatische  contractur.  Erb  says  :  "  Amongst  the  exciting  causes, 
catching  cold  is  both  the  most  important  and  the  most  common  ;  and  this 
statement."  he  adds,  "  is  supported  by  the  fact  that  many  physicians  have 
regarded  it  as  an  exquisite  example  of  rheumatic  disease.  Working  in  the 
wet  or  cold  or  in  water,  sleeping  on  the  damp  ground,  have  very  often  been 
regarded  as  causes,  and  the  swelling  in  the  joints  which  occurs  in  many 
instances  indicates  that  this  disease  has  a  somewhat  close  relation  to  true 
rheumatism."  It  must  be  recollected  that  Erb's  observations  have  been 
chiefly  with  adults.  As  regards  infancy  and  early  childhood,  other  causes 
of  tetany  are  apparently  more  common  than  taking  cold.  Adults  with 
tetany  often  attribute  the  attack  to  exposure  in  wet  and  inclement  weather, 
and  probably  correctly.  At  the  present  time,  in  Charity  Hospital,  a  female 
aged  thirty-nine  years  is  under  treatment  for  tetany.     She  said  that  her  sick- 


SYMPTOMS.  601 

ness  was  produced  by  exposure  in  wet  and  cold  weather.  She  was  employed 
as  a  seamstress,  and,  being  insufficiently  clothed,  sat  at  her  work  with  feet 
chilled  and  wet.  At  the  same  time  her  menstruation  had  been  irregular,  and 
she  had  diarrhoea,  apparently  produced  by  the  ex])osure.  Tonic  contractions 
occurred  in  the  muscles  of  the  fingers  and  toes  on  both  sides,  accompanied 
by  pain,  especially  in  the  affected  muscles  of  the  lower  extremities.  Several 
months  have  elapsed  since  the  commencement  of  the  disease,  and  the  fingers 
have  regained  nearly  or  quite  their  normal  state,  but  the  toes  are  firmly 
flexed.  The  chief  cause  of  the  tetany  in  this  case  appeared  to  be  taking 
cold,  from  which  probably  the  diarrhoea  resulted,  which,  as  we  have  seen,  is 
one  of  the  most  common  causes  of  the  tonic  contractions.  Trousseau  also 
relates  cases  in  which  exposure  to  cold  was  apparently  the  exciting  cause. 
Gowers  also  states  that  next  to  diarrha>a  the  most  common  causes  are  "  expo- 
sure to  cold,  acute  disease,  and  lactation." 

Among  the  other  recognized  causes  of  tetany  we  may  mention  sucklings 
pregnancy,  and  the  development  at  the  time  of  commencing  puberty.  The 
first  cases  seen  by  Trousseau  in  Necker  Hospital  occurred  in  women  recently 
confined  who  were  wet-nursing,  so  that  at  first  he  designated  the  disease 
rheumatic  contraction  occnrrimj  in  nursea.  Gowers  says  that  the  frequency 
of  the  disease  in  adult  women  is  chiefly  due  to  maternity.  The  following  are 
occasional  causes  mentioned  by  various  writers  :  anaemia,  prolonged  muscular 
eS"ort,  alcoholism,  onanism  (Gowers),  ergotism,  violent  excitement  (Erb),  irri- 
tation of  uric-acid  calculi  (Eustace  Smith). 

From  the  nature  of  tetany  it  would  seem  probable  that  it  might  occa- 
sionally result  from  preputial  irritation,  but  I  have  not  been  able  to  find  the 
history  of  any  case  in  which  this  cause  was  assigned,  either  in  the  literature 
of  tetany  or  in  monographs  relating  to  a  narrow,  irritated,  or  inflamed  pre- 
puce. Tetany  does  not  result,  or  very  rarely  results,  from  burns  or  ordinary 
wounds ;  but  Weiss  in  1883  reported  13  cases  in  which  it  occurred  from 
exci.sion  of  the  thyroid,  and,  according  to  WiJlfler,  in  70  cases  of  this  opera- 
tion tetany  resulted  7  times. 

It  is  remarkable  that  this  disease  appears  to  occur  as  an  epidemic — a  fact 
not  easy  of  explanation,  unless  upon  the  supposition  that  the  rheumatismal 
cause  due  to  atmospheric  conditions,  or  the  psychical  or  emotional  cause 
giving  rise  to  imitation,  is  operative  at  the  time.  Bouchut  says  that  tetany 
occurred  as  an  epidemic  in  Germany  in  1717,  in  Belgium  in  1846.  and  in 
Paris  in  1855.  In  the  Paris  epidemic  it  occurred  equally  among  children 
and  adults,  and  was  the  occasion  of  interesting  observations  by  Aran  and 
Barthez.  Another  epidemic  occurred  in  Paris  in  1876  and  in  its  environs, 
especially  at  Gentilly,  where  in  a  school  the  teacher  and  thirty  pupils  were 
affected ;  but  some  of  the  pupils  afterward  confessed  that  they  had  feigned 
the  disease.  In  New  York  City,  in  the  first  quarter  of  1889,  I  saw  so  many 
cases  that  it  seemed  to  me  that  tetany  might  properly  be  regarded  as  an 
epidemic. 

Symptoms. — Ordinarily,  tetany  occurs  without  any  marked  premonitory 
symptoms,  but  in  some  instances  it  is  preceded  by  pain  in  the  head  or  spine, 
vomiting  without  any  previous  indigestion  or  gastric  derangement,  and  a 
general  feeling  of  indisposition.  Usually,  in  those  old  enough  to  express 
their  sensations,  tetany  begins  with  tingling,  burning,  or  other  unusual  sen- 
sory manifestations  in  the  limbs.  The  tonic  contractions  occur  suddenly, 
sometimes  in  the  upper  and  lower  extremities  simultaneously.  Rarely,  the 
contractions  occur  in  the  upper  extremities  alone  or  in  the  muscles  of  the 
trunk.  At  first  a  feeling  of  stiff"ness  is  experienced,  and  this  is  followed  by 
tonic  contractions,  with  the  fixing  of  the  aff"ected  part  in  a  state  of  per- 
sistent flexion  or  extension.     Usually,  as  regards  the  upper  extremities,  the 


602 


TETANY. 


contraction  of  the  thenar  and  hypothenar  muscles  causes  hollowness  of  the 
palms  of  the  hands ;  the  first  phalanges  of  the  fingers  are  flexed,  the  second 
and  third  phalanges  extended,  and  the  thumb  adducted  and  flexed  so  as  to 
press  against  the  index  finger  or  lie  underneath  it.  The  fingers  sometimes 
incline  toward  the  ulnar  side,  and  sometimes  are  pressed  against  each  other. 
Usually  the  hand  is  slightly  flexed,  as  is  also  the  forearm.  The  muscles 
which  move  the  arm  usually  escape,  but  exceptionally  there  is  adduction  of 
the  arm  on  the  shoulder.  The  hand  may  be  extended  instead  of  flexed, 
and  all  the  joints  of  the  fingers  extended,  or  they  may  all  be  flexed  and  the 
fist  closed. 

The  thighs  may  be  adducted  or  flexed,  the  legs  extended  or  flexed,  the 
foot  extended,  forming  a  talipes  equinus,  and  the  toes  flexed,  as  in  the  fol- 
lowing interesting  case  now  in  Charity  Hospital,  which  has  been  alluded  to 
above.  Though  the  patient  is  an  adult,  her  case  is  I'elated  here,  since  it  aids 
in  throwing  light  on  the  nature  of  the  disease : 

Case. — Mary  F.  O ,  native  of  the  United  States,  seamstress,  married,  and 

of  apparently  healthy  parentage,  states  that  her  health  was  good  previously  to  the 
present  sickness.  She  says  that  she  has  never  had  venereal  disease  and  never 
taken  stimulants  in  excess,  though  in  the  habit  of  using  whiskey  at  breakfast. 
She  had  been  married  four  years,  and  three  years  ago  had  a  stillborn  child  at  the 
seventh  month,  but  has  had  no  other  miscarriage  and  has  had  no  confinement  at 
term.  Her  catamenia,  which  formerly  were  scanty  and  at  unusually  long  inter- 
vals, have  during  the  last  four  months  been  normal  in  regard  to  time  and  quan- 
tity. She  has  been  subject  to  afternoon  headaches  for  years.  She  has  had  the 
average  appetite,  has  partaken  largely  of  rye  bread  at  her  meals,  and  her  stools 
have  been  normal. 

In  January,  1 888,  the  patient,  being  employed  as  a  seamstress  in  a  shop  at  a 
distance  from  her  residence,  began  to  experience  unusual  fatigue,  and  on  return- 

FiG.  38. 


ing  from  her  day's  work  she  frequently  noticed  a  painful  burning  sensation  in 
her  feet,  the  pain  extending  upward  along  the  calves  of  her  legs.  This  pain  in 
the  feet  and  legs  gradually  increased  until  March  12_,  1888,  at  the  time  of  the 
deep  snow  accompanying  the  "  blizzard."  After  walking  through  the  snow  she 
sat  all  day  at  her  work  with  wet  feet,  and  at  this  time  she  began  to  experience  a 
dull  intermittent  pain  extending  from  both  ankles  to  the  knees,  and  accompanied 
by  great  lassitude,  so  that  walking  required  an  effort.  In  July  the  pain  became 
more  constant,  but  at  the  time  of  her  admission  into  Charity  Hospital  (August 


SYMPTOMS.  603 

17th)  it  was  not  so  constant  or  severe.  Soon  after  her  admission  the  feet  became 
strongly  extended,  forming  a  talipes  equinus,  and  the  toes  of  both  feet  were  also 
strongly  Hexed.  Sensation  in  the  toes,  but  not  in  the  feet,  was  almost  completely 
lost.  A  few  days  subsequently  the  tingers  on  both  sides  were  similarly  flexed, 
but  without  pain  or  loss  of  sensation.  In  about  six  months  the  flexion  of  the 
fingers  ceased,  and  she  can  now  use  them  nearly  as  well  as  before  the  attack. 
The  toes  also  are  not  so  strongly  flexed  as  at  first,  and  they  have  regained  sensa- 
tion. The  bladder  has  never  been  aflected,  but  the  sphincter  ani  was  paralyzed 
for  a  time  in  August,  so  that  the  feces  escaped  involuntarily  in  bed.  The  patient's 
memory  was  considerably  impaired  after  the  exposure  at  the  time  of  the  "  bliz- 
zard," but  is  now  (June,  1889)  apparently  nearly  or  quite  normal.  Otherwise  no 
impairment  of  the  mental  faculties  has  been  observed. 

The  tetany  in  this  case  has  been,  as  usual,  bilateral  and  for  the  most  part 
«qual  on  the  two  sides,  with  a  little  more  acuteness  of  sensation  in  the  right  than 
left  limbs.  The  feet  continue  in  the  position  of  talipes  equinus,  with  toes  flexed, 
and  the  contracted  muscles  hard  to  the  feel,  almost  like  cartilage.  No  oedema 
has  been  observed,  but  perspiration  occurs  from  the  extremities  during  sleep. 

In  mild  cases  or  those  of  ordinary  severity  the  contractions  are  limited  to 
the  muscles  of  the  extremities,  and  are  more  marked  and  persistent  in  those 
that  move  the  hands,  feet,  fingers,  and  toes  than  in  other  muscles ;  but  in 
severe  cases  the  muscles  of  the  trunk  and  head  participate.  Contraction  of 
the  abdominal  muscles  produces  rigidity  of  the  abdominal  walls.  Spasm  of 
certain  of  the  thoracic  muscles  occasionally  occurs,  causing  dyspnoea  and 
even  lividity.  In  some  of  these  cases  of  embarrassed  respiration  the  dia- 
phragm is  probably  involved.  Opisthotonos,  retention  of  urine,  anteflexion 
of  the  neck  from  contraction  of  the  sterno-mastoids,  fixation  of  the  jaws  from 
spasm  of  the  masseters,  retraction  of  the  angles  of  the  mouth,  stiflFness  of 
the  tongue,  and  indistinct  articulation  are  occasional  symptoms  in  severe 
cases  of  tetany. 

The  contractions  render  the  affected  muscles  hard  and  unyielding,  and  the 
child  cries  from  pain  when  attempts  are  made  to  straighten  the  limb.  If  the 
spasm  be  slight  some  voluntary  movement  of  the  affected  muscles  is  possi- 
ble, but  it  is  restrained  and  difficult.  In  severe  cases,  with  the  muscles  tense 
and  unyielding,  voluntary  motion  is  impossible.  Except  in  the  mildest  forms 
of  the  disease  pain  is  felt  in  the  contracted  muscles,  such  as  all  people  expe- 
rience when  a  spasm  occurs  in  the  calf  of  the  leg,  and  the  pain  ma}^  pass 
upward  along  the  limb.  The  pain  may  occur  in  paroxysms  with  distinct 
intermissions,  or,  without  ceasing,  it  may  vary  in  severity  at  difierent  times, 
probably  from  some  variation  in  the  degree  of  spasm.  Certain  subjective 
symptoms,  such  as  numbness  and  tingling,  which  sometimes  occur  in  tetany, 
may  continue  during  the  intermissions  or  remissions.  After  some  hours  or 
days  the  rigidly-contracted  muscles  relax  and  the  disease  disappears,  except 
perhaps  that  a  degree  of  stiifness  remains.  But  the  respite  is  usually  not 
long.  The  spasms  recur,  and  several  successive  recurrences  and  intermissions 
take  place,  running  over  months,  before  the  disease  is  permanently  cured. 
During  the  intervals  in  the  contractions  the  affected  nerves  and  muscles  are 
in  ordinary  cases  unduly  excitable,  so  that  sudden  pressure  or  percussion 
causes  some  contraction.  Trousseau  was  perhaps  the  first  who  noticed  and 
■called  attention  to  the  fact  that  compression  of  the  artery  and  nerve  sup- 
plying the  contracted  muscles  in  tetany  causes  or  increases  the  contraction. 
Occasionally  this  result  cannot  be  obtained. 

It  is  an  interesting  fact  that  in  cases  which  I  have  observed  the  spasms 
do  not  cease  in  sleep,  though  the  contraction  of  the  muscles  may  not  be  as 
great  as  when  the  patient  is  awake. 

The  electrical  excitability  of  the  nerve  which  supplies  the  contracted 
muscles  is  increased.     Gowers  states  that  he  has  obtained  contractions  in  the 


604  TETANY. 

muscles  of  the  face  by  the  voltaic  current  from  a  single  cell.  The  increased 
excitability  of  the  nerves  is  apparent  if  either  the  direct  or  induced  current 
be  used.  According  to  Erb,  when  the  circuit  is  closed  the  earliest  contrac- 
tions occur  at  the  point  of  application  of  the  positive  pole.  Both  opening 
and  closing  the  circuit  cause  a  more  prolonged  contraction  of  the  muscles  in 
tetany  than  in  health.  When  the  contractions  are  strong,  oedema  sometimes 
occurs,  especially  upon  the  dorsal  surfaces  of  the  hands.  It  was  present  in 
cases  treated  by  Henoch,  who  attributes  it  to  compression  and  consequent  pas- 
sive congestion  of  the  veins,  produced  by  contraction  of  the  interossei  muscles, 
the  congestion  giving  rise  to  serous  transudation.  When  the  paroxysms  are 
severe,  perspiration  sometimes  occurs,  and  an  erythematous  redness  may 
appear  over  the  aifected  muscles.  Occasionally  in  acute  attacks  the  temper- 
ature is  moderately  increased,  but  ordinarily  it  is  normal.  Tetany  does  not 
usually  affect  the  functions  of  the  internal  organs,  but  in  a  case  related  by 
Kussmaul  and  another  by  Nonchen  albuminuria  was  for  a  brief  period  pres- 
ent, and  in  one  recorded  instance  the  urine  exhibited  traces  of  sugar  during 
the  paroxysms.  Occasionally  in  long-continued  tetany  the  contracted  mus- 
cles undergo  a  degree  of  atrophy  which  is  attended  by  diminished  electrical 
irritability.  Growers  states  that  "  general  muscular  atrophy  "  has  also  been 
observed  following  tetany. 

The  following  may  be  regarded  as  typical  cases  of  tetany  in  infancy  as 
I  have  observed  it  in  New  York.  The  following  case  occurred  in  the  New 
York  Infant  Asylum  during  my  term  of  service,  and  the  resident  physician, 
Dr.  Virginia  M.  Davis,  has  kindly  furnished  me  the  history  from  her  note- 
book : 

Case  I. — Gertrude  A ,  born  in  the  New  York  Infant  Asylum,  April  30, 

1888,  was  well  except  a  mild  attack  of  pertussis  until  March  9,  1889,  when  she 
had  a  prostrated  appearance,  and  the  thermometer  indicated  a  temperature  of 
105°,  and  a  little  later  105.5°.  During  the  following  six  hours  she  had  five  large, 
watery,  but  yellow  stools.  She  was  restless,  her  features  sunken,  extremities  cool, 
her  surface  covered  with  a  clammy  perspiration,  and  her  pulse  feeble.  Her  diar- 
rhoea was  checked,  and  she  slept  during  the  following  night.  From  March  9th 
to  14th  she  had  slight  fever  (100.4°-100.6°)  and  her  stools  were  normal,  but  dur- 
ing the  week  ending  with  the  14th  she  lost  one  pound  in  weight.  The  following 
are  the  subsequent  notes  of  the  case : 

March  14th. — Is  restless ;  temperature  in  the  morning  100.4°,  in  the  even- 
ing 103° ;  has  had  no  stool  in  the  last  twenty-four  hours.  To-day  has  had  for 
the  first  time  contraction  of  the  flexor  muscles  of  the  hands,  feet,  fingers,  and 
toes,  so  that  in  the  evening  all  the  fingers  and  toes  are  firmly  flexed.  The  dorsal 
surfaces  of  the  hands  and  feet,  and  the  fingers  and  toes  as  far  as  the  articulations 
of  the  first  and  second  phalanges,  are  oedematous.  The  flexions  can  be  overcome 
by  the  employment  of  considerable  force,  but  the  attempt  is  painful.  An  ery- 
thematous eruption  has  appeared  over  the  upper  part  of  the  chest  and  upon  the 
back. 

March  15th. — Temperature  100.6°;  thumbs  extended,  voluntary  movement 
of  fingers  returning ;  toes  still  flexed  ;  oedema  as  before;  rash  fading;  stools  nor- 
mal. March  16th.  Temperature  99°-99.8°.  The  contractures  have  entirely  dis- 
appeared during  the  day.  Had  four  stools.  17th.  Bowels  constipated ;  slight 
contractures  of  the  fingers.  18th.  Morning  temperature  103° ;  evening,  101°. 
In  the  evening  contractures  of  both  extremities  disappearing;  stools  normal; 
gums  swollen.  From  this  time  the  constipation  was  relieved  by  small  doses  of 
calomel,  and  the  tetany  ceased.  Some  elevation  of  temperature  was  a  prominent 
symptom  previous  to  and  during  the  tetany,  and  on  one  day  (May  17th)  an  attack 
of  general  clonic  convulsions  or  eclampsia  occurred.  The  tetany  ceased  on  the 
18th  or  19th,  but  between  the  20th  and  30th  maculae  and  papules  appeared  on  the 
surface,  due  perhaps  partly  to  the  medicines  employed,  which  were  chiefly  the 
bromides  and  chloral. 

Case  II. — Edward  McI ,  aged  fifteen  months  (practice  of  Dr.  Vineberg, 


SYMPTOMS.  605 

but  examined  by  myself),  has  healthy  parentage,  and  no  other  child  in  family  has 
had  any  nervous  ailment,  except  a  sinj^lc  attack  of  eclampsia  during  measles  in 
one  of  the  children.  Edward  is  nourished  in  part  at  the  Vjreast  and  in  part  from 
the  table.  He  has  four  teeth,  all  having  cut  the  gum  since  the  age  of  twelve 
months.  He  has  had  diarrhoea  much  of  the  time  since  birth,  and  during  the  last 
two  months  has  had  free  perspiration  from  the  head.  The  mother  states  that 
during  the  first  months  of  his  life  he  occasionally  held  his  breath,  especially  at 
night,  but  with  this  exception  no  symptoms  resembling  a  convulsive  attack  were 
observed  until  recently,  when,  during  an  attack  of  coughing,  his  face  grew  red, 
his  eyes  turned  upward,  and  his  respiration  ceased  for  a  moment.  When  he  was 
at  the  age  of  twelve  months  the  mother  first  noticed  that  the  toes  were  flexed  and 
the  feet  extended  as  in  talipes  equinus.  Considerable  force  was  required  to  over- 
come the  tonic  contraction  of  the  affected  muscles,  and  when  the  pressure  was 
relaxed  the  feet  immediately  assumed  the  former  position  of  talipes.  The  thumbs 
"were  strongly  flexed  across  the  palms  of  the  hands,  the  index  and  middle  fingers 
forcibly  extended  and  se])arated  from  each  other,  and  the  ring  and  little  fingers 
were  flexed  against  the  palm.  These  abnormal  flexions  and  extensions  continued 
more  than  three  months,  with  occasional  intervals  of  two  or  three  days,  during 
which  the  action  of  the  affected  muscles  was  nearly  normal.  The  child  presents 
evidences  of  rachitis  in  the  shape  of  its  head  and  enlargement  of  the  epiphyses 
of  the  extremities. 

The  treatment  employed  by  Dr.  Vineberg  consisted  in  change  of  diet  and  in 
the  use  of  the  following  prescription : 

R.  Zinci  sulphat.,  gr.  \  ; 

Atropise  sulphat.,        gr.  j^ij.     Misce, 
To  be  taken  three  times  daily. 

With  this  treatment  the  spasms  of  the  muscles  entirely  disappeared  within  a 
week,  and  two  weeks  later  had  not  returned. 

It  is  our  purpose  to  treat  mainly  of  tetany  as  it  occurs  in  children,  but  in 
order  to  give  completeness  to  our  remarks  on  this  disease  it  is  necessary  also 
to  describe  it  as  it  occurs  in  the  adult.  The  following  case,  related  by  Trous- 
seau, gives  a  clear  and  vivid  idea  of  the  symptoms  of  severe  tetany  as  it 
occurs  in  the  adult.  A  dissipated  young  man  was  found  one  morning  lying 
in  the  street,  "  stiff  as  a  poker  "  from  the  occurrence  of  tetany  during  the 
night.  He  was  conscious  and  complained  of  great  pain,  but  spoke  indis- 
tinctly from  the  clenched  state  of  his  jaws.  Muscles  in  his  extremities  were 
rigidly  contracted,  and,  being  unable  to  walk,  he  had  fallen  down  and  could 
not  rise.  The  rigidity  of  the  muscles  of  the  chest  and  abdomen,  and  prob- 
ably of  the  diaphragm,  rendered  respiration  difficult.  His  face  was  livid,  and 
lie  had  paroxysms  of  dyspnoea  that  threatened  suffocation.  The  tetany  finally 
abated,  and  he  was  able  to  walk  and  attend  to  slight  duties,  but  at  intervals 
he  had  recurrence  of  the  spasms,  and  finally  died  of  phthisis. 

Adults,  unlike  young  children,  give  a  clear  description  of  their  subjective 
symptoms.  Frequently — probably  in  a  majority  of  instances  in  the  adult, 
as  in  the  child — tetany  is  preceded  by  certain  .sensory  symptoms,  as  formi- 
cation, a  sensation  of  weight  or  dragging,  of  heat  or  cold,  or  even  of  pain. 
Soon  afterward  in  using  the  limbs  the  patient  observes  some  stiffness  or  that 
the  movements  are  not  so  free  and  easy  as  previously.  The  spasms  succeed, 
and,  as  in  children,  their  duration  and  severity  vary  greatly  in  different 
patients.  In  the  adult,  as  in  the  child,  in  mild  tetany  the  contractions  are 
limited  to  the  muscles  of  the  hands,  feet,  fingers,  and  toes,  and  the  severe 
disease  usually  attacks  first  these  muscles,  and  afterward  extends  to  the 
muscles  of  the  head,  face,  neck,  and  trunk.  Cases  might  be  cited  from  the 
literature  of  tetany  in  which  the  contractions  occurred  in  the  muscles  of  the 
face,  causing  unsightly  visage,  the  motor  muscles  of  the  eye,  causing  strabis- 


606  TETANY. 

mus,  the  pharyngeal  and  laryngeal  muscles,  the  muscles  of  the  tongue  and 
diaphragm,  causing  embarrassment  of  speech,  respiration,  and  deglutition, 
sterno-cleido  and  other  muscles  of  the  neck,  changing  the  position  of  the 
head,  and  in  the  various  muscles  of  the  trunk.  In  a  case  observed  by 
Dr.  Herard  the  recti  muscles  in  the  abdominal  walls  stood  out  like  two  tense 
cords.  However  severe  the  disease  may  be,  a  marked  remission  or  distinct 
intermission  soon  occurs,  the  progress  of  tetany  being  characterized  by 
intervals  of  complete  relief.  In  not  a  few  of  the  reported  adult  cases  tetany 
has  reappeared  at  varying  intervals  during  a  series  of  years,  being  due  to  the 
recurrence  of  the  causes  which  first  produced  it. 

Pathology. — Since  tetany  in  itself  is  rarely  fatal,  only  a  few  post-mortem 
examinations  have  been  made,  and  in  these  no  lesions  have  been  discovered 
which  appeared  to  sustain  a  causal  relation  to  the  disease.  In  the  spinal  cord 
minute  hemorrhages,  points  of  apparent  myelitis,  lymphoid  cells,  hyperaemia 
of  the  spinal  meninges  and  of  the  cord  in  their  upper  portions  (Bouchut), 
and  softening  of  the  cord  in  the  cervical  region,  have  been  observed  in  certain 
cases,  but  these  lesions  are  believed  to  result  from  the  excessive  functional 
activity  of  the  cord.  The  exaggerated  excitation  of  the  motor  nerves  is 
probably  also  attended  by  some  change  in  their  nutrition.  Gowers  says  that 
change  in  their  nutrition  consequent  on  their  excited  action  is  undoubtedly 
present.  He  states  that  a  nutritive  change  in  the  motor  nerve-fibres  is 
usually  consequent  on,  and  secondary  to,  a  similar  change  in  the  motor  cells 
of  the  spinal  cord,  the  axis-cylinders  of  the  nerves  being  prolonged  processes 
of  these  cells.  Slight  changes  have  been  observed  in  these  cells  in  those 
who  have  had  tetany  severely,  and  the  fact  that  this  disease  is  bilateral 
indicates  that  it  has  a  central  origin.  Gowers  adds  that  the  sensory  nerves 
are  also  probably  implicated,  from  the  fact  that  sensory  symptoms  often 
precede  the  spasms  of  tetany.  As  to  the  seat  of  the  disease,  nothing  fur- 
ther is  at  present  known  ;  but  Gowers,  after  a  careful  survey  of  the  facts 
relating  to  the  pathology  of  tetany,  remarks  :  "  On  the  whole,  our  present, 
knowledge  of  the  pathology  of  the  disease  points  to  the  nerve-cells  of  the. 
spinal  cord  and  medulla  as  the  parts  chiefly  deranged,  and  the  way  in  whichi 
the  cells  in  rare  cases  seem  to  undergo  subsequent  atrophy  suggests  that  the- 
disturbance  is  a  primary  one  of  the  cells  themselves,  and  is  not  produced  by 
the  agency  of  any  vaso-motor  mechanism.  It  is  difficult  to  conceive  that 
symptoms  of  such  definite  and  uniform  character  can  be  the  result  of  any 
vascular  spasm.  The  occasional  wasting,  with  diminished  irritability,  is 
especially  important  as  suggesting  that  the  nutritional  changes  in  the  motor- 
cells  and  fibres,  causing  the  increased  excitability,  may  sometimes  go  on  to 
structural  degeneration." 

Diagnosis. — It  may  assist  in  the  diagnosis  to  ascertain  that  the  attack 
has  immediately  followed  the  occurrence  of  one  of  the  recognized  causes  of 
tetany,  as  diarrhoea  or  other  intestinal  ailment  or  exposure  to  cold.  We  may 
diagnosticate  tetany  from  tetanus  from  the  fact  that  it  is  very  rare  under  the 
age  of  one  month,  if  indeed  it  ever  occur  in  the  newly-born,  whereas  tetanus 
almost  never  occurs  in  infancy  after  the  first  month  or  in  childhood,  nearly 
all  cases  occurring  during  the  first  three  weeks  after  birth.  It  is  also  dis- 
tinguished from  tetanus  by  the  fact  that  it  begins  in  the  extremities,  has 
periods  of  cessation  or  intermittence,  and  the  masseters,  which  in  tetanus 
early  undergo  the  peculiar  tonic  contraction,  are  not  aflPected  or  are  aflFected 
only  at  a  late  stage  and  in  the  most  severe  cases. 

In  organic  disease  of  the  brain  the  contractions  do  not,  as  a  rule,  intermit, 
and  they  are  frequently  limited  to  one  side  ;  besides,  other  symptoms  clearly 
referable  to  the  brain  are  usually  present.  The  bilateral  and  symmetrical 
nature  of  tetany,  the  occurrence  of  the  contractions  in  corresponding  groups 


PROGNOSIS—TREATMENT.  607 

of  muscles  on  the  two  sides,  distinguisli   the  disease  frou)  those  contractions 
which  occur  from  lesions  in  the  course  of  the  nerves. 

Prognosis. — Tetany,  whether  intermittent,  remittent,  or  occurring  with 
little  variation  in  the  spasms,  soon  ceases  in  some  cases  and  never  returns. 
In  other  instances  it  does  not  cease  entirely  for  months,  though  varying  in 
severity  at  different  times.  Certain  patients  have  attacks  of  it  at  intervals 
during  a  series  of  years,  their  health  being  good  when  not  affected  by  it. 
Thus  the  case  of  a  woman  is  related  whose  first  attack  was  at  the  age  of 
twenty-two  years,  and  who  had  a  recurrence  of  the  disease  every  winter,  and 
was  still  having  it  at  the  age  of  thirty-four  years.  This  appears  to  have  been 
one  of  those  cases  which  have  been  attributed  to  a  rheumatismal  cause  inci- 
dent to  cold  weather.  Lussana  relates  a  similar  case  in  which  tetanj^  occurred 
each  winter  during  ten  successive  years.  In  some  instances  years  elapse 
between  the  attacks,  as  in  a  case  related  by  Choostek.  Maccall  states  that 
a  woman  had  tetany  five  times  when  wet-nursing  five  successive  children,  and 
was  well  in  the  intervals. 

During  infancy  and  childhood  tetany,  when  uncomplicated,  ends  favor- 
ably, with  possibly  now  and  then  a  rare  exception.  In  this  respect  it  con- 
trasts with  tetanus,  which,  whatever  the  age,  is,  with  few  exceptions,  fatal. 
The  few  cases  found  in  the  literature  of  this  disease  in  which  death  appar- 
ently resulted  directly  from  tetany  have  been,  so  far  as  I  have  been  able  to 
ascertain,  adults.  Dr.  Blondean  states  that  in  Lourcine  Hospital,  Paris,  a 
young  woman  whose  health  had  been  greatly  impaired  by  syphilis  and  a  mis- 
carriage had  an  obstinate  diarrhoea.  Tetany  set  in  with  great  violence.  The 
muscles  of  the  face,  neck,  and  chest  were  rigidly  contracted.  The  face  was 
livid,  the  eyes  fixed,  the  pulse  could  not  be  counted,  and  the  breathing  was 
labored  and  stertorous.  She  was  bled  from  the  arm,  and  subsequently  twelve 
leeches  were  ordered  to  be  applied  behind  the  ears,  but  during  their  appli- 
cation she  died.  The  post-mortem  examination,  conducted  with  great  care, 
revealed  an  apparently  healthy  state  of  all  the  organs  except  "  traces  of  con- 
gestion in  the  meninges,  the  veins  of  which  contained  a  little  more  dark 
blood  than  usual."  Growers  states  that  death  may  occur  in  consecjuence  of 
pulmonary  congestions  and  a  low  form  of  pneumonia  which  result  from 
repeated  attacks  of  tetany.  Tetany  following  excision  of  the  thyroid  is  more 
likely  to  be  fatal  than  when  it  occurs  from  other  causes.  But,  we  repeat,  so 
rarely  is  tetany  fatal  that  most  of  those  who  have  contributed  to  the  litera- 
ture of  this  disease  have  never  observed  a  fatal  case.  Muscular  weakness 
for  a  time,  and  even  more  or  less  muscular  atrophy,  occasionally  follow  an 
attack  of  tetany. 

Treatment. — The  cause  or  causes  of  the  attack,  so  far  as  they  can  be 
ascertained,  should  obviously  be  promptly  treated,  and  if  possible  removed. 
Especially  should  diarrhcea  or  any  other  abnormal  state  of  the  digestive  sys- 
tem receive  appropriate  treatment.  If  the  patient  have  been  exposed  to  cold, 
and  the  cause  be  apparently  of  a  rheumatismal  nature,  warm  baths  and 
diaphoretics,  such  as  are  employed  in  breaking  up  a  cold,  may  be  advantage- 
ously employed. 

In  the  treatment  of  the  tetany  of  children  the  bromide  of  potassium  is  a 
most  useful  remedy.  Four  grains  dissolved  in  cold  water  or  any  convenient 
vehicle  may  be  given  every  third  or  fourth  hour  to  a  child  of  from  one  and 
a  half  to  two  years.  It  is  a  safe  remedy,  and  it  usually  causes  a  diminution 
or  cessation  of  the  spasms.  Cannabis  Indica,  chloral,  and  hypodermic 
injections  of  morphia  which  have  been  employed  in  adult  cases  with  apparent 
benefit  should  not  be  recommended  for  young  children.  It  will  be  recollected 
that  in  the  case  treated  by  Dr.  Yineberg,  related  in  a  preceding  page,  the 
infant  at  the  age  of  fifteen  months  took  one-quarter  of  a  grain  of  sulphate 


608  CHOREA. 

of  zinc  and  y^^  of  a  grain  of  sulphate  of  atropia  three  times  daily,  and  with 
this  treatment  and  a  change  of  diet  recovered  within  a  week.  Chloroform 
inhalation  has  been  used,  and  during  the  narcosis  produced  by  it  active 
massage  treatment  of  the  aiFected  limbs  has  been  employed  with  apparent 
benefit.  Gowers  states  that  faradism  is  contraindicated.  and  that  the  best 
results  have  been  obtained  from  the  voltaic  current,  either  with  both  poles 
applied  to  the  spine  or  with  the  negative  pole  to  the  spine  and  the  positive 
over  the  affected  muscles.  But  the  treatment  by  electricity,  by  chloroform, 
and,  we  may  add,  by  ice  over  the  spine,  as  practised  by  Trousseau,  is  more 
applicable  to  adult  cases  than  to  children. 

A  large  proportion  of  children  having  tetany  exhibit  rachitic  symptoms, 
and  when  such  symptoms  are  present  cod-liver  oil  and  iron  should  be  pre- 
scribed, and  at  the  same  time  that  the  bromide  of  potassium  and  other  reme- 
dies designed  to  relieve  the  tetany  are  employed. 


CHAPTER  Xiy. 

CHOREA. 

Chorea,  or  St.  Vitus's  or  St.  Guy's  dance,  is  a  neurosis  which  is  charac- 
terized by  irregular  and  involuntary  muscular  movements,  without  loss  of 
consciousness.  The  movements  occur  in  the  muscles  of  volition,  and  there 
is  probably  no  one  of  them  that  may  not  be  engaged,  though  some  are  more 
frequently  affected  than  others.  It  is  not  known  that  any  involuntary  mus- 
cle is  ever  involved,  though  Sir  William  Jenner  has  expressed  the  opinion 
that  occasionally  the  papillary  muscles  of  the  heart  are,  so  that  by  their 
spasmodic  contractions  they  produce  insufficiency  of  the  mitral  valve.  This, 
according  to  him,  affords  explanation  of  the  fact  that  in  certain  instances  a 
mitral  regurgitant  murmur  is  heard,  which  disappears  about  the  time  that 
the  external  movements  cease.  It  is  rare,  however,  that  a  mitral  regurgitant 
murmur,  heard  during  chorea,  ceases  when  the  latter  terminates,  and  it  is 
not  improbable  that  in  such  cases  there  is,  after  all,  a  lesion  of  the  valve, 
due  to  recent  endocarditis,  whether  of  a  rheumatic  or  other  origin ;  for  a 
valve  may  be  so  thickened  by  recent  inflammation  as  to  cause  a  murmur,  and 
after  a  few  weeks  or  months  the  infiltrating  substance  be  so  absorbed  that 
the  murmur  is  no  longer  audible.  If  we  admit  the  fact  that  cardiac  bruits 
occasionally  appear  and  disappear  with  chorea,  this  explanation  seems  to  me 
more  plausible  than  that  of  Jenner.  Hillier  says  in  reference  to  this  sub- 
ject :  "  My  own  experience  leads  me  to  doubt  the  existence  of  dynamic  apex 
murmurs  in  chorea  ;  that  is  to  say,  murmurs  produced  in  hearts  entirely  free 
from  organic  change.  If  such  murmurs  ever  occur,  they  are  certainly  rare. 
Organic  murmurs  of  the  heart,  on  the  other  hand,  are  common  in  chorea, 
and  I  am  inclined  to  believe  that  organic  disease  of  the  heart  often  exists  in 
chorea  when  there  is  no  murmur."  We  shall  see,  by  a  case  presently  to  be 
related,  that  this  opinion  is  correct.  Hillier  also  calls  attention  to  the  fact 
that  choreic  movements  are  irregular ;  but  a  cardiac  bruit  occurring  regu- 
larly and  uniformly,  if  not  due  to  organic  disease,  would  require  rhythmical 
contractions  of  the  papillary  muscles  to  produce  it.  We  infer  from  this  that 
the  bruit  does  not  have  a  choreic  origin. 

In  the  class  of  children's  diseases  in  the  Bureau  for  the  Relief  the  Out- 
door Poor  in  New  York  City,  16,986  children  were  treated  in  the  two  years 


AGE— CAUSES.  609 

and  three  months  ending  with  March  81,  1S77.  Of  these  cases  82,  or  1  in 
every  207,  had  chorea.  The  patients  wore  all  under  the  age  of  fifteen  years. 
Stati.stics  published  by  observers  in  Europe  show  that  the  relative  frequency 
of  this  disease  is  probably  about  the  same  in  the  large  European  cities  as  in 
New  York.  Thus,  according  to  liillicr,  amongst  122,621  out-patients  treated 
at  the  Hospital  for  Sick  Children  in  London,  406,  or  1  in  322,  had  chorea, 
while  of  the  in-patients,  174  in  5585,  or  1  in  every  32,  were  choreic.  In  the 
Parisian  Hospital  for  Sick  Children,  of  84,968  admitted  in  twenty-one  years, 
531  had  chorea,  or  1  in  every  161. 

Agk. — Chorea  may  occur  at  any  period  of  life,  but  a  large  majority  of  the 
cases  are  in  childhood.  It  is  rare  in  infancy  and  it  rarely  begins  after  puber- 
ty. Under  the  age  of  five  years  the  proportionate  number  diminishes  as  we 
approach  the  time  of  birth.  The  youngest  in  the  statistics  of  Hillier  was 
three  months.  In  1870,  in  the  Bureau  for  the  Out-door  l^oor  a  child  was 
presented  for  treatment  who,  the  mother  said,  had  had  chorea  from  birth, 
and  in  1877,  I  treated  a  young  woman  with  severe  general  chorea  who, 
repeatedly  questioned,  uniformly  said  that  she  had  had  the  disease,  without 
any  assignable  cause,  from  the  first  week  of  her  life,  and  her  friends  corrobo- 
rated the  statement.  The  following  table  exhibits  the  relative  frequency  of 
chorea  at  different  ages  : 

6  years       6  to  10       10  to  1.5 
and  under,    years.         years. 

Children's  Hospital,    London,   Hillier,  none  over   12  years 

admitted 81  237  104 

M.  Rnfz 10  61  118 

Bureau  for  Out-door  Poor  (prior  to  1875) 2  26  16 

At  and  under         3  to  5         5  to  10       10  to  15 
3  years.  years.        years.         years. 

Bureau  for  Out-door  Poor  (since  January  1,  1875)      5  30  337  ISO 

M.  See  collected  the  statistics  of  531  cases  occurring  in  the  Children's 
Hospital,  Paris,  and  from  them  concludes  that  the  maximum  frequency  of 
chorea  is  between  the  sixth  and  tenth  years.  Only  28  of  his  cases  were 
under  six  years,  the  remainder,  503,  occurring  between  the  sixth  year  and 
puberty. 

Cause.s. — The  profession  are  nearly  agreed  in  regard  to  certain  causes  of 
chorea,  while  there  is  a  diversity  of  opinion  in  reference  to  others.  It  is 
admitted  that  in  a  large  proportion  of  cases  there  is  a  neuropathic  state 
which  antedates  and  predisposes  to  chorea.  This  state  is  often  manifested 
in  the  family  history  by  a  proneness  to  aflPections  of  the  nervous  system,  and 
in  the  individual  by  a  highly  excitable  state  of  the  emotions,  so  that  he 
evinces  joy,  grief,  or  anger  from  slight  causes. 

All  writers  admit  that  there  is  often  an  inherited  predisposition  to  chorea. 
In  27  of  48  cases,  RadclifFe  found  that  father,  mother,  brother,  or  sister  had 
been  or  was  the  subject  of  one  or  other  of  the  following  disorders :  paralysis, 
epilepsy,  apoplexy,  hysteria,  or  insanity.  The  children  of  parents  who  when 
young  had  chorea  or  who  exhibit  proneness  to  ailments  of  the  nervous  sys- 
tem are  more  liable  to  chorea  than  other  children.  Hence  the  fact,  some- 
times observed,  of  different  children  in  the  same  family  becoming  affected 
with  chorea  when  they  attain  the  age  at  which  this  disease  ordinarily 
occurs.  In  one  family  in  my  practice  three  girls  at  different  times  were 
affected. 

Sex. — The  emotions  are  strong  in  girls,  since  in  them  the  nervous  system 
predominates,  while  the  muscular  power  is  weaker  than  in  boys.  Hence  a 
partial  explanation  of  the  fact  which  statistics  fully  establish,  that  the  pro- 
39 


610  CHOREA. 

portion  of  choreic  boys  to  girls  is  about  in  the  ratio  of  one  to  two  and  a  frac- 
tion. I  have  remarked,  in  this  city,  the  large  proportion  of  cases  in  school- 
girls between  the  ages  of  six  and  twelve  years,  the  severe  discipline  and 
confinement  of  the  public  schools  no  doubt  increasing  the  strength  of  the 
emotions,  and  weakening  the   control  of  the  will  over  the  muscles. 

Proportion  of  Males  to  Females. 

27  to  73.  Hughes's  Digest  of  Cases  in  Guy's  Hospital,  1846. 

IBS  to  393.  M.  See. 

50  to  94.  Out-door  department,  Bellevue. 

276  to  499.  Children's  Hospital,  London  West  (Lumleian  Lectures), 

491  to  1059  =  1  to  2.15. 

The  cases  treated  in  the  Out-door  Department,  Bellevue,  since  those 
contained  in  the  above  table  occurred  give  a  larger  percentage  of  females. 
Between  April,  1878,  and  December,  1883,  288  choreic  cases  were  treated 
in  this  department,  and  of  these  the  proportion  of  boys  to  girls  was  1  to  2.4 
(Chapin). 

Uterine  Irritation. — The  peculiar  changes  occurring  in  the  female  at 
puberty  constitute  an  important  cause.  Hence  another  reason  of  the  excess 
of  female  cases.  Dysmenorrhoea  and  pregnancy  are  causes  of  a  large  pro- 
portion of  cases  in  the  first  years  of  puberty.  In  the  male,  on  the  other 
hand,  the  changes  of  puberty  do  not  appear  to  increase  the  liability  to  the 
disease,  directly  or  indirectly,  and  male  cases  after  the  age  of  twelve  years 
are  comparatively  rare.  Iladcliff"e^  states  that  after  the  ninth  year  females 
are  more  liable  to  chorea  than  males,  in  the  proportion  of  5  to  2,  while  before 
the  ninth  year  the  two  sexes  are  equally  liable  to  it.  Carefully  prepared 
statistics,  however,  notwithstanding  the  high  authority  of  Radcliffe,  show  a 
preponderance  of  girls  under  the  age  of  nine  years,  though  not  so  great  as 
over  that  age.  In  the  Out-door  Department  at  Bellevue,  of  35  patients  under 
the  age  of  ten  years,  22  were  girls,  while  of  20  from  the  age  of  ten  years  to 
sixteen,  15  were  girls. 

According  to  West,^  in  775  children  with  chorea  under  the  age  of  ten 
years  treated  in   the  London   Children's   Hospital,  64  per  cent,   were  girls. 

Anaemia. — Among  the  most  common  predisposing  causes  of  chorea  is 
anaemia.  It  is  present  in  so  large  a  proportion  of  cases,  exhibiting  itself  by 
pallor  of  the  countenance  and  other  characteristic  signs,  that  medicines 
designed  to  improve  the  quality  of  the  blood  are  among  the  most  efficient 
remedies.  The  peculiar  neuropathic  state  already  alluded  to,  which  needs 
only  a  slight  additional  cause  for  the  development  of  chorea,  is  no  doubt 
largely  dependent  on  impoverishment  of  the  blood,  if  it  be  not  sometimes  due 
entirely  to  it.  Among  the  poor  of  a  large  city  like  New  York  or  in  hospital 
practice  the  proportion  of  anaemic  cases  of  chorea  is,  for  obvious  reasons, 
much  larger  than   would  appear  from  the  general   statistics. 

Rheumatism, — Dr.  Copeland,  M.  Bouteille,  and  afterward  M.  Germain 
See  in  a  more  extended  monograph,  directed  the  attention  of  the  profession 
to  rheumatism  as  a  cause  of  chorea.  Subsequent  observations  have  estab- 
lished the  fact  that  rheumatism  or  the  rheumatic  diathesis  is  so  frequently 
present  that  it  obviously  sustains  an  important  relation  to  chorea,  though  in 
what  manner  is  not  fully  ascertained.  This  relation  between  the  two  is  more 
frequently  observed  in  some  countries  than  in  others.  In  England  and 
France  so  large  a  proportion  of  choreic  patients  present  a  history  of  rheu- 
matism, either  in  themselves  or  family,  that  certain  physicians  of  these  coun- 
tries believe  that  rheumatism  is  the  most  common  cause  of  the  disease.  In 
'  Beynolds's  System  of  Medicine.  ^  Lumleian  Lectures. 


CAUSES.  ()11 

Germany,  on  the  other  hand,  according  to  Romberg,  in  the  majority  of  cases 
no  relation  can  be  traced  between  chorea  and  rlieumatism.  Probably  the 
hirgcst  number  of  choreic  cases  treated  in  one  institution  in  this  country  is  in 
the  Bureau  for  the  Relief  of,  the  Out-door  Poor  in  this  city  ;  and  it  has  been 
our  practice  during  the  last  few  years  to  examine  each  patient  for  heart  dis- 
ease and  question  the  parents  as  regards  rheumatism.  Without  referring  to 
the  exact  statistics,  I  should  say  that  more  than  half  give  the  history  of 
rheumatisTii  in  themselves  or  parents  or  had  unequivocal  signs  of  heart  dis- 
ease. One  of  the  physicians  of  the  class  found  that  22  in  38  consecutive 
eases  of  chorea  gave  the  history  of  rheumatism  or  of  heart  disease  in  them- 
selves or  parents. 

Various  theories  have  been  promulgated  in  explanation  of  the  relation- 
ship of  the  rheumatic  and  choreic  diseases.  It  has  been  suggested  that 
chorea  is  due  to  rheumatism  of  the  brain  or  spinal  cord.  This  is  simply  an 
hypothesis,  the  truth  or  falsity  of  which  can  only  be  ascertained  by  carefully 
conducted  necropsies ;  but  the  theory  appears  improbable  in  view  of  all  the 
facts.  Another  theory  attributes  chorea  to  the  state  of  the  blood  which  is 
present  in  those  having  rheumatism  or  the  rheumatic  diathesis,  as  well  as  in 
certain  other  conditions.  This  theory  is  enunciated  by  Dr.  Ogle,  as  follows : 
"  Recognizing  the  frequent  existence  of  these  fibrinous  deposits  or  granula- 
tions on  the  heart's  valves  in  chorea,  I  should  be  much  inclined  to  look  upon 
these  post-mortem  appearances  rather  as  results  of  some  antecedent  general 
condition  of  the  blood  common  also  to  the  choreic  condition.  It  is  very  freely 
recognized  that  this  affection  is  frequently,  in  some  way  or  other,  connected 
with  that  condition  of  blood  which  obtains  in  what  we  call  anasmia  or  that 
existing  in  rheumatic  constitutions.  In  both  of  these  states  we  know  that 
the  fibrin  of  the  blood  is  much  in  excess  (as  also  it  is  in  pregnancy,  another 
condition  looked  upon  as  obnoxious  to  chorea)  ;  and  in  these  states  we  know 
that  the  fibrin  with  which  the  blood  is  surcharged  is  very  prone  to  be  readily 
precipitated,  either  owing  to  its  superabundance  or  from  other  obscure  and 
acquired  properties,  ....  upon  the  heart's  walls  or  valves.  May  not  this 
hyperinosis  be  the  explanation  of  the  coincidence  alluded  to?"' — namely,  the 
occurrence  of  chorea  in  those  affected  with  rheumatism.  Others  still  hold 
that  chorea  is  the  result  of  the  heart  disease,  and  not  directly  of  rheumatism, 
occurring  when  the  heart  is  affected  from  other  causes  as  well  as  when  the 
lesion  has  a  rheumatic  origin.  This  theory  is  plausible,  and  probably  to  a 
certain  extent  correct.  Heart  lesions  observed  in  children  result  from  scarlet 
fever  in  a  considerable  proportion  of  cases,  though  it  is  true  that  the  endo- 
carditis and  pericarditis  of  scarlet  fever  are  believed  often  to  have  a  rheu- 
matic origin,  occurring  in  some  instances  from  scarlatinous  rheumatism,  but 
in  other  cases  from  scarlatinous  uraemia.  Occasionally  also  the  heart  disease 
appears  to  have  occurred  independently  of  both  rheumatism  and  scarlet  fever. 
Thus  in  a  fatal  case  of  chorea  with  valvular  disease  related  to  the  London 
Pathological  Society,  April  6,  1869,  the  child  was  always  healthy  up  to  the 
present  illness  (chorea),  and  there  was  no  history  of  rheumatism  in  the  fam- 
ily. The  more  observations  accumulate  the  more  important  does  heart  dis- 
ease in  itself  appear  as  a  cause  of  chorea.  In  nearly  all  recorded  cases  of 
fatal  chorea  which  were  supposed  to  be  due  to  rheumatism,  and  in  which  post- 
mortem examinations  were  made,  endocardial  and  usually  valvular  disease  has 
been  found.  We  shall  see  that  certain  eccentric  causes  of  irritation  aid  in 
producing  chorea,  and  may  not  the  valvular  disease  or  the  endocarditis  which 
causes  the  valvular  lesion  operate  in  a  similar  manner  as  a  cause?  We  know 
that  in  the  adult  severe  cardiac  disease  often  profoundly  affects  the  nervous 
system,  perhaps  in  consequence  of  the  irregular  and  embarrassed  circulation, 

'  British  and  Foreicjn  Med.-Chir.  Rev.,  January,  1868. 


612  CHOREA. 

and  certainly  in  the  child  a  similar  cause  would  be  likely  to  produce  a  more 
decided  effect. 

But  there  is  an  ingenious  theory  which  attributes  chorea  to  minute 
emboli  detached  from  vegetations  on  the  valves,  and  arrested  by  capillaries 
in  the  corpora  striata  or  other  portion  of  the  cerebro-spinal  axis.  Since  atten- 
tion was  directed  to  this  matter,  emboli  have  been  found  in  one  case  in  the 
medulla  oblongata,  although  this  portion  of  the  spinal  axis  appeared  healthy 
to  the  naked  eye.  Further  observations  are  necessary  in  order  to  determine 
how  much  truth  there  is  in  this  theory  ;  but  it  seems  probable,  for  reasons  to 
be  stated,  that  if  capillary  embolism  do  cause  chorea,  it  is  only  in  a  limited 
number  of  cases,  and  that  therefore  those  British  observers  who  regard  it  as 
the  common  cause  have  been  led  into  error  by  the  large  proportion  of  choreic 
cases  which  in  their  climate  are  complicated  by  valvular  lesions. 

That  embolism  is  not  a  common  cause,  if  indeed  a  cause  at  all,  appears 
probable  from  the  following  facts :  First.  In  many  cases  of  chorea  there  are 
no  vegetations  or  other  appreciable  lesions  which  could  give  rise  to  emboli. 
Secondly.  Most  patients  recover,  and  some  speedily,  by  treatment,  which  we 
would  not  expect  if  the  cause  were  embolism.  Thirdly.  Embolism  is  not 
infrequent  in  the  cerebral  vessels  of  the  adult  without  the  occurrence  of 
chorea.  Indeed,  the  conditions  which  produce  embolism  are  much  more  com- 
mon in  adults  than  in  children,  while  the  reverse  is  true  as  regards  the  liability 
to  chorea.  Fourthly.  Dogs  sometimes  have  chorea,  but  the  injection  of 
minutely  divided  fibrin  or  other  substance  into  the  veins  of  the  dog  is  not 
followed  by  chorea  as  one  of  the  phenomena.  Fifthly.  Were  capillary  emboli 
the  cause,  we  would  expect  to  find  an  occasional  embolus  in  the  larger  vessels 
of  the  brain,  so  as  to  be  appreciable  to  the  naked  eye ;  but  I  find  no  examples 
of  this  in  all  the  recorded  autopsies  which  I  have  been  able  to  consult.  More- 
over, it  seems  improbable  that  capillary  embolism,  when  producing  no  lesion 
appreciable  to  the  naked  eye,  would  so  arrest  the  circulation  and  disturb  the 
function  of  the  brain  or  spinal  cord  as  to  cause  chorea,  for  the  ill-eff"ects 
of  such  an  obstruction  would  be  likely  to  be  obviated  by  the  numerous 
anastomoses. 

In  1877  the  unusual  opportunity  occurred  in  my  asylum  practice  of 
determining  whether  there  are  any  fixed  anatomical  characters  in  the 
cerebro-spinal  axis  in  chorea ;  in  other  words,  whether  chorea  is  a  neurosis, 
as  we  have  designated  it  in  our  definition,  and  the  case  is  so  interesting  in 
other  respects  that  I  shall  relate  it  entire : 

Case. — Charles ,  a  foundling,  born  October  15,  1874,  was  received  in  the 

New  York  Foundling  Asylum  soon  after  his  birth.  When  two  weeks  old  he  was 
removed  to  a  family  in  the  city  to  be  wet-nursed.  His  health  continued  good  till 
the  age  of  three  months,  when  he  had  bronchitis  and  keratitis,  the  former  mild 
and  lasting  only  a  few  days,  but  the  latter  continuing  nearly  two  months,  being 
attended  by  moderate  injection  of  the  conjunctiva,  with  some  purulent  discharge, 
which  caused  adhesion  of  the  eyelids  during  sleep.  From  this  time  he  remained 
well,  with  the  exception  of  a  slight  attack  of  dysentery,  till  the  age  of  about  nine 
and  a  half  months,  when  he  began  to  have  febrile  symptoms.  In  the  morning 
hours  he  seemed  in  tolerable  health,  but  at  mid-day  or  a  little  later  than  mid-day 
of  each  day  he  was  observed  to  have  slight  irregularity  or  embarrassment  of 
respiration,  and  lividity,  with  coolness  of  the  extremities;  which  state,  supposed 
at  the  time  to  be  the  algid  stage  of  a  somewhat  irregular  intermittent  fever,  lasted 
from  one  to  two  or  three  hours,  and  was  succeeded  by  fever,  which  continued 
during  the  remainder  of  the  day;  sometimes  the  fever  abated  in  perspiration. 

On  August  4,  1875,  a  few  days  after  the  commencement  of  these  irregular 
febrile  symptoms,  Charles  was  brought  to  the  dispensary  of  the  institution  for 
treatment,  and  Dr.  Reid,  who  was  on  duty  that  day,  carefully  examined  the  case 
and  prescribed  the  sulphate  of  quinia.     This  medicine,  continued  a  few  days, 


CAUSES.  613 

relieved  the  symptoms,  but  every  four  to  six  weeks,  for  more  than  a  year,  the 
febrile  attacks  returned,  and  were  uniformly  relieved  by  the  same  medicine.  In 
other  respects  the  patient  had  the  usual  health. 

On  or  about  February  1,  1878,  the  nurse  noticed  that  Charles  had  what  she 
designated  "  spells  of  trembling,"  in  which  he  seemed  excited  and  feverish,  and 
which  were  sometimes  attended  by  or  followed  by  perspiration.  In  the  course 
of  anotlu'r  week  the  irregular  muscular  movements  became  more  marked  and 
constant,  and  they  increased  in  severity  till  near  the  time  of  the  admission  of 
the  patient  into  the  asylum,  about  March  1st.  The  nurse  had  noticed  in  Feb- 
ruary slowness  and  some  difficulty  of  micturition,  and  Dr.  Reid  examined  him 
with  a  catheter  for  calculus,  and  also  his  prepuce  for  any  source  of  irritation,  but 
nothing  abnormal  was  discovered,  either  in  the  condition  of  the  bladder  or  the 
external  organs.  In  the  latter  part  of  April  the  chorea  had  become  so  severe 
that  irregular  muscular  action  occurred  in  all  the  limbs  and  in  the  muscles  of 
the  eyes,  producing  such  grimaces  and  contortions,  with  strabismus,  that  the 
woman  with  whom  he  was  boarding  became  alarmed,  and  returned  him  to  the 
asylum,  stating  that  he  had  become  crazy. 

On  March  12th  my  attention  was  first  called  to  this  child,  when  I  made  the 
following  entry  in  my  note-book :  Family  history  unknown ;  no  history  of  rheu- 
matism in  patient's  case;  he  may  or  may  not  have  had  it;  heart  sounds  normal ; 
pulse  104 ;  all  the  limbs  and  the  muscles  of  the  face,  eyes,  and  eyelids  involved  in 
choreic  movements,  which  continue  constantly  except  during  sleep.  The  patient 
cannot  walk  or  stand  without  support ;  appetite  good,  apparently  better  than  in 
health,  for  he  eats  every  kind  of  food  handed  to  him,  and  carries  the  food  with 
his  own  hand  to  his  mouth,  although  these  movements  are  very  irregular  and 
jerking.     Three  drops  of  Fowler's  solution  ordered  after  each  meal. 

March  17th. — Condition  not  much  changed,  but  perhaps  slight  improvement ; 
in  addition  to  other  choreic  movements  the  eyes  twitch  spasmodically ;  pulse  84, 
temperature  982°;  bowels  irregular;  no  cough;  appetite  good.  Increase  medi- 
cine to  five  drops. 

30th. — The  urine  examined  since  the  last  record  was  found  very  pale  and  abun- 
dant ;  its  specific  gravity  low,  1004,  without  albumen.  When  an  equal  quantity 
of  nitric  acid  was  added  to  it,  after  twelve  hours  crystals  of  nitrate  of  urea  occu- 
pied about  one-half  of  the  volume  of  the  urine.  The  patient's  sleep  is  quiet,  but 
the  choreic  movements  recommence  as  soon  as  he  awakens,  but  in  a  milder  form  ; 
is  able  to  walk  without  support,  but  with  unsteady  gait.  My  term  of  service 
ended  March  31st.  On  the  following  day  laryngo-tracheitis  was  suddenly  devel- 
oped, ending  fatally  in  forty-eight  hours  at  the  age  of  two  years  five  and  a  half 
months. 

Autopsy,  April  4th. — Slight  oedema  about  the  aperture  of  the  glottis;  general 
and  intense  redness  of  mucous  membrane  of  larynx,  trachea,  and  bronchial  tubes ; 
as  far  as  they  can  be  traced,  posterior  portions  of  lungs  greatly  congested.  The 
heart,  lungs,  brain  with  one  eye  attached  to  it  by  optic  nerve,  and  the  entire  spi- 
nal cord  were  sent  to  Prof.  Francis  Delafield,  for  microscopic  examination.  They 
were,  as  soon  as  removed,  placed  in  a  solution  of  bichromate  of  potassium.  The 
following  is  a  brief  statement  of  the  examination  which  was  made : 

Microscopic  Appearances.  By  Prof.  Francis  Delafield. — Brain  presented  no 
change  apparent  to  the  naked  eye  except  a  considerable  degree  of  congestion. 
It  was  hardened  in  bichromate  of  potassium  and  chromic  acid.  Minute  exami- 
nation of  the  convolutions  of  the  brain,  the  large  ganglia,  the  cerebellum,  the 
pons  Varolii,  and  the  medulla  oblongata  showed  nothing  except  a  uniform  filling 
of  the  vessels  with  blood,  as  if  they  were  injected.  There  were  no  apoplexies, 
no  changes  in  the  walls  of  the  vessels. 

Spinal  cord  appeared  to  be  entirely  normal. 

The  Heart. — The  auricles  and  ventricles  were  of  normal  size.  The  aortic 
valves  were  atheromatous  and  somewhat  rigid ;  the  mitral  valves  were  thickened 
and  insufficient ;  the  endocardium  of  the  left  ventricle  was  thickened. 

The  Lungs. — The  capillaries  in  the  walls  of  the  air-vesicles  were  dilated,  and 
there  was  an  increase  of  epithelial  cells  within  the  air-vesicles. 

In  this  case  there  seemed  to  be  no  lesion  associated  with  the  chorea  except 
the  organic  disease  of  the  heart  and  the  changes  in  the  lungs  secondary  to  this 
condition  of  the  heart. 

The  above  microscopic  examination  was  made  with  sufficient  minuteness,  and 


614  CHOREA. 

it  is  seen  that  no  emboli  were  discovered  and  no  lesion  of  the  cerebro-spinal  axis 
except  congestion,  which  was  attributable  to  the  mode  of  death — namely,  by 
obstructed  respiration.  Moreover,  it  will  be  recollected  that  there  were  no  car- 
diac bruits,  and  apparently  not  sufficient  roughness  of  the  edge  or  surface  of  the 
valves  to  cause  precipitation  of  fibrin,  which  would  be  necessary  in  order  that 
emboli  should  form. 

Fright. — A  not  infrequent  cause  of  chorea  is  sudden  and  profound  emo- 
tion, especially  fright.  All  statistics  give  fright  as  the  cause  of  a  certain 
proportion  of  cases,  though  there  are  usually  other  potential  co-operating 
causes,  as  anaemia  or  valvular  disease.  Fright  was  stated  as  the  cause  of 
chorea  in  31  of  the  100  cases  occurring  in  Guy's  Hospital  reported  by 
Hughes,  or  nearly  1  in  3.  But  the  statistics  of  other  observers  do  not  give 
so  large  a  proportion  of  cases  originating  in  this  way.  Chorea  may  commence 
within  a  few  hours  after  the  fright  or  not  till  the  lapse  of  several  days  (eight 
or  ten).  If  several  weeks  have  passed  since  the  fright,  as  in  some  reported 
cases,  the  chorea  is  probably  due  to  other  causes.  In  rare  instances  chorea 
is  said  to  have  been  caused  by  sudden  and  excessive  joy. 

Imitation. — Under  unusual  circumstances,  especially  in  a  state  of  great 
mental  excitement,  imitation  has  been  known  to  cause  a  form  of  chorea. 
Hecker  describes  an  epidemic  of  it  occurring  in  the  Middle  Ages  and  spread- 
ing through  villages.  In  modern  times  it  is  rare  that  chorea  originates  from 
this  cause,  nevertheless  occasional  examples  have  been  recorded. 

But  the  disease  which  occurs  from  imitation  diifers  from  the  ordinary  form 
and  has  been  termed  chorea  major,  while  the  chorea  which  is  the  subject  of 
this  article  is  sometimes  designated,  in  contradistinction,  chorea  minor. 

In  chorea  major  the  patient  leaps,  dances,  or  whirls  like  a  top.  It  has  its 
origin  commonly  in  religious  excitement,  and  spreads  by  imitation  almost  in 
the  manner  of  an  infectious  disease.  The  epidemic  of  the  Middle  Ages  was 
a  chorea  major.  I  have  not  been  able  to  find  any  account  of  cases  spi'eading 
by  imitation  in  modern  times  which  were  not  examples  of  the  same  form  of 
chorea.  Thus  in  the  Edinbivrgh  Journal  of  Medicine  and  Surgery,  for  July, 
1839,  there  is  a  clear  description  of  chorea  major  occurring  successively  in 
five  children  in  the  same  family.  Br.  Bewar,  the  attending  physician,  states 
that  one  of  the  children  whom  he  was  called  to  see  was  sitting  near  the  fire- 
place, when  her  head  dropped  on  her  chest  and  she  appeared  to  doze  some 
minutes.  In  the  mean  time  the  respiration  became  a  little  accelerated,  the 
face  altered  and  flushed,  the  eyes  wild.  In  less  than  one  minute  she  bounded 
from  one  extremity  of  the  apartment  to  the  other,  leaping  over  chairs,  a  chest, 
and  then  throwing  herself  upon  the  floor  ;  she  attempted  to  stand  upon  her 
head,  rolled  upon  the  floor,  and  then,  rising,  ran  with  extreme  swiftness  in 
the  room,  till  she  finally  fell  again  upon  the  floor,  where  she  remained  motion- 
less some  minutes.  Then,  recovering,  she  noticed  those  who  surrounded  her, 
and  asked  of  her  sister  a  toy  which  she  had  allowed  to  fall.  The  whole  par- 
oxysm lasted  twenty  minutes. 

Obviously,  the  symptoms  of  chorea  major  diff'er  materially  from  those  of 
chorea  minor,  and  it  is  a  question  whether  it  should  have  the  same  generic 
name.  It  is  a  curious  and  interesting  disease  in  its  psychical  and  patholog- 
ical aspect,  but  it  is  so  rare  in  modern  times  that  a  knowledge  of  it  is  of 
little  practical  importance. 

Intestinal  Irritation. — In  rare  instances  intestinal  worms  cause  chorea, 
though   in   these  cases  there   have  usually  been   some  co-operating  causes. 

The  following  is  an  example  related  by  Mr.   Ogle:^    "Ellen  L ,  nine 

years  old,  had  been  under  treatment  about  a  month  with  chorea,  rheuma- 
tism, and  worms.  She  had  not  slept  in  four  days,  and  there  was  constant 
^  Lond.  Medico-Chir.  Rev.,  Jan.,  1868. 


ANATOMICAL   CHARACTERS.  615 

spasmodic  movement  of  the  body  and  face.  Her  general  condition  was  very 
unpromising.  As  she  liad  passed  portions  of  a  tape-worm  at  intervals  during 
the  last  three  months,  one  drachm  of  the  oleum  filicis  maris  was  administered 
in  mucilage,  which  caused  tlic  expulsion  of  the  entire  worm.  From  that  time 
she  fully  and  rapidly  recovered  from  the  chorea,  though  a  mitral  murmur 
remained." 

Lesions  of  Brain  and  Spinal  Cord. — Although  we  reject  the  theory 
that  cerebral  emboli  are  the  common  cause  of  chorea,  and  believe  that  in  a 
large  majority  of  cases  there  are  no  cerebro-spinal  lesions,  nevertheless 
experiments  and  also  occasional  cases  establish  the  fact  that  if  not  true 
chorea,  at  least  choreiform  movements  now  and  then  result  from  a  struc- 
tural affection  of  the  nervous  centres. 

Experiments  on  certain  of  the  lower  animals  demonstrate  that  irregular 
muscular  movements  may  be  produced  by  traumatic  injury  of  certain  por- 
tions of  the  cerebro-spinal  axis,  as  the  corpora  quadrigemina,  crura  cerebri, 
pons  Varolii,  crura  cerebelli,  thalami  optici,  parts  of  the  medulla  oblongata, 
and  the  upper  portion  of  the  spinal  cord.  Pressure  on  the  projecting  part  of 
the  medulla  oblongata  of  an  acephalous  monster  also  causes  convulsive  move- 
ments. At  the  meeting  of  the  New  York  Academy  of  Medicine,  April  20, 
1871,  Professor  Post  related  the  case  of  a  child  who  was  struck  over  the 
occiput  with  a  billet  of  wood,  and  chorea  followed,  due.  in  all  probability,  to 
the  injury  of  the  brain  which  resulted. 

If  irregular  muscular  movements,  choreic  or  choreiform,  result  from  trau- 
matic injury  of  certain  portions  of  the  nervous  centres,  may  they  not  also 
occasionally  occur  from  lesions  of  the  same  parts  produced  by  disease?  Sir 
Benjamin  Brodie'  relates  the  case  of  a  choreic  girl  dying  in  St.  George's 
Ho.spital,  in  whom,  after  a  careful  post-mortem  examination,  the  only  morbid 
appearance  observed  was  a  tumor  the  size  of  a  hazelnut  connected  with  the 
pineal  gland.  Dr.  Broadbent'^  described  another  case  before  the  London 
Pathological  Society  in  which  a  tumor  was  found  arising  from  the  centre  of 
the  spinal  cord ;  and  Chambers  one  in  which  tubercles  were  imbedded  in  the 
cord.  Romberg  quotes  from  Frerichs  a  case  in  which  the  medulla  oblongata 
was  pressed  upon  by  an  enlarged  odontoid  process;  and  Dr.  Aitkin*  one  in 
which  the  specific  gravity  of  the  thalamus  opticus  and  corpus  striatum  was 
greater  on  one  side  than  on  the  other.  Rilliet  and  Barthez  relate  other  similar 
cases,  and  they  remark  :  "  We  may  conclude  from  these  different  cases  that 
there  exist  two  species  of  chorea — the  one  essentially  a  simple  neurosis,  while 
the  other  depends  on  an  alteration  of  the  encephalo-rachidian  system.  In  a 
word,  it  is  of  chorea  as  of  convulsions,  that  it  is  sometimes  idiopathic,  some- 
times symptomatic."  Still,  the  cases  in  which  it  is  symptomatic  are  so  few 
that  it  is  proper  to  consider  chorea,  as  it  ordinarily  occurs,  one  of  the  neu- 
roses until  the  microscope  detects  some  anatomical  cause  in  the  cerebro-spinal 
system  of  which  we  are  now  ignorant. 

Anatomical  Characters. — We  have  seen  that  chorea  has  no  constant 
anatomical  characters.  Lesions  which  probably  sustain  a  causal  relation  to 
the  disordei'ed  muscular  action  are  sometimes  present,  and  others  are  some- 
times observed  which  are  neither  a  cause  nor  a  result,  their  presence  being  a 
coincidence.  But  there  are  two  lesions  which,  though  often  absent,  have 
been  observed  in  so  large  a  proportion  of  fatal  cases  that  they  are  justly 
regarded  as  an  occasional  result  when  chorea  is  severe.  Dr.  Hughes  of  Lon- 
don collected  records  of  the  post-mortem  appearances  of  14  cases,  with  the 
following  result  as  regards  the  cerebro-spinal  axis :   Brain,  14  cases ;  healthy, 

'  London  Lancet,  Dec.  19,  1840. 

^  Transactions  London  Patholof/iral  Society,  vol.  xiii.  p.  246. 

"*  Glasgow  Medical  Journal,  vol.  i. 


616  CHOREA. 

4  cases ;  only  congested,  3  cases ;  softened  in  part  or  entirely,  6  cases  (some 
of  these  6  also  congested).  In  some  of  the  1-1  cases  those  occasional  results 
of  congestion — to  wit,  transudation  of  serum  and  extravasation  of  blood  in 
greater  or  less  quantity — were  also  observed.  Spinal  cord  :  healthy,  3  cases  ; 
congested,  2  cases  (one  slightly,  in  the  other  the  engorged  vessels  were  large 
and  numerous)  ;  softening  in  medulla  oblongata,  1  case ;  softening  opposite 
fourth  and  fifth  vertebrae,  12  cases.  In  1  there  was  soft,  in  another  firm,  adhe- 
sion of  the  spinal  meninges,  and  in  1  it  is  stated  that  the  rachidian  fluid  was 
opaque.  Of  16  fatal  cases  of  chorea  occurring  in  St.  George's  Hospital, 
"  congestion  (more  or  less  complete)  of  the  nervous  centres  (brain  or  spinal 
cord,  or  both)  was  met  with  in  6  cases."  Softening  of  certain  parts  of  the 
brain  was  observed  in  1  case,  and  of  the  spinal  cord  in  another.^  Other  sta- 
tistics of  the  anatomical  character  of  fatal  chorea  correspond,  in  the  main, 
with  those  of  Hughes  and  Ogle.  The  lesions  observed  by  them  are  probably 
not  present  in  ordinary  cases,  occurring  only  when  the  choreic  movements  are 
so  severe  that  the  patient  is  deprived  of  needed  repose  and  the  important 
functions  of  the  economy,  as  circulation  and  nutrition,  are  seriously  dis- 
turbed. 

The  post-mortem  examination  of  other  parts  besides  the  cerebro-spinal 
axis  furnishes  a  negative  result,  if  we  except  such  affections  as  have  been 
ascertained  to  act  as  causes  of  chorea.  What  portion  of  the  nervous  centre 
is  chiefly  involved  in  chorea  is  uncertain.  Some,  as  Sir  Benjamin  C.  Brodie,^ 
consider  chorea  a  disease  of  the  nervous  system  generally,  while  others  have 
attributed  it  to  disease  or  disorder  of  a  certain  part,  as  the  corpus  striatum, 
cerebellum,  etc.  Finally,  it  is  stated  that  in  late  experiments  on  choreic  dogs 
the  movements  do  not  cease  when  the  spinal  cord  is  severed  from  the  brain, 
nor  also  on  division  of  the  posterior  roots  of  the  spinal  nerves.^  In  these 
cases,  therefore,  the  part  of  the  axis  which  is  in  fault  would  appear  to  be 
solely  the  spinal  cord. 

Symptoms. — Chorea  is  partial  or  general.  It  is  partial  when  it  affects  a 
few  muscles  or  groups  of  muscles,  as  those  of  one  arm,  the  face  or  neck,  or 
of  one  eye.  It  is  designated  general  when  all  the  limbs  and  certain  of  the 
muscles  of  the  face  and  trunk  are  involved.  Statistics  show  that  partial 
chorea  occurs  more  frequently  on  the  left  than  on  the  right  side,  and  in  gen- 
eral chorea  the  movements  on  the  left  side  usually  predominate.  The  com- 
mencement is  in  most  cases  gradual.  Even  when  finally  chorea  becomes 
general,  certain  muscles  only  are  affected  in  the  commencement  in  ordinary 
cases.  The  child  in  whom  this  disease  is  about  to  begin  is  observed  to  be 
fretful  and  impatient  from  slight  causes,  and  the  irregular  muscular  action 
is  sometimes  misunderstood  by  the  parents,  who  reprimand  him  for  his  sup- 
posed fidgety  habit.  In  exceptional  instances,  especially  when  the  cause  is  a 
sudden  and  profound  emotion,  the  commencement  is  abrupt  and  the  disease 
is  severe  and  general  from  the  first. 

In  a  majority  of  cases  the  muscles  which  are  primarily  affected  are  those 
of  the  face,  neck,  fingers,  or  hand  on  the  left  side.  Sydenham  erred,  unless 
the  clinical  history  of  chorea  has  changed  during  the  last  two  centuries,  when 
he  stated  as  the  common  fact  that  a  tottering  gait  is  its  first  manifestation, 
but  now  and  then  such  a  case  does  occur.  Whenever  choreic  movements 
appear  other  muscles  besides  those  first  affected  are  soon  involved,  so  that  in 
the  course  of  a  few  weeks,  sometimes  of  a  few  days,  all  the  muscles  that 
participate  are  engaged. 

1  Ogle :  Brit,  and  For.  Medico-Chir.  Rev.,  Jan.,  1868. 
^  London  Lancet,  Dec.  19,  1840. 

^  Legros  et  Onimus :  Rech.  sur  les  mouvements  choreiformes  du  Chien,  Acad,  des 
Sci.,  9  Mai,  1870,  Jjyons  Med.  Jour.,  June  5,  1870. 


SYMPTOMS.  617 

A  muscle  affected  by  chorea  alternately  contracts  and  relaxes,  but  less 
forcibly  and  rapidly  than  in  eclampsia,  and  the  movement  is  partly  controlled 
by  volition.  This  produces  an  unsteady  and  tremulous  action  of  the  part, 
whether  a  limb,  the  neck,  or  the  face,  which  at  once  arrests  attention  and 
indicates  the  nature  of  the  disease.  The  I'esult  is  similar,  as  regards  the 
muscular  action,  whether  the  patient  wills  a  movement  or  attempts  to  control 
those  which  chorea  produces. 

If  the  case  be  of  ordinary  severity,  the  movements  continue  with  but 
momentary  intermissions,  except  during  sleep,  when  they  ordinarily  cease. 
In  grave  cases  patients  are  often  deprived  of  the  proper  amount  of  sleep  in 
consequence  of  the  severity  and  persistence  of  the  muscular  action,  and  in 
exceptional  instances,  especially  when  the  result  is  fatal,  the  movements  con- 
tinue in  sleep,  but  the  sleep  is  not  sound  and  is  frequently  interrupted.  In 
profound  sleep  the  muscles  are  always  in  repose. 

The  older  writers  have  left  us  graphic  descriptions  of  those  diseases  which 
have  striking  external  manifestations,  though  often  with  somewhat  of  exag- 
geration. Sydenham  says  of  chorea  :  "  The  patient  cannot  keep  it  (his  hand) 
a  moment  in  the  same  place  ;  whether  he  lay  it  upon  his  breast  or  any  other 
part  of  his  body,  do  what  he  may,  it  will  be  jerked  elsewhere  convulsively. 
If  any  vessel  filled  with  drink  be  put  into  his  hand,  before  it  reaches  his 
mouth  he  will  exhibit  a  thousand  gesticulations,  like  a  mountebank.  He 
holds  the  cup  out  straight,  as  if  to  move  it  to  his  mouth,  but  has  his  hand 
carried  elsewhere  by  sudden  jerks.  Then,  perhaps,  he  contrives  to  bring  it 
to  his  mouth,  and  if  so,  he  will  drink  the  liquid  off  at  a  gulp,  just  as  if  he 
were  trying  to  amuse  the  spectators  by  his  antics." 

In  severe  general  chorea  a  similar  description  is  applicable  to  the  move- 
ments of  the  legs  and  features.  Grimaces  and  distortions  of  the  features 
occur,  while  the  gait  is  halting  and  unsteady,  or  it  is  impossible  to  walk,  and 
the  patient  lies  or  sits.  The  speech  is  slow,  thick,  and  indistinct  in  conse- 
quence of  the  muscles  of  the  tongue  and  larynx  becoming  engaged,  and  even 
mastication  and  deglutition  are  rendered  difficult.  The  imperfect  speech  in 
chorea  is  attributed  partly,  however,  to  the  mental  state  in  severe  protracted 
cases.  Chorea,  except  when  mild,  is  accompanied  by  other  symptoms  refer- 
able to  the  nervous  system.  More  or  less  impairment  of  the  mental  faculties 
occurs  in  chronic  cases  when  severe,  exhibiting  itself  in  dulness  or  apathy. 
The  countenance  sometimes  presents  in  aggravated  cases  almost  the  appear- 
ance of  idiocy.  The  muscles,  instead  of  becoming  hypertrophied  and  more 
powerful  by  their  frequent  contraction,  grow  softer,  more  flabby,  and  weaker. 
Indeed,  a  partial  paralysis  sometimes  results,  so  that  a  degree  of  numbness  is 
experienced  in  the  affected  part  and  the  limb  when  raised  cannot  be  sustained. 
Pain  is  not  a  symptom  of  chorea,  but  fugitive  rheumatic  or  neuralgic  pains 
are  sometimes  experienced.  Derangement  of  the  digestive  function,  exhibited 
by  a  poor  or  capricious  appetite,  constipation,  etc.,  are  common. 

In  rare  instances  chorea  affects  the  respiratory  muscles  so  as  to  produce  a 
peculiar  involuntary  barking  or  squeaking  voice  by  the  forcible  expulsion  of 
air  over  the  tense  vocal  cords.  In  a  case  treated  by  Dr.  L.  C.  Gray  in  the 
N.  Y.  Polyclinic  the  patient,  a  boy  of  fifteen  years,  had  been  choreic  since 
his  seventh  year,  and  chorea  in  its  usual  form  had  continued  one  year  when 
the  barking  sound  commenced,  and  this  has  continued  until  the  present  time. 
Dr.  French  of  Brooklyn  also  treated  a  similar  case,  having  the  following  his- 
tory :  A  boy  of  nine  years  had  choreic  twitchings  of  the  facial  muscles  at 
the  age  of  five  years.  After  continuing  several  months,  they  ceased  during 
an  entire  winter,  after  which  the  peculiar  sound  of  the  voice,  resembling  the 
squeak  of  a  young  turkey,  commenced.  It  occurred  at  the  beginning,  middle, 
or  end  of  respiration.     It  alternated  with  choreic  movements  of  other  parts 


618  CHOREA. 

of  the  system,  so  that  when  they  ceased  it  returned.  By  the  laryngoscope 
the  irregular  action  of  the  vocal  cords  was  observed,  but  the  expiratory  mus- 
cles of  the  chest  were  also  involved,  so  as  to  produce  the  peculiar  sound  by 
the  forcible  expulsion  of  air.  In  Dr.  French's  case  these  vocal  sounds  ceased, 
except  at  rare  intervals,  after  three  months  of  medicinal  treatment.^ 

The  urine  of  choreic  patients  has  been  examined  by  Drs.  Walsh,  Ford, 
Bence  Jones,  Handfield  Jones,  Radcliffe,  and  others,  and  its  elements  have 
been  found  in  most  cases  to  vary  from  their  normal  quantity.  Dr.  Handfield 
Jones^  read  a  paper  before  the  Clinical  Society  of  London  in  1871  on  two 
cases  of  chorea  in  which  he  had  made  careful  chemical  analysis  of  the  urine, 
with  the  following  result :  During  the  height  of  the  disease  the  amount  of 
the  urine  was  much  in  excess  of  what  it  was  when  the  disease  had  ceased; 
the  urea  excreted  during  the  choreic  period  was  in  excess,  as  was  also  the 
phosphoric  acid  excreted  when  the  choreic  symptoms  were  at  their  maximum, 
but  the  quantity  of  this  acid  was  less  than  the  average  during  convales- 
cence ;  a  moderate  amount  of  uric  acid  during  the  disease  was  also  observed, 
but  none  upon  recovery. 

Prognosis  ;  Course. — Chorea,  though  obstinate  and  often  incurable  in 
adults,  usually  terminates  favorably  in  children  in  two  to  four  months, 
Bouchut  considers  its  ordinary  duration  at  from  thirty  to  fifty  days,  which  is 
certainly  shorter  than  the  average  duration  in  this  country,  except  when  the 
■disease  is  materially  abridged  by  treatment.  The  same  author  states  that  it 
may  continue  only  a  few  days,  as  he  has  observed  in  cases  which  occurred 
during  convalescence  from  scarlet  fever.  But  tremulousness  of  the  muscles, 
•occurring  in  the  state  of  weakness  following  a  grave  disease  and  abating  as 
the  general  health  is  restored,  I  should  not  consider  as  properly  choreic,  any 
more  than  that  occurring  from  over-fatigue.  As  the  choreic  movements 
gradually  increase  in  the  initial  period  till  a  certain  maximum  is  reached,  so 
their  decline  is  gradual.  Temporary  variations  also  occur  throughout  the 
•disease  as  regards  the  extent  of  the  movements,  which  are  aggravated  by 
mental  excitement,  bodily  fatigue,  certain  functional  derangements,  especially 
of  digestion,  and  sometimes  from  causes  which  are  not  apparent. 

Though,  as  a  rule,  chorea  in  children  ordinarily  terminates  favorably 
under  different  and  even  injurious  modes  of  treatment,  there  are  exceptional 
cases.  Romberg  relates  the  history  of  a  patient  who  died  at  the  age  of 
seventy-six  years,  having  had  chorea  since  the  age  of  six  years.  In  chorea 
limited  to  a  few  muscles  or  a  group  of  muscles  the  prognosis  is  more  doubt- 
ful than  when  it  alFects  a  large  number,  since  in  the  former  case  the  cause  is 
more  likely  to  be  some  lesion  of  the  cerebro-spinal  axis.  Thus,  chorea 
involving  only  certain  muscles  of  the  neck  or  of  the  eyes  is  sometimes  due 
to  this  cause,  and  is   then  very  obstinate. 

Again,  observations  demonstrate  that  chorea,  when  at  first,  in  all  prob- 
ability, strictly  a  neurosis,  but  of  a  protracted  and  grave  character,  may  give 
rise  to  a  central  organic  disease.  This  is  the  course  of  most  of  the  fatal 
cases,  congestion,  softening,  or  other  lesion  occurring  over  a  greater  or  less 
extent  of  the  nervous  centres.  Radcliff"e  has  known  cerebral  meningitis  to 
supervene  in  two  instances.  With  the  occurrence  of  a  lesion  of  the  cerebro- 
spinal axis  new  symptoms  arise,  such  as  headache,  convulsions,  delirium,  and 
paralysis,  and  the  choreic  movements  cease  or  continue  according  to  the 
nature  of  the  lesion. 

Chorea,  like  certain  other  diseases  either  of  a  nervous  character  or  having 
a  nervous  element,  is  more  or  less  modified  by  intercurrent  inflammatory  and 
febrile  affections.  The  oft-quoted  expression  from  Hippocrates,  fehris  acce- 
dcns  solvit  spasmos,  observations  show  to  be  founded  in  fact,  the  most  frequent 

1  N.  Y.  Med.  Record,  Dec.  15,  1883:  Dr.  Chapin.  ^  London  Lancet,  July,  1871. 


DM  GNOSIS— TRE A  TMENT.  (3 1 9 

example  of  wliich  occurs  in  pertussis.  In  chorea  the  movements,  as  a  rule, 
are  either  rendered  milder  or  they  cease  as  long  as  the  febrile  excitement  con- 
tinues ;  but  there  are  exceptions,  and  the  subsequent  course  of  the  disease  is 
not  modified. 

Diagnosis. — This  is  not  difficult  in  ordinary  cases.  The  irregular  move- 
ments with  consciousness  preserved  enable  us  to  make  a  diagnosis  at  sight. 
In  its  commencement  and  when  it  continues  in  an  unusually  mild  form  chorea 
may  be  overlooked  by  the  physician,  as  it  often  is  by  the  parents,  the  move- 
ments being  attributed  to  a  fidgety  habit ;  but  medical  advice  is  seldom  sought 
till  the  movements  are  so  pronounced  that  it  is  impossible  to  err,  except 
through  gross  ignorance  or  carelessness. 

It  is  important  to  determine  when  chorea  merges  in  an  organic  disease, 
and  also  whether  there  is  a  local  cause  of  the  chorea.  A  careful  and  intelli- 
gent study  of  the  symptoms  and  history  of  the  case  is  requisite  in  order  to  a 
correct  diagnosis  in  these  particulars. 

Treatment. — Regimenal. — As  chorea  in  a  large  proportion  of  cases 
occurs  in  a  state  of  anEemia,  and  the  vital  forces  are  ordinarily  more  or  less 
reduced,  obviously  the  regimen  should  be  such  as  invigorates  the  system. 
Fresh  air  and  outdoor  exercise,  active  or  passive  according  to  circumstances, 
with  the  avoidance  of  undue  excitement,  are  requisite,  and  the  diet  should  be 
nutritious,  but  plain  and  unirritating.  The  various  functions  should  be  pre- 
served so  far  as  possible  in  their  normal  state.  In  exceptional  instances, 
when  the  choreic  movements  are  violent,  the  patient  should  lie  in  bed,  and  the 
muscular  action,  if  so  constant  and  excessive  as  to  deprive  him  of  the  requisite 
sleep,  should  be  restrained  by  light  and  well-padded  splints. 

Medicinal. — Sometimes  among  the  co-operating  causes  is  one  of  a  local 
nature  which  is  susceptible  of  removal,  as  a  carious  and  painful  tooth,  intes- 
tinal worms,  etc.,  and  measures  calculated  to  effect  this  are  obviously 
required.  Allusion  has  already  been  made  to  a  case  in  which  the  employ- 
ment of  the  oleo-resina  filicis  and  the  expulsion  of  a  tape-worm  effected  a 
speedy  cure. 

The  remedy  which  has  been  most  employed  in  chorea,  and  which  in  con- 
sequence of  the  antemia  is  plainly  indicated  in  a  large  proportion  of  cases, 
is  iron.  It  does  not  interfere  with  the  employment  of  other  remedies  which 
have  a  more  specific  effect.  Nearly  all  the  ferruginous  preparations  have 
been  prescribed  in  different  cases  with  benefit.  Radcliffe  gives  the  preference 
to  the  iodide  of  iron,  believing  that  iodine  as  well  as  iron  exerts  a  curative 
influence.  I  have  prescribed  the  ammonio-citrate,  since  it  is  easy  of  adminis- 
tration in  simple  syrup  and  is  well  tolerated ;  but  I  now  prefer  liquor  ferri 
peptonati,  recently  introduced  from  Germany.  It  should  be  given  in  doses 
of  one  to  three  teaspoonfuls  three  times  daily. 

But  iron  must  not  be  regarded  as  the  main  remedy,  but  rather  as  an 
adjuvant.  Observations  during  the  last  few  years  in  both  continents  have 
more  and  more  established  the  claims  of  arsenic  to  be  regarded  as  the  most 
efficacious  of  all  medicinal  agents  in  the  treatment  of  chorea.  Properly 
administered,  it  abridges  the  duration  of  this  disease  more  certainly  than  any 
other  agent,  and  within  a  few  days  begins  to  modify  the  choreic  movements 
in  the  severest  cases.  It  is  conveniently  given  in  the  form  of  Fowler's  solu- 
tion. It  is  better  tolerated  by  children  than  by  adults,  and  should  be  admin- 
istered to  them  in  a  larger  proportionate  dose.  A  child  of  eight  years  can 
take  five  drops,  diluted  in  water,  three  times  daily  after  eating,  and  the  dose 
may  be  increased,  if  needed,  to  eight,  ten,  twelve,  or  even  fifteen  drops.  I 
seldom  observe  any  gastric  irritability  or  other  unpleasant  effect  from  its  use 
when  it  is  administered  largely  diluted  and  after  the  meals,  but  if  such  occur, 
it  should,  of  eoui'se,  be  suspended  for  a  time. 


620  CHOREA. 

While  not  hesitating  to  recommend  iron  and  arsenic  as  superior  to  all 
other  medicines  in  the  treatment  of  chorea,  it  is  not  proper  to  ignore  the 
opinions  of  other  members  of  our  profession  who  have  had  ample  experience 
and  recommend  other  agents  instead. 

Trousseau  gave  the  preference  to  strychnine,  increasing  the  doses  in  some 
cases  until  it  began  to  produce  its  poisonous  effects. 

Professor  Hammond^  says:  "My  main  reliance  is  on  strychnia,  which,  I 
think,  should  be  given  in  gradually  increasing  doses,  somewhat  after  the 
manner  recommended  by  Trousseau This  plan  of  treatment  cer- 
tainly shortens  the  duration  of  the  disease  very  materially,  and  causes  great 
improvement  in  the  general  health  of  the  patient.  Sometimes  the  effect  is 
so  well  marked  and  is  so  immediate  that  it  is  not  necessary  to  increase  the 
doses  to  the  extent  of  causing  muscular  cramps,  but  generally  the  full  thera- 
peutical effect  of  the  drug  is  not  obtained  till  the  calf  of  the  leg  or  the  nucha 
has  slight  tonic  spasm.  I  have  never  seen  the  slightest  ill-consequence 
follow  this  mode  of  treatment,  and  the  doses  are  increased  so  gradually  that 
with  careful  watching  danger  need  not  be  apprehended."  Dr.  Hammond  has 
treated  thirty-two  children  with  this  agent  without  a  single  failure. 

But  as  chorea  terminates  favorably  with  smaller  and  safe  doses,  even  if 
the  time  required  be  longer,  it  does  not  seem  proper  to  recommend  its  em- 
ployment to  the  extent  of  producing  physiological  effects  for  general  prac- 
tice. Bouchut,  speaking  upon  this  point,  says  :  "  But  with  these  precautions 
strychnia  is  extremely  dangerous,  for  I  have  seen  at  the  Hopital  des  Enfants 
Malades  a  young  girl  of  thirteen  years  die  in  tetanus "  produced  by  an 
increased  dose  of  this  drug  (article  on  Chorea).  Dr.  West,  in  his  Lumleian 
Lectures,  also  says  :  "  I  have  seen  one  instance  in  which  its  employment,  while 
it  failed  to  benefit  a  somewhat  severe  case  of  chorea,  was  followed  by  two  attacks 
of  violent  tetanic  convulsions,  which  nearly  proved  fatal ;"  and  he  adds  :  "  The 
twitching  of  the  limbs  of  itself  prevents  our  becoming  aware  of  the  dose 
being  excessive."  Therefore,  Dr.  West  does  not  favor  the  employment  of 
this  agent.  Still,  any  agent  may  be  given  in  an  overdose,  and  it  is  not 
difficult  to  prescribe  strychnia  in  a  dose  which  may  be  efficient,  and  yet  safe 
for  children,  at  the  age  at  which  chorea  ordinarily  occurs. 

I  have  employed  bromide  of  potassium  in  a  few  cases,  but  with  so  little 
benefit  that  I  am  not  inclined  to  continue  its  use  for  this  disease.  Others 
have  not  been  more  successful.  However  efficacious  the  bromide  may  be  in 
epilepsy,  it  does  not  appear  to  be  a  remedy  for  chorea. 

Cimicifuga,  first  employed  by  Jesse  Young  of  this  country,  is  highly 
esteemed  by  Philadelphia  physicians  in  the  treatment  of  chorea.  I  have 
employed  the  fluid  extract  in  doses  of  half  a  drachm,  increased  to  one 
drachm,  for  a  child  from  six  to  ten  years  of  age,  and,  though  it  benefits 
some  cases,  it  has  no  appreciable  effect  either  in  moderating  the  movements 
or  abridging  the  duration  of  others. 

Ether,  asafoetida,  valerian,  musk,  the  oxide  and  sulphate  of  zinc,  tur- 
pentine, tartar  emetic,  opium,  and  numerous  other  remedies  have  been 
recommended,  and  some  of  them  have  seemed  useful  in  certain  cases.  In 
this  city  sulphate  of  zinc  has  been  frequently  employed  as  a  remedy  for 
chorea,  and  in  gradually  increasing  doses  till  more  than  twenty  grains  were 
administered  three  times  daily ;  but  it  has  not  appeared,  so  far  as  I  have 
been  able  to  ascertain,  to  exert  any  marked  influence  either  on  the  severity 
or  duration  of  the  choreic  movements.  Justice,  however,  requires  us  to 
state  that  Dr.  West,  who  has  written  recently  on  the  nervous  diseases  of 
children,  thinks  that  it  has  been  beneficial  in  certain  cases  in  which  he  has 
employed  it,  and  he  regards  it  on  the  whole  as  the  best  remedy. 

^  Diseases  of  the  Nervous  System,  page  617. 


PARALYSIS.  621 

Radclifl'e,  who  has  had  ample  experience  in  the  treatment  of  nervous 
affections,  writes :  "  In  an  ordinary  case  of  chorea  the  plan  of  treatment 
which  I  have  now  adopted  as  a  rule  for  some  time  is  to  give  cod-liver  oil  in 
conjunction  with  hypophosphite  of  soda,  making  the  draught  containing  the 
latter  salt  the  vehicle  for  the  administration  of  the  cod-liver  oil."  Some- 
times camphor  or  the  sesquicarbonate  of  ammonia  is  added.  Of  more  than 
thirty  cases  treated  in  this  way,  the  average  duration  was  under  three  weeks. 
Radcliffe  began  to  prescribe  these  remedies  on  theoretical  grounds,  believing 
that  phosphorus  and  cod-liver  oil  were  required  to  restore  "  nerve-tone,"  and 
the  result  of  this  treatment  has  certainly  been  such  as  to  commend  it  to  the 
profession.  To  children  he  gives  from  five  to  eight  grains  of  the  hypophos- 
phite of  sodium  three  times  daily. 

In  those  severe  cases,  in  which  choreic  uiovements  prevent  the  proper 
amount  of  sleep,  a  moderate  dose  of  hydrate  of  chloral  may  occasionally  be 
advantageously  administered. 

Electricity  has  been  numy  times  employed  in  the  treatment  of  chorea, 
and  though  some,  chiefly  electricians,  believe  that  it  has  a  curative  effect, 
others,  and  the  majority,  fail  to  see  any  material  benefit  from  its  use. 

Cold  general  baths,  the  shower-bath,  frictions  along  the  spine,  etc.  have 
been  employed  ;  but  the  local  treatment  which  has  so  far  been  most  success- 
ful, and  which  promises  to  supersede  all  other  local  measures,  consists  in  the 
■application  of  ether  spray  over  the  spine.  About  two  ounces  of  ether  are 
employed  at  each  sitting,  the  spray  being  applied  from  an  atomizer  up  and 
•down  the  whole  length  of  the  spine  if  the  chorea  be  general.  The  opera- 
tion, which  occupies  from  ten  to  fifteen  minutes,  should  be  repeated  daily 
or  every  second  da3\  A  considerable  number  of  cases  have  been  reported 
in  which  the  spray  has  apparently  had  a  good  eff"ect  in  controlling  the  dis- 
ease. But  I  repeat  my  belief,  from  the  large  number  of  cases  seen  in  the 
Bureau  for  the  Relief  of  the  Out-door  Poor,  that  the  arsenical  and  ferrugi- 
nous treatment  gives  more  satisfaction  than  any  or  all  other  measures. 


CHAPTER   XV. 

PAKALYSIS. 

Paralysis  in  young  children,  especially  infants,  is  in  most  instances  due 
to  causes  which  seldom  produce  it  in  adults.  The  principal  cause  of  it  in  the 
adult — namely,  cerebral  apoplexy — is  indeed  rare  in  children.  Paralysis  in 
children  has  the  following  recognized  causes :  1st.  A  change  in  the  blood, 
not  fully  understood,  induced  by  certain  grave  diseases,  as  diphtheria,  typhoid 
fever,  measles,  scarlet  fever,  etc.  2d.  Reflex  influence.  The  function  of 
some  part  of  the  system  is  in  some  way  disturbed,  and  paralysis  occurs  in 
certain  muscles,  perhaps  at  a  distance  from  the  cause,  and  it  disappears  when 
that  cause  is  removed,  unless  it  have  continued  too  long.  The  only  rational 
explanation  is  found  in  the  fact  of  a  continuous  connection  between  the  local 
cause  and  the  paralyzed  muscles  through  the  aff"erent  and  efferent  nerves  and 
the  nervous  centres.  3d.  Compression  or  injury  of  a  nerve-trunk.  These 
cases  are  rare.  Pressing  of  the  portio  dura  by  the  blades  of  forceps  during 
birth,  described  in  the  next  chapter,  is  an  example.  4th.  An  anatomical 
alteration  in  the  muscular  fibres,  the  nerves  and  nervous  centres  remaining 
unaffected.     This   has  been  designated  myogenic  paralysis.     This   form   of 


622  PARALYSIS. 

paralysis  is  probably  often  of  a  rheumatic  nature.  Paralysis  of  the  face  or 
other  portions  of  the  surface,  which  sometimes  occurs  in  children  and  adults 
from  prolonged  exposure  to  cold  winds,  is  of  this  nature.  5th.  Some  anatom- 
ical change  in  the  nervous  centres,  as  congestion,  hemorrhage,  inflammation, 
emboli,  compression  and  laceration  of  brain,  whether  by  tumors,  inflamma- 
tory products,  or  other  causes,  etc.  If  there  be  hemiplegia,  the  presumption 
is  that  the  disease  causing  it  is  cerebral ;  if  paraplegia,  that  it  is  spinal. 
The  following  is  an  interesting  example  of  hemiplegia.  The  case  was  related 
by  me,  and  the  specimen  presented  to  the  New  York  Pathological  Society  : 

Case. — Maggie ,  aged  two  years  and  eight  months,  was  admitted  into  the 

New  York  Foundling  Asylum  about  the  1st  of  September,  1874.  She  seemed  to 
be  in  good  health  and  was  plump  and  well-developed,  and  her  mother  stated 
that  she  had  had  no  serious  sickness.  After  her  admission  she  continued  well, 
having  the  usual  appetite,  amusing  herself  through  the  day,  and  presenting  no 
symptoms  to  attract  attention  till  December  6th.  On  the  evening  of  December 
5th  she  ate  her  supper  as  usual,  and  was  placed  in  her  crib,  ctpparently  in  perfect 
health.  At  3  A.  M.  the  sister  who  was  in  charge  of  the  ward  found  her  in  severe 
general  eclampsia.  Immediately,  in  addition  to  the  usual  local  treatment,  she 
administered  five  grains  of  bromide  of  potassium,  and  this  was  repeated  at  inter- 
vals till  six  or  seven  doses  were  administered.  Nevertheless,  the  spasmodic 
movements  continued,  with  more  or  less  violence,  till  1^  P.  M.,  and  in  the  muscles 
of  the  leg  somewhat  longer. 

On  my  arrival  at  the  asylum,  at  about  6  P.  M.,  I  found  her  lying  quietly, 
rather  stupid,  but  easily  aroused.  Her  vision  was  evidently  good,  and  she  was- 
conscious ;  the  pupils  responded  to  light  and  the  direction  of  the  eyes  was  nor- 
mal; pulse  104,  no  cough,  and  respiration  natural;  temperature,  as  ascertained 
by  the  thermometer  in  the  axilla,  also  normal.  There  was  no  apparent  paralysis- 
of  the  muscles  of  the  face,  but  the  right  arm  and  leg  were  paralyzed,  though  the 
paralysis  was  not  complete.  The  great  toe  flexed  on  tickling  the  sole  of  the  foot, 
but  the  foot  itself  had  little  or  no  motion,  and  on  my  attempting  to  flex  the  leg, 
which  was  extended,  some  rigidity  of  the  muscles  was  observed.  At  times  the 
patient  produced  slight  movement  of  the  thigh  upon  the  trunk.  The  muscles  of 
the  right  upper  extremity  were  more  flaccid  than  those  of  the  leg,  and  motion 
of  the  forearm  was  totally  lost,  while  a  little  movement  remained  of  the  arm  on 
the  trunk.  During  the  two  or  three  days  succeeding  the  convulsions  sensation  in 
the  right  limbs  did  not  appear  to  be  entirely  lost,  though  greatly  enfeebled. 
Subsequently  paralysis  in  the  right  limbs,  both  of  the  nerves  of  sensation  and 
motion,  was  nearly  or  quite  total,  and  continued  so  till  death.  Nevertheless, 
tickling  the  sole  of  the  foot  caused  some  movement  of  the  great  toe.  On  the  left 
side  sensation  and  motion  were  perfect. 

The  record  of  December  9th  runs :  Has  vomiting  to-day  for  the  first  time ; 
apparently  sees  well,  and  appearance  of  the  eyes  normal ;  has  no  retraction  of 
head  or  rigidity  of  muscles  of  neck  or  along  the  spine ;  pulse  96,  temperature  in 
the  axilla  normal ;  lies  quiet  and  with  eyes  shut ;  is  stupid,  and  not  fretful  when 
aroused  ;  the  bowels  move  regularly. 

December  11th,  continues  to  vomit  at  intervals ;  pulse  68.  Dec.  16th,  pulse 
80,  temperature  100°;  vomited  once  yesterday,  none  to-day;  lies  in  a  constant 
doze ;  takes  bromide  of  potassium  gr.  iv  three  times  daily.  Dec.  18th,  moans  at 
times,  as  if  in  pain ;  pulse  180,  temperature  100° ;  takes  the  bromide  gr.  iv  every 
four  hours. 

Dec.  19th,  pulse  180,  temperature  103°  ;  she  has  convergent  strabismus,  and 
the  eyes  have  a  wild,  almost  insane  look,  but  she  sees,  grasping  hurriedly  the 
percussion  hammer  presented  toward  her ;  jiaralysis  of  nerves  of  motion  and  sen- 
sation in  the  right  extremities  nearly  complete  ;  slight  movement  is  still  produced 
in  the  great  toe  by  titillation ;  the  vomiting  has  ceased;  tongue  covered  with  a 
thick  fur ;  movements  of  the  bowels  pretty  regular ;  has  a  slight  cough,  such  as  is 
common  in  cerebral  disease. 

Dec.  22d,  lies  quietly  on  her  side  in  perpetual  slumber,  with  eyes  constantly 
shut;  pulse  118,  temperature  101i°;  the  bowels  still  move  nearly  normally;  the 
pupils,  exposed  to  the  light,  are  seen  to  oscillate,  but  are  constantly  more  dilated 
than  in  health ;  the  urine  passes  freely ;  circumscribed  flushing  of  the  features 


PARALYSIS.  bi^3 

at  intervals ;  a  rash  like  lichen  over  abdomen  and  chest,  possibly  due  to  the 
large  quantity  of  bromide  of  potassium  administered.  24th,  pulse  intermittent; 
pupils  dilated. 

Dec.  2r)tli,  died  in  profound  stupor  to-day,  having  lived  nineteen  days  from  the 
commencement  of  the  nuihidy. 

Aidojisi/. — About  thirty  hours  after  death,  weather  cool.  On  removing  the 
calvarium  and  dura  mater,  which  presented  no  unusual  appearance,  the  vessels 
of  the  pia  mater  were  found  rather  more  injected  tiiaii  usual,  but  not  more  so 
than  we  sometimes  observe  in  those  who  die  of  diseases  which  do  not  involve  the 
brain.  The  cerebro-spinal  fluid  was  scanty  and  the  surface  of  the  brain  rather 
dry.  The  vertex  of  the  left  hemisphere  was  unusually  prominent,  rising  perhaps 
half  an  inch  higher  than  that  on  the  opposite  side.  At  the  highest  point,  which 
was  about  one  and  a  half  inches  from  the  median  line,  was  a  circular  yellowish 
spot  upon  the  surface  of  the  brain  about  one  and  a  half  inches  in  diameter. 
Pressure  upon  this  spot,  made  lightly  so  as  not  to  produce  rupture,  communicated 
the  sensation  of  a  large  cavity  underneath  hlled  with  liquid  and  apj^roaching  to 
within  two  or  three  lines  of  the  surface.  There  was  no  adhesion  or  exudation 
over  this  spot,  and  the  surface  of  the  brain  appeared  entirely  normal,  except  a 
little  cloudiness  of  the  pia  mater  over  a  space  which  could  be  covered  by  a  five- 
cent  piece,  a  little  posterior  to  the  optic  commissure.  The  incised  surface  of  the 
brain  at  a  distance  from  the  abscess  showed  no  increase  of  vascularity.  The 
right  hemisphere  appeared  in  every  way  normal,  except  that  its  lateral  ventricle 
was  filled  with  pus,  but  not  distended. 

On  the  left  side,  occupying  the  centre  of  the  hemisphere,  was  an  abscess  as 
large  as  the  fist  of  a  child  of  two  years,  extending  from  within  two  or  three  lines 
of  the  vertex,  wliere  its  site  corresponded  with  the  yellow  spot  on  the  surface  of 
the  brain,  to  the  roof  of  the  lateral  ventricle.  Through  this  roof  the  abscess  had 
burst,  filling  and  distending  the  ventricle  with  pus,  and  thence  making  its  way 
into  the  lateral  ventricle  of  the  opposite  hemisphere.  The  whole  amount  of  pus 
contained  in  the  abscess  and  the  two  ventricles  was  perhaps  two  ounces.  The 
walls  of  the  left  lateral  ventricle  were  much  softened,  the  upper  part  of  the 
corpus  striatum  and  thalamus  opticus  being  nearly  diffluent ;  the  walls  of  the 
right  lateral  ventricle  were  slightly  softened,  but  to  less  depth.  The  pai'ietes  of 
the  abscess,  which  extended  from  the  roof  of  the  ventricle  to  the  vertex,  as 
already  stated,  were  indurated  to  the  depth  of  one  and  a  half  lines  in  consequence 
of  proliferation  of  the  connective  tissue,  except  at  the  base  of  the  abscess,  which 
corresponded  with  the  roof  of  the  ventricle,  where  softening  had  occurred.  The 
spinal  cord,  so  far  as  it  could  be  examined  from  the  cranial  cavity,  had  the  usual 
vascularity  and  seemed  nearly  or  quite  normal. 

The  cause  of  encephalitis  from  which  the  abscess  resulted  was  obscure.  This 
inflammation,  so  far  as  can  be  ascertained,  was  idiopathic,  which  is  known  to  be 
a  rare  disease.  There  was  no  history  of  otitis,  which  is  one  of  the  most  frequent 
causes  of  cerebral  abscess,  nor  of  heart  disease,  so  as  to  produce  embolism.  It 
seems  probable,  since  there  was  no  fever  till  about  the  fourth  day  after  the  con- 
vulsions, that  an  abscess  had  primarily  occurred  in  the  hemisphere  between  the 
roof  of  the  ventricle  and  the  vertex,  probably  weeks  previously.  The  bursting 
of  this  into  the  lateral  ventricles,  and  the  constitutional  disturbance,  inflamma- 
tion, and  softening  to  which  this  gave  rise,  afford  sufficient  explanation  of  the 
history  of  the  case  after  the  commencement  of  the  convulsions. 

Paralysis  occurring  as  a  symptom  or  sequel  of  some  obvious  local  or  gen- 
eral disease,  as  diphtheria,  lesion  of  the  nervous  centres,  etc.,  and  which  may 
occur  at  any  age,  need  not  detain  us.  It  is  described  in  connection  with  the 
primary  diseases  on  which  it  depends. 


624  POLIOMYELITIS  ACUTA  ANTERIOR. 


CHAPTER   XVI. 
POLIOMYELITIS    ACUTA    ANTERIOR. 

This  form  of  paralysis  occurs,  with  few  exceptions,  between  the  ages  of 
six  months  and  seven  years. 

Symptoms. — The  previous  health  of  the  patient  is  usually  good.  The 
paralysis  does  not  always  commence  in  the  same  manner.  In  a  few  instances 
it  begins  suddenly  in  the  day-time  when  the  child  is  apparently  in  perfect 
health.  In  others  it  begins  abruptly,  after  sound  sleep.  The  child  goes  to 
bed  well,  sleeps  through  the  night,  and  awakens  in  the  morning  paralyzed. 
I  have  known  it  to  occur  in  one  instance  after  sleep  in  the  middle  of  the  day. 
In  these  cases  there  has  sometimes  been  an  exposure  before  the  sleep  to  wind 
or  rain  or  from  sitting  on  a  cold  stone.  But  in  the  majority  of  cases  the 
paralysis  is  preceded  and  accompanied  by  a  very  decided  elevation  of  tem- 
perature, which  comes  on  suddenly  without  appreciable  cause,  and  after  a 
few  days  the  power  of  motion  is  found  to  be  lost  in  one  or  more  of  the  limbs. 
No  symptom  occurs  during  the  fever  indicative  of  disease  of  the  brain :  con- 
sciousness is  retained,  and  the  headache  or  apparent  liability  to  convulsions 
is  no  greater  than  in  other  pathological  states  accompanied  by  an  equal  amount 
of  fever.  The  paralysis  is  at  its  maximum  in  the  commencement.  Occur- 
ring as  by  a  stroke,  the  full  extent  of  the  paralytic  state  is  exhibited  at  once, 
and  so  far  as  there  is  any  subsequent  change  it  is  an  improvement  as  regards 
the  number  of  muscles  aifected  and  the  degree  of  the  paralysis.  Most  fre- 
quently the  muscles  of  one  or  both  lower  extremities  are  aifected.  Occa- 
sionally one  of  the  upper  extremities  is  also  paralyzed  in  addition  to  the 
lower,  but  paralysis  of  an  upper  extremity  is  less  in  degree,  and  disappears 
sooner,  than  of  the  lower.  The  bladder  and  lower  bowel  remain  unaffected, 
since  only  the  muscles  of  volition  are  involved.  Sensation  is  unimpaired  in 
the  affected  limbs,  and  in  the  commencement  there  is  even  in  some  cases  a 
state  of  hyperaesthesia  (West).  The  fever  which  precedes  and  accompanies 
the  paralysis  in  certain  cases  gradually  abates,  and  in  a  few  days  nothing 
abnormal  remains  except  the  loss  of  power  in  the  affected  muscles.  These 
muscles  are  flaccid  and  relaxed,  so  that  the  limb  falls  by  its  weight  when 
unsupported,  and  they  are  usually  free  from  pain.  The  number  of  muscles 
paralyzed  varies  greatly  in  different  cases.  Only  one  muscle  or  a  single 
group  of  muscles  may  be  affected,  or,  on  the  other  hand,  both  the  extensor 
and  flexor  muscles  of  two  or  more  limbs  may  be  paralyzed.  In  the  opinion 
of  Mr.  Adams,  the  following  table  exhibits  the  groups  of  muscles  and  single 
muscles  most  frequently  involved,  and  in  the  order  stated : 

Groups. 

1.  Extensors  of  toes  and  flexors  of  the  foot. 

2.  Extensors  and  supinators  of  the  hand. 

3.  Extensors  of  leg,  and  with  them  usually  the  first  group. 

Single  Muscles. 

1.  Extensor  longus  digitorum  of  toes. 

2.  Tibialis  anticus. 

3.  Deltoid. 

4.  Sterno-mastoid. 


PROGNOSIS— ETIOLOGY.  625 

The  following  is  an  example  of  infantile  paralysis  as  it  not  infrequently 

occurs  when  the  result  is  favorable  :  A.  K ,  Oerman,  female,  aged  three 

years  and  four  months,  fleshy  ;  had  been  in  the  habit  of  sitting  on  the  ground 
near  the  house  and  on  the  door-sill.  On  July  2,  1871,  she  had  a  sound  sleep 
in  the  afternoon,  having  been  entirely  well  previously,  and  awoke  trembling 
and  with  a  high  fever  at  S]  p.  M.  At  S  p.  M.,  the  febrile  excitement  con- 
tinuing, general  clonic  convulsions  occurred,  lasting  about  ten  minutes.  At 
this  time  I  was  called  to  see  her,  and  found  her  face  flushed,  surface  hot,  and 
pulse  about  130.  Consciousness  returned  after  the  convulsion.  Her  intelli- 
gence was  good,  tongue  moist  and  slightly  furred,  bowels  rather  constipated, 
and  the  urine  freely  passed.  The  fever  continued  two  days,  when  it  grad- 
ually and  entirely  abated,  but  before  it  ceased  paralysis  of  the  left  lower 
extremity  was  observed.  No  weight  at  first  could  be  sustained  upon  this 
limb,  and  it  hung  powerless  when  we  endeavored  to  make  her  walk.  The 
attempt  caused  her  to  cry,  as  if  in  pain,  and  pressing  upon  the  thigh  or 
moving  it  had  the  same  effect.  The  thigh  of  this  limb  appeared  slightly 
swollen  on  inspection,  but  measurement  did  not  indicate  any  notable  enlarge- 
ment. The  difterence  in  circumference  was  not  more  that  one-eighth  to  one- 
fourth  of  an  inch.  There  was  no  appreciable  increase  of  heat  in  the  thigh 
over  the  general  temperature  of  the  body.  Sensibility  remained  in  every 
part  of  the  limb,  and  the  loss  of  power  was  not  complete,  for  on  the  first 
day,  as  soon  as  the  paralysis  was  observed,  slight  and  imperfect  movements 
could  be  produced  by  pinching  the  limb.  In  three  weeks  the  use  of  the 
limb  was  fully  restored  by  mildly  stimulating  liniments  and  simple  medicines 
to  regulate  the  bowels.  The  tenderness  which  was  observed  in  this  case  is 
only  occasionally  present,  and  has  been  attributed  to  hyperaesthesia. 

Prognosis  ;  Progress. — The  paralysis  in  nearly  all  cases  soon  begins  to 
abate.  The  power  of  motion  returns  little  by  little,  and  whatever  improve- 
ment occurs  is  permanent.  There  is  no  retrogression  in  the  convalescence. 
The  sooner  improvement  commences  the  more  favorable  is  the  prognosis.  In 
the  most  favorable  cases  there  is  complete  restoration  in  from  three  to  four 
weeks.  In  other  patients,  while  certain  of  the  muscles  regain  the  power  of 
motion,  other  muscles,  oftener  those  of  the  lower  extremity  than  of  the 
upper,  do  not  recover  their  function,  and,  unless  proper  remedial  measures  be 
employed,  and  even  with  them  in  certain  instances,  atrophy  soon  commences. 
The  temperature  of  the  paralyzed  limb  falls  three,  five,  or  even  eight  degrees, 
and  the  amount  of  blood  which  circulates  in  it  is  diminished,  so  that  the 
pulse  of  the  limb  is  feebler  and  its  vessels  smaller  than  in  health.  With  the 
atrophy  the  contractility  of  the  muscular  fibres  by  the  electric  current  dimin- 
ishes, and  in  unfavorable  cases  after  a  time  powerful  induced  and  even  pri- 
mary currents  have  no  appreciable  effect.  The  nutrition  of  a  paralyzed 
limb  is  always  imperfect,  and  if  the  paralysis  occur  in  a  child  its  growth 
is  retarded.  Therefore,  in  cases  of  protracted  or  permanent  infantile  paral- 
ysis of  one  limb  a  disproportion  occurs  both  in  diameter  and  length  between 
it  and  that  on  the  opposite  side.  If  the  paralysis  continue,  the  ligaments  of 
the  paralyzed  limb  become  relaxed  and  lengthened.  West  mentions  a  case 
of  paralysis  of  the  deltoid  in  which  the  humero-scapular  ligaments  were  so 
extended  that  the  humerus  dropped  from  the  glenoid  cavity,  so  as  to  increase 
the  length  of  the  limb  three-fourths  of  an  inch.  In  the  paralysis  of  certain 
muscles  of  the  lower  extremity  and  continuance  of  the  contractile  power 
in  others  we  have  the  conditions  which  give  rise  to  club-feet,  and  accord- 
ingly this  deformity  is  the  common  result  of  the  paralysis  when  it  is  not 
cured. 

Etiology.— As  this  form  of  paralysis  is  not  fatal,  opportunity  for  post- 
mortem examination  in  a  recent  ease  seldom  occurs.  Hence  the  difi&culty  in 
40 


626  POLIOMYELITIS  ACUTA   ANTERIOR. 

determining  the  exact  anatomical  change  in  the  nervous  system  which  pro- 
duces the  paralysis.  Medical  literature  contains  records  of  a  considerable 
number  of  cases  in  which  autopsies  have  been  made,  but  death  occurred  so 
long  after  the  commencement  of  the  paralysis,  usually  months  or  years, 
that  it  is  difficult  to  determine  whether  lesions  which  have  been  observed 
were  a  cause  or  consequence.  In  a  majority  of  these  autopsies  a  spinal  lesion 
of  some  sort  was  detected,  but  in  some  instances  none  could  be  discovered 

Mr.  Adams  in  his  treatise  on  club-foot  relates  a  case  in  which  the  spinal 
cord,  carefully  examined,  probably  only  with  the  naked  eye,  seemed  normal. 
Robin  examined  the  spinal  cord  microscopically  in  one  case,  but  discovered 
nothing  abnormal,  and  Elischer  made  autopsies  in  two  cases  of  this  paralysis 
in  which  death  had  occurred  from  variola,  but  with  a  negative  result  as 
regards  the  nervous  system.'  The  examinations  by  Robin  and  Elischer, 
since  they  were  microscopic,  have  been  justly  regarded  as  important,  and 
they  have  been  related  by  writers  in  order  to  sustain  the  theory  that 
infantile   paralysis   is  peripheral   and  not   centric. 

Very  little  was  effected  prior  to  1863  in  determining  the  cause  or  causes 
of  this  paralysis  by  post-mortem  examinations,  because  the  microscope  was 
so  little  used,  and  because  in  most  of  the  cases  reported  the  clinical  history 
or  microscopic  lesions  were  such  as  to  show  or  to  render  it  highly  probable 
that  the  paralysis  was  not  of  the  kind  which  we  have  been  describing. 
Thus,  Beraud  reported  a  case  in  which  tubercles  were  found  in  the  spinal 
cord ;  Hammond,  a  case  in  which  a  clot  was  found  in  the  spinal  cord ;  and 
Jaccoud,  one  of  spinal  arachnitis  with  thickening  of  the  meninges.  Since 
1863,  17  autopsies  have  been  recorded  in  which  the  spinal  cord  was  carefully 
examined,  and  upon  these  we  must  chiefly  rely  for  our  data  by  which  to 
determine  what  are  the  anatomical  changes  in  the  nervous  system  which 
probably  cause  this  paralysis.  The  reader  will  find  these  cases  tabulated 
in  a  lecture  by  E.  C.  Seguin,  M.  D.,^  and  the  most  important  of  them  nar- 
rated in  a  paper  on  infantile  paralysis,  showing  great  research,  published  by 
Dr.  Mary  Putnam  Jacobi.^  It  is  true  that  all  but  3  of  these  post-mortem 
examinations  were  made  many  years  after  the  occurrence  of  the  paralysis ; 
but  in  the  3  cases  which  were  reported  by  Roger  and  Daraaschino,  only  two, 
six,  and  thirteen  months  had  elapsed.  The  following  were  the  chief  lesions 
observed  in  these  cases  as  regards  the  spinal  cord : 

Cases. 

1.  Atrophy  of  motor-cells  in  anterior  cornua 10 

2.  Nerve-cells,  normal 2 

3.  Atrophy  (variously  recorded)  of  anterior  columns,  or  cornua,  or  part 

of  cord,  or  roots  of  anterior  nerves 8 

4.  Sclerosis 9 

5.  Myelitis,  recorded  as  diffused,  central,  or  slight 7 

6.  Central  softening  (the  three  most  recent  cases) 3 

7.  Small  clot  in  cord  (Hammond's  case) 1 

8.  Sciatic  neuritis 1 

The  most  common  lesions  in  these  cases  were  those  of  inflammation  of 
the  anterior  cornua  of  the  spinal  cord,  or  such  as  are  known  to  result  from  this 
inflammation — to  wit,  atrophy  of  the  nervous  substance  and  sclerosis. 

With  the  data  furnished  by  these  post-mortem  examinations  and  the  clin- 
ical histories  of  cases  we  are  better  prepared  to  consider  the  theories  regard- 
ing the  etiology  of  this  malady.  The  views  of  MM.  Roger  and  Damaschino 
are  entitled  to  much  consideration,  since  the  autopsies  which  they  made  were 
in  cases  of  shoi'ter  duration,  and  therefore  nearer  the  date  of  the  commence- 

^  Jahrbuch  filr  Kinderh.,  1873.  ^  N.  Y.  Med.  Record,  January  15,  1874. 

*  N.  Y.  Obst.  Jour.,  for  May,  1874. 


ETIOLOGY.  627 

ment  of  the  paralysis,  than  those  which  have  been  reported  by  other  observ- 
ers. Roger  and  Daniaschino^  published  a  series  of  papers  on  this  malady, 
which  they  conclude  with  the  following  propositions :  "  1.  The  alteration 
peculiar  to  infantile  paralysis  is  a  lesion  of  the  spinal  marrow,  which  causes 
the  atrophy  of  muscles  and  nerves.  2.  The  seat  of  this  lesion  is  the  ante- 
rior part  of  the  gray  substance  of  the  medulla,  where  softened  portions  of 
spinal  substance  are  seen.  3.  This  softening  is  of  an  inflammatory  nature — 
in  fact,  a  simple  myelitis.  4.  Infantile  paralysis  should  therefore  be  called 
spinal  paralysis  of  children,  and  be  classed  among  the  aff'ections  of  the  spinal 
marrow,  as  depending  on  myelitis." 

The  views  of  Roger  and  Damaschino,  expressed  above,  seem  to  harmonize 
more  closely  with,  and  to  afford  a  more  satisfactory  explanation  of,  the  symp- 
toms, history,  and  lesions  thus  far  observed  in  ordinary  or  typical  cases  than 
does  any  other  theory.  Many  neuropathists  regard  suddenly-occurring  active 
congestion  of  the  anterior  cornua  as  the  cause  of  infantile  paralysis ;  but 
there  is  that  affinity  between  active  congestion  and  inflammation  that  they 
may  be  regarded  as  having  the  same  pathological  eff'ect  in  this  instance,  and 
therefore  the  two  theories  of  a  spinal  congestion  and  spinal  inflammation  may 
be  considered  as  one.  It  is  not  improbable  that  in  some  of  the  cases  which 
more  speedily  recover  there  is  simple  congestion  ;  while  in  the  more  obstinate 
cases  and  those  with  inflammatory  symptoms  the  congestion  has  passed  into 
an  inflammation  or  inflammation  was  present  from  the  first.  According  to 
this  theory,  the  atrophy  so  genei'ally  observed  in  the  twelve  cases  in  which 
autopsies  were  made  must  be  considered  a  degenerative  change  resulting  from 
the  inflammation.  That  so  accurate  an  observer  and  so  excellent  a  micro- 
scopist  as  Robin  could  detect  nothing  abnormal  in  the  case  which  he  examined 
was  probably  due  to  the  fact  that  the  inflammation  or  congestion  abated  with- 
out producing  any  degenerative  changes  in  the  nervous  substance. 

Professor  Charcot  regards  atrophy  of  the  motor-cells  as  the  cause  of  the 
paralysis,  but  it  is  much  more  in  consonance  with  the  facts  to  consider  the 
cellular  atrophy  a  result  than  a  cause.  For  how  could  atrophy,  which  always 
occurs  gradually  and  by  progressive  increase,  be  the  cause  of  a  disease  which 
begins  abruptly  and  is  most  intense  in  the  very  commencement  ?  Besides, 
atrophy  does  not  occur  without  some  antecedent  disease  to  cause  it. 

In  a  report  to  the  International  Congress  at  Amsterdam,  Drs.  Damaschino 
and  Roger  give  the  following  summary  of  the  result  of  their  recent  study  of 
the  pathology  of  infantile  paralysis  :  ^ 

1.  The  anatomical  lesions  are  situated  in  the  motor  regions  of  the  spinal 
cord. 

2.  They  consist  of  a  central  myelitis,  with  a  stadium  of  softening  and 
atrophic  destruction  of  the  cells  of  the  gray  substance,  together  with  sclero- 
sis of  the  lateral  columns  and  considerable  atrophy  of  the  anterior  roots  and 
the  nerves  leading  to  the  paralyzed  muscles. 

3.  Atrophy  of  the  cells  is  not — as  Charcot  is  of  opinion — the  whole  pro- 
cess, as  it  is  in  progressive  muscular  atrophy. 

4.  The  opinion  of  Leyden,  that  there  is  a  circumscribed  and  diff"used  mye- 
litis in  children,  is  worthy  of  consideration. 

It  remains  for  future  examination  to  decide  whether  the  myelitis  begins 
as  interstitial  or  parenchymatous  in  the  connective  tissue  or  the  nerve-cells. 

Recent  observations  by  Drummond  (1885),  Gowers  (1888),  and  others  have 
apparently  established  the  theory  of  Roger  and  Damaschino — to  wit,  that 
the  paralysis  which  we  are  considering  results  from  acute  inflammation  of 
the  gray  matter  of  the  spinal  cord,  and  entirely  or  chiefly  of  the  gray  matter 
in  the  anterior  cornua,  that  of  the  posterior  cornua  not  being  affected. 

'  Gaz.  med.  de  Paris,  1871.  '^  Le  Frog  res  medical,  No.  39,  1880. 


628  POLIOMYELITIS  ACUTA  ANTERIOR. 

All  muscular  fibres  which  are  in  a  state  of  disuse  begin  in  a  few  weeks  to 
atrophy  and  undergo  fatty  degeneration.  The  transverse  striae  in  the  primi- 
tive muscular  fasciculus  gradually  disappear,  and  are  replaced  by  granules 
of  fat,  and  later  still  by  small  oil-globules.  If  we  examine  with  the  micro- 
scope the  fibres  from  a  muscle  which  has  been  a  considerable  time  paralyzed, 
but  which  has  still  some  electric  contractility,  we  will  find  in  places  the  strias 
remaining,  but  numerous  opaque  granules  of  a  fatty  nature  within  the  sarco- 
lemma  wherever  the  striae  are  absent,  and  in  other  places,  where  the  degen- 
eration is  most  advanced,  oil-globules  occur,  always  small.  If  the  paralysis 
be  more  profound,  the  striae  have  all  disappeared.  At  a  later  stage,  usually 
after  some  years  in  cases  of  complete  and  incurable  paralysis,  the  fatty  mat- 
ter may  be  to  a  considerable  extent  absorbed,  and  the  fibrous  network  of  the 
muscle  which  remains  presents  a  tendinous  appearance.  There  is  a  great 
difference,  however,  in  different  cases  as  regards  the  rapidity  with  which 
these  changes  occur.  Hammond  states  that  he  found  the  strige  remaining  in 
two  cases  after  the  lapse  of  more  than  four  years  of  decided  paralysis.  The 
nerves  of  the  paralyzed  part  also  undergo  atrophy. 

Diagnosis. — This  is  easy  as  soon  as  the  attention  of  the  physician  is 
directed  to  the  state  of  the  limbs.  In  a  large  proportion  of  cases  the  mother 
or  nurse  first  observes  the  paralysis  and  calls  the  attention  of  the  physician 
to  it.  A  knowledge  and  recollection  of  the  facts  in  relation  to  this  paral- 
ysis should  lead  the  physician  to  examine  the  state  of  the  limbs  in  all  cases 
of  fever  in  young  children  occurring  without  apparent  cause. 

Prognosis. — It  may  be  confidently  predicted,  if  the  child  be  seen  early 
and  correctly  treated,  that  the  paralysis  will  diminish,  if  it  cannot  be  entirely 
cured.  If  the  paralysis  have  continued  a  considerable  time,  and  there  be  no 
electric  contractility  of  the  muscles,  there  is  poor  prospect  of  any  improve- 
ment. The  induced  current  will  fail  sometimes  to  cause  muscular  contrac- 
tion, when  the  direct  current  may  produce  it ;  but  if  there  be  no  response  to 
the  direct  current,  there  is  no  therapeutic  agent  which  can  restore  the  use  of 
the  limb. 

In  cases  seen  soon  after  the  paralysis  commences  and  before  the  stage  of 
atrophy  the  prognosis  is  most  favorable  when  there  is  still  slight  voluntary 
motion,  and  improvement  commences  early.  In  most  instances,  even  when 
the  paralysis  has  been  mild  and  of  comparatively  short  duration,  the  extrem- 
ity, although  its  motion  be  fully  restored,  is  for  a  long  time  weaker  than 
before  the  attack. 

Treatment. — A  physician  called  at  the  commencement  of  the  paralysis 
should  endeavor  to  remove  every  cause  which  might  increase  the  irritability 
of  the  nervous  system.  The  bowels  should  be  kept  open  and  the  diet  be 
plain  and  unirritating. 

Local  treatment  is  very  useful  at  all  periods  of  the  paralysis.  In  the 
first  days  cold  applications,  as  by  an  India-rubber  bag  containing  ice,  should 
be  made  over  the  spine.  Stimulating  embrocations  over  the  spine  and  upon 
the  paralyzed  limb  are  appropriate  after  the  cold  has  been  discontinued,  and 
benefit  may  also  be  derived  from  dry  cups  along  the  spine.  Ergot,  the  bro- 
mide and  iodide  of  potassium,  which  may  be  administered  variously  combined 
or  singly,  are  the  appropriate  remedies  for  the  first  twelve  or  fourteen  days. 
Administered  every  three  or  four  hours  in  proper  dose,  they  are  the  most 
effectual  of  all  internal  remedies  for  diminishing  spinal  congestion  and  pre- 
venting effusion  and  permanent  structural  change  in  the  cord.  Unfortu- 
nately, this  first  stage  is  in  many  instances  far  advanced  before  proper  treat- 
ment is  employed  to  subdue  the  myelitis,  either  from  an  incorrect  diagnosis 
or  because  the  physician  is  not  summoned  until  structural  changes  have 
occurred,  which  constitute  the   second  stage. 


TREATMENT.  G29 

If  the  paralysis  continue  or  if  it  do  not  progressively  diminish,  we  should 
not  delay  niure  than  two  weeks  from  the  conuneiicement  of  the  disease  before 
employing  appropriate  measures  to  restore  the  use  of  the  limbs  and  arrest 
atrophy  of  the  muscles.  The  expectant  plan  of  treatment,  which  is  proper 
in  many  diseases  of  children,  is  unsuited  to  this.  Muscular  atrophy  may 
commence  in  three  weeks,  and  the  farther  it  has  advanced  the  more  difficult 
and  tedious  will  be  the  cure.  Therefore,  by  the  close  of  the  second  week,  if 
the  paralysis  continue  or  be  not  rapidly  disappearing,  iron  as  a  tonic  with 
strychnia  should  be  prescribed.  There  is  probably  no  better  formula  for  the 
exhibition  of  these  agents  than  the  following  from  Professor  Hammond : 

R.  Strych.  sulphat.,  gr.  j  ; 

Ferri  pyropliosphat.,  ,^ss; 

Acidi  pho.sphorici  dilut.,  5ss ; 

Syr.  zingib.,  Siijss.     Misce. 

One-third  of  a  teaspoonful  or  one-ninetieth  of  a  grain  of  strychnia  is  suffi- 
cient for  a  child  of  two  years,  administered  three  times  daily.  Hillier,  Bar- 
well,  and  others  have  employed  subcutaneous  injections  of  strychnia,  with,  it 
is  stated,  a  good  result.  While  in  the  first  and  second  weeks  the  child  has 
been  allowed  to  remain  quiet,  he  should  now  be  encouraged  to  use  his  limbs. 
Frequent  muscular  contraction  must,  if  possible,  be  produced,  and  the  volun- 
tary movements,  when  not  totally  lost,  aid  greatly  in  promoting  the  nutri- 
tion of  the  muscles  and  restoring  their  function.  Immersing  the  limb  for 
half  an  hour  in  water  at  a  temperature  of  110°  or  115°,  rubbing  the  limb  with 
a  coarse  towel,  and  kneading  the  muscles  aid  also  in  restoring  nutrition  and 
tone  to  them. 

But,  fortunately,  we  have  an  invaluable  agent  in  the  electric  fluid,  which 
can  be  made  to  penetrate  the  muscles  and  cause  their  contraction  when  every 
other  measure  has  failed.  The  induced  current  should  be  employed  upon  the 
limb  every  day  or  second  day  if  it  cause  the  muscles  to  act,  but  if  the  loss  of 
power  be  of  long  standing  or  complete,  so  that  the  induced  current  is  not 
sufficiently  powerful,  the  direct  current  should  be  used  instead.  It  is  not 
regarded  as  important  which  way  the  current  passes,  provided  that  the  mus- 
cles contract. 

In  a  large  proportion  of  cases  a  cure  cannot  be  efi"ected  until  the  lapse  of 
several  months,  so  that  the  patience  of  the  physician  and  friends  may  be  put 
to  the  test ;  but  if  muscular  atrophy  can  be  prevented  and  the  limb  kept  at 
nearly  the  normal  temperature,  this  mode  of  treatment  will  ordinarily  in  the 
end  be  successful.  The  primary  affection  which  caused  the  paralysis  will, 
with  some  exceptions,  be  removed  by  the  treatment  indicated  above,  after 
which  the  state  of  the  muscles  and  their  nervous  supply  demand  the  whole 
attention.  Observations  show  that  by  treatment  perseveringly  employed 
fatty  degeneration  of  the  muscular  fibres  can  be  not  only  arrested,  but  the  fat 
which  has  already  been  deposited  within  the  sarcolemma  may  be  absorbed  and 
the  muscular  striae  restored.  In  those  cases  in  which  it  has  been  necessary 
to  employ  the  direct  current  the  induced  should  be  used  whenever  by  the 
improvement  of  the  case  it  is  found  sufficiently  powerful. 


630 


FACIAL  PARALYSIS. 


CHAPTER  XVII. 


FACIAL  PARALYSIS. 


Causes. — Facial  paralysis  in  tlie  new-born  commonly  occurs  from  pres- 
sure of  the  blade  of  the  forceps  upon  the  portio  dura  at  a  point  external  to 
the  stylo-mastoid  foramen.  It  may  also  occur  in  children  of  any  age  from 
exposure  of  the  face  to  a  cold  wind.  The  pressure  of  a  tumor  upon  some 
part  of  the  portio  dura,  or  even  of  the  fist  of  the  child  placed  under  the  face 
during  sleep,  may  cause  it.  It  may  also  result  from  disease  of  the  temporal 
bone,  producing  pressure  on  the  nerve,  as  caries,  periostitis,  suppuration,  or 
hemorrhage  into  the  aquaeductus  Fallopii,  and  also  from  intracranial  disease 
aflPecting  the  pons  Varolii  or  the  medulla  oblongata. 

Symptoms. — The  portio  dura,  which  is  a  nerve  of  motion,  supplies  the 
muscles  of  the  face,  and  therefore  its  loss  of  function  is  at  once  manifest  in 
distortion  of  the  features.  The  eye  of  the  affected  side  remains  open  in  con- 
sequence of  paralysis  of  the  orbicularis  palpebrarum,  the  upper  lid  being 
raised  by  the  levator  muscle,  which  is  not  paralyzed,  since  its  nerve  is  derived 
from  the  third  pair.  From  the  inability  to  wink,  the  eye  becomes  irritated 
by  dust  and  constant  exposure,  and  in  children  old  enough  to  have  an  abun- 
dant lachrymal  secretion  the  tears  are  liable  to  flow  over  the  cheek.  On  ac- 
count of  the  paralyzed  and  relaxed  state  of  the  facial  muscles  the  mouth  is 
drawn  toward  the  healthy  side,  while  the  affected  side  presents  a  swollen 
appearance.  Movement  of  the  eyebrow  of  the  anterior  portion  of  the  scalp 
on  the  paralyzed  side  is  also  impossible,  since  the  occipito-frontalis  and  cor- 
rugator  supercilii  are  supplied  by  the  portio  dura.  If  the  cause  of  the  dis- 
ease is  located  above  the  origin  of  the  chorda  tympani,  the  flow  of  saliva  and 
sense  of  taste  on  the  affected  side  are  impaired.  If  the  injury  be  posterior  to 
the  gangliform  enlargement,  those  symptoms  are  superadded  which  are  due 
to  paralysis  of  the  petrosal  nerves. 

The  accompanying  woodcut  represents  a  case  which  was  under  observa- 
tion in  the  New  York  Infant  Asylum.  Its  age  at  admission  was  about  five 
months,  and  its  previous  history  was  unknown.  The  paralysis  was  perma- 
nent. Death  occurred  some  months  later 
from  an  intercurrent  disease,  and  no  cause 
of  the  paralysis  could  be  discovered  in  a 
careful  examination. 

Prognosis. — This  depends  on  the  cause. 
If  the  cause  be  peripheral,  as  from  the  pres- 
sure of  the  forceps  or  from  cold,  the  prog- 
nosis is  favorable.  In  case  of  deep-seated 
lesion,  unless  syphilitic,  the  prognosis  is  usu- 
ally unfavorable.  A  syphilitic  lesion  can 
often  be  removed  by  appropriate  remedies 
and  the  paralysis  be  cured. 

Treatment. — In  paralysis  of  the   new- 
born  from  pressure   of  the  forceps   all  that 
is   required   is  occasional  rubbing  or  gentle 
kneading  over  the  affected  muscles.    In  those 
who  are  older  the  nature  of  the  cause,  so  far  as  ascertained,  must  deter- 
mine the  treatment.     If  there  be  ijlandular  swellino;s  and  discharge  from  the 


PSEUDO-HYPERTROPHIC  PARALYSIS.  G31 

ear  from  scrofula,  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron  are  required 
internally,  with  appropriate  external  treatment  of  the  glands  and  ear.  If 
syphilis  be  the  cause,  mercurials  and  the  iodide  of  potassium  should  be  em- 
ployed. If  the  patient  do  not  soon  begin  to  improve,  the  treatment  recom- 
mended for  ini'antile  paralysis,  modified  somewhat  on  account  of  the  difference 
in  h)cation,  is  appropriate.  Iron  and  strychnia  may  be  administered  inter- 
nally. The  external  treatment  should  consist  of  friction,  kneading,  hot  appli- 
cations, and  the  electric  current.  The  current  should  have  only  moderate 
intensity,  for  a  high  degree  of  it  might  injure  vision.  It  should  be  applied 
every  second  day,  with  one  pole  over  the  mastoid  foramen  and  the  other  moved 
slowly  over  the  muscles. 


CHAPTER  XVIII. 

PSEUDO-HYPERTROPHIC   PARALYSIS. 

This  is  a  rare  disease.  It  was  first  described  by  Duchenne  in  1861,  and 
since  the  attention  of  the  profession  was  directed  to  it  cases  have  been 
observed  on  the  Continent,  in  Grreat  Britain,  and  in  this  country.  Though 
our  acqaintance  with  it  is  so  recent,  it  has  been  fully  and  accurately 
described  by  various  writers  in  our  language.  The  Transaction?;  of  the  Lon- 
don Fiitliological  Society  for  18G8  contain  a  translated  paper  relating  to  it, 
communicated  by  M.  Duchenne,  with  photographic  views  and  remarks  by 
Lockhart  Clarke,  and  also  the  histories  of  two  cases  occurring  in  London 
and  exhibited  to  the  Society  by  Adams  and  Hillier.  In  this  country  an 
elaborate  paper  has  appeared  on  this  form  of  paralysis  from  the  pen  of  Dr. 
Webber'  of  Boston,  who  succeeded  in  collecting  the  records  of  41  cases;  and 
more  recently  Dr.  Poore,'^  physician  to  the  New  York  Charity  Hospital,  col- 
lated the  records  of  85  cases,  which  furnish  the  material  of  his  monograph. 

Weakness  of  the  legs  and  a  peculiar  waddling  gait  are  the  first  observ- 
able symptoms,  and  by  them  we  are  able  to  ascertain  approximately  the  date 
of  the  commencement  of  the  paralysis.  In  27  of  the  cases  collated  by  Dr. 
Poore  the  malady  began  so  early  in  infancy  that  they  were  never  able  to 
walk  like  other  children  ;  in  .5  there  is  no  record  in  regard  to  the  time  when 
the  peculiar  gait  was  first  observed  or  whether  they  ever  could  walk  ;  52,  or 
about  two-thirds  of  the  cases,  walked  well  at  first,  having  no  symptoms  of 
the  paralysis  till  after  the  age  of  two  years.  In  15  of  these  weakness  of 
the  legs  and  the  peculiar  gait  were  first  observed  between  the  ages  of  two 
and  a  half  and  five  years ;  in  23  between  the  ages  of  five  and  ten  years ;  in 
6  between  the  ages  of  ten  and  sixteen  years ;  and  in  8  over  the  age  of  six- 
teen years.  It  is  seen,  therefore,  that  this  malady  is  pre-eminently  one  of 
infancy  and  childhood. 

The  gait,  which  is  unsteady  and  waddling,  has  been  compared  to  that 
of  a  duck.  The  child  stands  with  the  legs  wide  apart,  and  from  the  weak- 
ness of  the  legs  and  unsteadiness  of  the  gait  frequently  stumbles  and  falls. 
In  many  cases  this  muscular  weakness  and  difficulty  in  walking  occur 
before  there  is  any  perceptible  enlargement  of  the  muscles  beyond  the 
normal  size. 

The  hypertrophy  occurs  without  tenderness,  pain,  or  other  nervous  symp- 

^  Boston  Med.  and  Surg.  Jour.,  Nov.,  17,  1870. 
^  JN'eu,'  York  Medical  Journal,  for  June,  1875. 


632 


PSE  Un  O-HYPEB  TB  OPHIC  PA  RA  L  YSIS. 


Fig.  40. 


toms,  and  without  fever  or  constitutional  disturbance.  Occasionally  the 
patient  complains  of  stiffness  or  aching  in  the  limbs,  especially  after  exer- 
cise, even  before  the  enlargement  is  observed,  and  exceptionally  there  is 
pain,  even  acute,  in  the  legs.  The  hypertrophy  is  ordinarily  observed  first 
in  the  calf  of  one  leg,  and  then  in  the  opposite  calf.  In  a  case  related  by 
Niemeyer  the  muscles  of  the  gluteal  region  were  first  affected.  In  nearly 
all  cases  the  gastrocnemii  are  hypertrophied.  There  were  only  2  exceptions 
in  the  85  cases  collated  by  Dr.  Poore,  but  almost  any  of  the  other  muscles 
or  groups  of  muscles  may  also  be  involved.  The  muscles  which  are  most 
prominently  affected  and  which  produce  the  characteristic  defoi'mities  are 
those  of  the  extremities  and  posterior  aspect  of  the  trunk.  Spinal  curva- 
ture, which  is  attributed  to  the  weakened  state  of  the  erector  muscles  of  the 
spine,  appears  early  and  is  seldom  absent.  The  bending  is  such  that  a 
plumb-line,  falling  from  the  most  posterior  of  the  spinal  processes,  falls 
behind  the  plane  of  the  sacrum  ;  and  this  is  a  means  of  distinguishing  this 
disease  from  certain  other  spinal  aflFections.     The  woodcut  represents  a  case 

which  came  to  the  children's  class  at  Bellevue 
in  April,  1872.  The  boy  was  two  years  old, 
and  the  mother  stated  that  the  peculiar  gait  and 
the  enlargements  had  only  been  observed  from 
four  to  six  weeks,  and  yet  the  curvature  of  the 
spine  was  quite  marked.  He  did  not  return  to 
the  class,  and  his  subsequent  history  is  therefore 
unknown. 

Of  the  muscles  in  the  upper  extremities  the 
deltoid  and  scapular  are  most  frequently  en- 
larged. Hypertrophy  of  the  temporals  has  been 
observed  in  3  cases,  of  the  masseters  in  2,  of  the 
tongue  in  3,  and  of  the  heart  in  4  (Poore). 

We  shall  see  presently  that  atrophy  occurs 
in  the  muscular  element  of  the  parts  which  are 
affected,  and  that  the  hypertrophy  is  due  to  hy- 
perplasia of  the  connective  tissue.  Now,  occa- 
sionally this  hyperplasia  does  not  occur  or  is  tardy 
in  occurring,  while  the  atrophy  has  taken  place. 
Therefore,  certain  muscles  may  have  less  than 
the  normal  volume,  which,  from  contrast  with 
those  which  are  hypertrophied,  increases  the  de- 
In  ordinary  cases  the  enlargement  advances  more  rap- 
greater  in  the  gastrocnemii,  which  are,  as  we  have 
first  affected,  than  in  other  muscles,  and  therefore 
the  prominence  and  hardness  of  the  calves  of  the  legs  are  greater  than  else- 
where. In  advanced  cases  walking  is  impossible,  and  the  patient  is  obliged 
to  remain  in  a  reclining  posture.  Sometimes  from  the  unequal  muscular 
action  the  feet  become  extended  and  the  toes  flexed,  so  that  the  child  in 
attempting  to  walk  steps  on  the  anterior  part  of  the  sole  of  the  foot,  as  in 
talipes  equinus. 

In  the  first  stages  of  the  disease  the  electric  contractility  of  the  muscles 
is  nearly  normal,  but  in  advanced  cases  response  to  the  galvanic  current 
becomes  more  and  more  feeble  according  to  the  degree  of  atrophy  of  the 
muscular  fibres.  The  skin  retains  its  normal  sensibility,  with  exceptional 
instances  in  which  there  is  numbness  either  general  or  in  places.  Reddish 
or  bluish  mottling  of  the  surface  of  the  extremities  is  sometimes  observed, 
which  is  attributed  by  some  to  obstructed  venous  circulation  in  the  hyper- 
trophied muscles,  and  by  others  is  supposed  to  be  due  to  the  peculiar  neuro- 


formed  appearance, 
idly  and  continues 
stated,    the    muscles 


ANATOMICAL   CHARACTERS— CAUSES.  633 

pathic  state.  The  bladder  and  rectum  are  not  involved.  The  mental  facul- 
ties are  more  or  less  blunted  and  feeble  in  certain  cases,  especially  when  the 
disease  begins  in  early  infancy,  but  in  some  patients  they  do  not  seem  to  be 
materially  impaired. 

Anatomical  Characters. — There  have  been  so  few  post-mortem  exami- 
nations of  those  who  died  having  this  disease  that  it  is  still  uncertain  whether 
there  is  any  centric  lesion.  Cohnheim  examined  the  spinal  cord  in  one  case, 
and  could  find  nothing  abnormal.  Recently,  Mr.  Kcsteven  has  examined  the 
brain  and  spinal  cord  from  a  case,  and  found  dilatation  of  the  perivascular 
canals  both  in  the  brain  and  spinal  cord,  and  also  spots  of  granular  degen- 
eration, chiefly  in  the  white  substance,  "  caused  by  loss  of  cerebral  tissue 
replaced  by  morbid  matter."  ^  As  this  child  was  imbecile,  it  is  not  improba- 
ble that  these  lesions  were  connected  with  the  mental  state  and  not  the  mus- 
cular disease. 

Professor  Charcot^  reports  a  careful  miscroscopic  examination  of  the  spi- 
nal cord  and  of  the  nerves  in  a  case  which  had  continued  ten  years.  He 
could  discover  no  deviation  from  the  healthy  state.  More  recently  Dr.  H. 
Lockhart  Clarke^  examined  a  case  and  found  the  eneephalon  healthy,  but  in 
the  spinal  cord  there  was  more  or  less  disintegration  of  the  gray  substance  in 
each  lateral  half,  and  in  places  dilatation  of  vessels  and  commencing  sclerosis. 

It  seems,  therefore,  that  central  lesions  are  not  essential  and  are  some- 
times absent.  When  they  do  occur  it  is  probable  that  they  are  consecutive 
to  the  paralysis. 

The  essential  lesions  in  this  malady  are  atrophy  of  muscular  fibres  and 
hyperplasia  of  the  connective  tissue  which  surrounds  these  fibres.  The 
hyperplasia  of  the  one  element  in  the  muscle  is  greater  than  the  atrophy  of 
the  other,  and  hence  the  increase  of  volume  above  the  normal  size.  The 
atrophy  is  probably  a  primary  lesion,  for  muscular  weakness  ordinarily  occurs 
for  a  considerable  time  before  there  is  any  evidence  of  the  enlargement,  and, 
as  we  have  seen,  certain  muscles  may  undergo  the  atrophy  without  the  hyper- 
plasia. Still,  the  mechanical  effect  of  the  newly-formed  connective  tissue 
doubtless  increases  the  atrophy  in  those  muscular  fibres  which  this  tissue 
surrounds,  and  the  comparatively  quiet  state  of  muscles  in  consequence  of 
paralysis  not  only  tends  to  promote  the  atrophy  and  degeneration  of  these 
muscles,  but  also  of  contiguous  healthy  muscles. 

The  muscles  which  are  involved  in  this  paralysis  present  a  pale  yellowish 
hue,  resembling,  says  Niemeyer,  the  appearance  of  lipoma.  Examining  by 
the  microscope,  we  find,  in  addition  to  a  large  increase  in  the  fibrous  tissue 
and  atrophy,  and  in  some  places  disappearance  of  the  muscular  element,  more 
or  less  fatty  matter,  granular  and  globular,  occupying  the  interstices.  Mr. 
Kesteven  describes  as  follows  the  appearance  of  the  muscles  in  the  case  which 
he  examined  :  "  The  muscular  substance  is  pale,  almost  white,  and  very  greasy. 
The  superabundance  of  fat  is  evident  to  the  naked  eye.  The  muscular  fibres 
present  the  ordinary  striation,  but  less  distinctly  than  usual.  The  ultimate 
fibres  are  pale,  and  separated  by  a  large  increase  of  areolar  and  fibrous  tissue." 

Causes. — Why  there  is  this  strange  perversion  of  nutrition,  so  that  there  is 
an  exaggerated  development  of  the  connective  tissue  of  the  muscles  and  atro- 
phy of  the  muscular  fibres,  is  unknown.  Boys  are  more  liable  to  be  aflPected 
than  girls.  Of  the  85  cases  embraced  in  the  statistics  of  Dr.  Poore,  73  were 
boys,  and  there  was  a  similar  excess  of  males  in  the  cases  collated  by  Dr. 
Webber. 

There  is  in  a  considerable  proportion  of  cases  the  record  of  hereditary 
transmission,  and  in  almost  all  the  instances  the  predisposition  is  acquired 

^  Jour,  of  Med.  Sci.,  Jan.,  1871.  ^  Archiv.  de  Physiol.,  March,  1872. 

'  Medico-Chir.  Trans.,  1874. 


634      DISEASES  OF  THE  SPINAL   COED  AND  ITS  COVERINGS. 

from  the  mother's  side.  Thus  in  37  of  Dr.  Poore's  cases  "  2  or  more  belonged 
to  the  same  family."  In  some  instances  three  and  even  four  maternal  rela- 
tives had  this  form  of  paralysis.  In  one  case  observed  by  Duchenne,  and  in 
a  few  others  subsequently  observed,  this  malady  seemed  to  be  congenital,  for 
the  limbs  at  birth  were  unusually  large,  and  the  patients  when  they  came 
under  observation  were  unable  to  walk.  No  relation  has  been  observed 
between  this  paralysis  and  syphilis,  scrofula,  or  other  diathetic  diseases. 

Prognosis. — This  disease  is  in  most  instances  progressive,  terminating 
fatally  after  a  variable  period.  It  is  in  its  nature  chronic,  rarely  ending  in 
less  than  five  or  six  years.  A  considerable  proportion  live  longer,  some  even 
attaining  adult  age.  The  paralysis  may  be  stationary  for  a  time,  but  after- 
ward continue  to  increase.  Duchenne  has  reported  one  case  of  recovery.  In 
two  or  three  other  instances  patients  appeared  to  improve  somewhat  under 
treatment,  but  the  writers  admit  they  may  have  become  worse  afterward. 
Death  usually  occurs,  not  directly  from  the  paralysis,  but  from  some  inter- 
current disease,  especially  of  the  lungs. 

Treatment. — The  treatment  thus  far  employed  has  been  chiefly  local, 
consisting  in  the  use  of  electricity  and  kneading  or  shampooing  over  the 
affected  muscles.  Both  the  primary  and  induced  electric  currents  have 
been  employed,  but,  unfortunately,  without  any  appreciable  benefit  in  most 
cases.  Benedikt,  who  claims  a  better  result  from  electrization  than  any  other 
observer,  applied  the  copper  pole  over  the  lower  cervical  ganglion,  and  the 
zinc  pole  along  the  side  of  the  lumbar  vertebrae  by  means  of  a  broad  metallic 
plate. 


CHAPTER   XIX. 

DISEASES  OF  THE  SPINAL  COED  AND  ITS  COVEKINGS. 

The  diseases  of  the  spinal  cord  and  of  the  parts  which  cover  and  protect 
it  are  important,  but  they  are  less  understood  than  are  those  of  any  other 
portion  of  the  body.  This  is  partly  due  to  the  fact  that  in  many  cases  the 
spinal  disease  coexists  with  a  similar  pathological  state  of  the  brain  or  its 
meninges,  the  symptoms  of  which  predominate  and  mask  those  which  pertain 
to  the  spine  ;  partly  to  the  fact  that  the  chief  symptoms  of  spinal  disease  are 
often  located  in  organs  or  parts  which  are  at  a  distance  from  the  spine  ;  and, 
lastly,  to  the  fact  that  it  is  difficult,  for  obvious  reasons,  to  determine  the 
exact  state  of  the  spine  at  the  bedside,  while  post-mortem  inspection  of  the 
spine,  which  alone  can  give  accurate  pathological  knowledge,  is  less  frequently 
made  than  of  any  other  organ. 

Certain  spinal  diseases  occurring  in  childhood  are  the  same  as  in  adult 
life,  presenting  identical  symptoms  and  lesions  in  the  two  periods,  and  there- 
fore they  require  no  extended  notice  in  this  treatise.  Others  are  common  to 
childhood  and  maturity,  but  they  present  peculiarities  in  the  former  period 
which  require  to  be  pointed  out,  while  others  still  are  peculiar  to  childhood. 

The  so-called  spinal  irritation  or  anaemic  neuralgia  is  not  infi'equent  in 
delicate  and  poorly-fed  children.  I  have  from  time  to  time  observed  marked 
cases  of  it  in  the  class  in  the  Out-door  Department  of  Bellevue,  the  patients 
usually  being  above  the  age  of  thi'ee  or  four  years  and  exhibiting  evidences 
of  cachexia.  Most  of  them  have  been  spare  and  pallid,  some  affected  with 
a  nervous  cough  or  palpitation,  and  some  with  neuralgic  pains  in  the  chest, 
abdomen,   or  elsewhere,   which   pressure  at  a   certain  point  upon   the  spine 


CONGESTION  OF  THE  SPINAL   CORD  AND  ITS  MEMBRANE.    635 

intensified.  Tliese  cases  recover  by  better  feeding,  outdoor  exercise,  mild 
counter-irritation  along  the  spine,  and  the  use  of  tonics,  especially  of  iron. 
Primary  inflammation  of  the  cord  and  its  meninges  is  rare  in  children. 
Secondary  inflammation  of  these  parts  is,  on  the  other  hand,  more  common 
in  children  than  in  adults.  It  is  common  in  caries  of  the  vertebrae  and  in 
cercbro-spinal  fever.  The  preponderance  in  functional  activity  of  the  spinal 
cord  and  the  feeble  controlling  power  of  the  brain  render  infancy  and  child- 
hood more  liable  to  convulsions  and  reflex  paralysis  than  any  other  period  in 
life.  Cases  of  true  reflex  paralysis  occasionally  occur  in  children,  in  regard 
to  the  etiology  of  which  there  can  be  no  doubt.  Prof.  Sayre  of  this  city  has 
called  attention  to  the  fact  that  balanitis  and  preputial  adhesions  sometimes 
cause  paraplegia,  more  or  less  pronounced,  in  young  children,  and  which  is 
relieved  by  dividing  the  adhesions  and  restoring  the  mucous  surface  of  the 
glans  and  prepuce  to  its  normal  state.  Such  a  case  was  brought  to  the  chil- 
dren's class  in  the  Out-door  Department  at  Bellevue  in  April,  1875.  The 
child  could  not  walk  or  scarcely  stand  without  support,  but  after  the  division 
of  the  adhesions  and  subsidence  of  the  inflammation  locomotion  rapidly 
improved.'  In  another  instance  a  child  could  not  walk  properly,  having  a 
tottering  gait  and  dragging  one  foot.  The  preputial  and  urethral  orifices 
presented  an  irritated  appearance.  The  prepuce  was  stretched  and  separated 
from  the  glans  at  a  few  sittings,  the  instrument  used  being  an  infant's  catheter 
stiff'ened  with  a  wire,  so  that  it  served  as  a  pi'obe.  Large  masses  of  smegma, 
nearly  as  far  forward  as  the  preputial  orifice,  were  found  underneath.  These 
were  removed,  and  the  parts  were  smeared  with  sweet  oil.  The  patient  rap- 
idly recovered  the  full  use  of  his  limbs,  and  was  soon  entirely  well.  It  is 
well  known  that  masturbation  sometimes  causes  a  similar  weakness  of  the 
lower  extremities.  Dr.  AVest  relates  the  case  of  a  child  "  between  two  and 
tlu'ee  years  old  "  who  began  to  totter  in  his  gait,  and  finally  almost  ceased 
walking.  He  was  observed  to  practise  masturbation.  "  This  was  put  a  stop 
to,"  and  he  soon  recovered  his  health  and  his  power  of  locomotion.'^ 


CHAPTER   XX. 

CONGESTION  OF  THE  SPINAL  CORD  AND  ITS  MEMBRANE. 

Congestion  of  the  spinal  cord  and  meninges  occurs  both  as  a  primary 
and  secondary  malady,  the  latter  being  more  frequent  than  the  former.  It 
may  be  active  or  passive.  Active  congestion,  occurring  independently  of 
meningitis  or  myelitis,  is  in  most  instances  transient  and  subordinate  to  some 
graver  disease,  in  the  course  of  which  it  arises.  It  is  probably  often  over- 
looked. It  is  not  fatal,  and  its  symptoms  are  frequently  masked  by  those 
which  are  referable  to  the  brain  or  some  other  organ.  It  is  believed  to  be 
common  in  the  initial  period  of  certain  of  the  fevers  of  childhood.  It  is  not 
improbable  that  the  hyperfesthesia  observed  upon  the  thoracic  and  abdominal 
surfaces  and  along  the  thighs  in  the  commencement  of  remittent  and  certain 

'  Drs.  Holgate  and  Bosley.  formerly  attending  physicians  in  the  children's  class  at 
Eellevue,  made  many  examinations  of  the  state  of  the  prepuce  in  young  children. 
They  report  that  they  found  preputial  adhesions  almost  daily,  in  most  instances  without 
symptoms,  but  sometimes  with  dysuria,  and  occasionally  with  more  or  less  impairment 
of  the  use  of  the  legs. 

■■^  Diseases  of  Children,  page  146,  4th  Amer.  ed. 


636    CONGESTION  OF  THE  SPINAL   CORD  AND  ITS  MEMBRANE. 

other  febrile  diseases  has  its  origin  in  a  congested  state  of  the  spine.  To 
this  congestion  writers  attribute  the  lumbar  pain  and  occasional  paraplepia  in 
the  initial  stage  of  variola.  Active  spinal  congestion  may  also  result  from 
the  sudden  impression  of  cold,  and,  as  we  have  stated  above,  this  is  apparently 
the  most  frequent  cause  of  poliomyelitis  acuta  anterior. 

Certain  anatomical  circumstances  favor  the  occurrence  of  passive  con- 
gestion of  the  spinal  cord  and  meninges — to  wit,  the  tortuousness  of  their 
veins  and  the  absence  of  valves  in  these  veins,  the  lack  of  muscular  support 
of  the  vessels,  and  the  inferior  position  of  the  spine  in  sickness  as  the  patient 
lies  quietly  in  bed.  A  common  cause  of  passive  congestion  of  these  parts  is 
some  protracted  and  enfeebling  disease  which  diminishes  the  contractile  force 
of  the  heart  (cardiac  paresis),  producing  congestion  of  the  spinal  cord  in  the 
same  manner  as  under  similar  circumstances  hypostatic  congestion  of  the 
lungs  occurs.  Severe  convulsive  diseases,  as  tetanus  or  eclampsia,  when  pro- 
tracted or  occurring  at  short  intervals  commonly  produce  spinal  congestion. 
In  tetanus  this  congestion  is  extreme,  so  that  extravasation  of  blood  is  liable 
to  occur  from  the  engorged  vessels,  especially  those  of  the  pia  mater. 

Anatomical  Characters. — It  is  often  impossible,  at  post-mortem  exami- 
nations, to  determine  how  much  of  the  congestion  of  the  spine  and  its  meninges 
is  pathological  and  how  much  cadaveric,  since,  if  the  corpse  be  placed  on  its 
back  at  death,  a  very  considerable  engorgement  of  the  spinal  vessels  occurs 
from  gravitation  of  blood.  If  the  body  have  been  placed  on  the  side  or  face, 
this  cadaveric  congestion  is  prevented.  Since  in  active  congestion  the  arterioles 
and  capillaries  are  distended  with  arterial  blood,  the  color  is  a  brighter  red 
than  in  passive  congestion,  in  which  venous  blood  predominates.  Active  con- 
gestion of  the  cord  usually  coexists  with  that  of  the  meninges,  but  it  may 
occur  without  it.  In  cases  of  considerable  congestion  the  "  puncta  vascu- 
losa  "  appear  upon  the  incised  surface  both  of  the  white  and  gray  substance. 
If  the  congestion  be  protracted  or  if  it  recur  frequently,  it  may  produce  per- 
manent dilatation  of  the  arterioles  and  capillaries  in  greater  or  less  degree, 
and  it  may  also  lead  to  sclerosis  of  the  cord.  Passive  congestion  seldom,  per- 
haps never,  occurs  in  the  cord  without  being  equally  and  often  to  a  greater 
extent  present  in  the  meninges.  Continuing  for  a  time,  it  gives  rise  to  tran- 
sudation of  serum  into  the  interspaces  over  the  cord,  and  even  softening  of 
the  cord  may  occur  to  a  limited  extent  from  imbibition  of  serum.  In  either 
form  of  congestion  extravasations  of  blood  are  frequent. 

Symptoms. — Spinal  congestion  is  announced  by  pain  in  the  region  of  the 
spine,  usually  in  the  lumbar  or  dorsal  and  lumbar  portions,  and  irradiations 
of  pain  and  tingling  in  the  legs.  In  addition,  more  or  less  paralysis  of  the 
bladder  and  legs  may  result.  The  paraplegia  may  occur  early  or  not  till  the 
lapse  of  several  days.  In  active  congestion  the  symptoms  are  rapidly  devel- 
oped, and  they  attain  their  maximum  intensity  sooner  than  in  the  passive 
form.  In  passive  congestion  the  development  of  symptoms  is  not  only  more 
gradual,  but  they  are  ordinarily  less  pronounced,  and  are  attended  by  more 
fluctuation,  than  in  the  active  form.  The  paralysis,  if  present,  comes  on 
slowly  after  several  days,  and  is  incomplete.  Spinal  congestion,  especially 
of  the  passive  form,  is  sometimes  associated  with  cerebral  congestion — -as,  for 
example,  in  tetanus  and  severe  eclampsia — and  the  spinal  symptoms  therefore 
coexist  with  those  which  have  a  cerebral  origin.  The  duration  and  the  result 
of  a  hyperaemic  state  of  the  spinal  cord  and  its  meninges  depend  largely  on 
the  nature  of  the  cause.  If  it  be  not  relieved  within  a  few  days,  there  is 
strong  probability  that  some  other  serious  pathological  state  has  supervened, 
as  meningitis,  myelitis,  extravasation  of  blood,  or  serous  transudation,  with 
softening  of  the  nervous  substance. 

Treatment. — In  the  adult  spinal  congestion  sometimes  results  from  the 


VERTEBRAL   CARIES.  (j37 

sudden  cessation  of"  tlie  hcniurihoidal  or  catamenial  flow,  and  the  application 
of  leeches  or  wet  cups  along  the  spint;  is  indicated.  But  in  the  child  the 
abstraction  of  blood  is  seldom  re(|uired.  In  the  acute  stage  of  active  spinal 
congestion,  with  elevation  of  temperature,  cold  applications  along  the  spine 
are  often   beneficial,  as  by  an   India-rubber  bag. 

In  active  hypenvmia  laxatives  are  useful,  and  rubefacient  applications 
should  be  made  along  the  spine,  as  by  mustard  or  by  friction  with  a  stimu- 
lating liniment.  In  the  inflammatory  spinal  congestion  of  cerebro-spinal  fever 
I  have  employed  with  a  very  satisfactory  result  a  liniment  containing  equal 
parts  of  camphorated  oil  and  turpentine.  In  both  active  and  passive  hyper- 
aemia  lateral  decubitus  should  be  prescribed  rather  than  dorsal.  The  use  of 
ergot  in  order  to  diminish  the  turgescence  of  the  vessels  of  the  spinal  cord  and 
meninges  has  been  advocated  by  Brown-Sequard,  and  it  is  now  one  of  the 
recognized  remedies.  Bromide  of  potassium  is  also  a  remedy  of  value,  but 
it  is  more  useful  in  some  cases  than  in  others.  It  is  signally  beneficial  in 
those  cases  in  which  there  is  also  cerebral  congestion.  When  the  congestion 
is  increased  or  produced  by  clonic  convulsions  the  bromide  is  one  of  the  most 
relial)le  remedies  which  we  possess  for  the  removal  of  the  cause.  Thus,  it 
should  be  employed  in  the  treatment  of  the  spinal  and  cerebral  congestion  in 
the  commencement  of  variola,  in  which  convulsions  are  so  common,  and  in 
the  convulsions  of  pertussis  or  pneumonia,  which  cause  extreme  passive  con- 
gestion of  the  cerebro-spinal  axis.  Passive  congestion  of  the  spine,  common 
in  exhausting  diseases  and  due  to  feebleness  of  the  circulation,  is  best  treated 
by  stimulating  and  sustaining  remedies  and  by  the  lateral  decubitus.  It  is 
hypostatic,  and  may  be  associated  with  a  similar  congestion  in  the  posterior 
part  of  the  lungs. 


CHAPTER   XXI. 

VERTEBRAL   CARIES. 

Vertebral  caries,  designated  also  Pott's  disease,  occurs  chiefly  in  child- 
hood, but  now  and  then  adults  are  afi'ected  with  it.  It  is  an  osteitis  of  the 
bodies  of  one  or  more  vertebrae,  ending  in  their  ulceration  and  a  lifelong 
deformity  if  not  checked. 

CxVUSES. — A  reduced  state  of  system,  and  especially  the  scrofulous  diathe- 
sis, strongly  predispose  to  caries.  Hence  this  malady  is  more  common  in  the 
city  than  in  the  country,  where  better  hygienic  conditions  produce  a  more  vig- 
orous constitution.  Prolonged  antihygienic  conditions  and  protracted  ill-health 
from  whatever  cause  predispose  to  caries.  In  certain  cases  there  is  no  appa- 
rent exciting  cause,  while  in  others  there  is  the  history  of  a  fall  upon  or  some 
injury  of  the  spine. 

Vertebral  caries  may  occur  in  the  cervical,  dorsal,  or  lumbar  portions  of 
the  spinal  column,  but  it  is  more  common  in  the  lower  dorsal  than  elsewhere. 
With  the  development  of  the  osteitis  the  body  of  the  vertebra  which  is 
affected  becomes  hypera3mic,  and  the  spongy  tissue  is  soon  infiltrated  with 
blood  and  pus.  The  bone  becomes  swollen  and  softened,  and  therefore  less 
resisting  than  in  the  healthy  state,  so  that  it  yields  under  the  weight  of  the 
shoulders  and  head,  which  it  sustains.  Therefore,  after  the  osteitis  has  con- 
tinued a  certain  time  there  begins  to  be  posterior  convexity,  or  rather  angu- 
larity, of  the  spine,  for  while  the  vertebral  bodies  soften  and  yield  by  the 


638  VERTEBRAL   CARIES. 

weight  above  them,  the  arches  retain  their  integrity  and  firmness  and  are 
unyielding. 

Much  of  the  tediousness  and  suiFering  of  this  malady  is  due  to  the  fact 
that  the  inflammation  is  so  deep-seated  and  a  healthy  bony  barrier  is  inter- 
posed between  it  and  the  surface,  so  that  there  is  no  ready  escape  of  the  pus. 
It  permeates  the  spongy  tissue,  filling  the  cavities  produced  by  the  softening 
and  absorption  of  the  bone-substance.  If  the  inflammation  be  of  small 
extent,  the  amount  of  pus  small,  the  constitution  good,  and  if  the  disease 
be  early  recognized  and  properly  treated,  the  child  may  recover  without 
any  fistulous  opening  by  absorption  of  the  pus,  and  with  little  remaining 
deformity. 

In  the  large  proportion  of  cases,  however,  the  history  is  different.  The 
disease  is  not  recognized  till  the  stage  of  deformity,  the  caries,  is  so  exten- 
sive and  the  pus  so  abundant  that  it  escapes  between  the  vertebrae,  forming 
an  abscess  external  to  them  which  connects  with  the  interior  of  the  vertebrae- 
by  a  fistulous  canal.  This  abscess,  if  in  the  cervical  region,  may  press  upon 
the  pharynx  or  oesophagus  or  upon  the  air-passages,  producing  dangerous 
obstruction  to  respiration.  This  disease  will  be  treated  of  hereafter.  The  pus 
may  point  and  discharge  externally  near  the  seat  of  the  caries,  but  in  a  large 
proportion  of  instances  it  takes  a  long  and  circuitous  route  to  the  surface  or 
it  opens  internally.  There  are  instances  in  which  it  discharges  into  the 
pleural  or  abdominal  cavity  or  into  one  of  the  abdominal  organs.  If,  as  is 
sometimes  the  case,  it  establishes  a  connection  with  the  intestine  and  escape 
in  the  stools,  the  result  will  probably  be  favorable.  In  other  instances  it 
descends  into  the  pelvic  cavity  and  finds  an  outlet  by  the  inguinal  ring  or 
sciatic  notch,  or  it  enters  the  sheath  of  the  iliacus  or  psoas  muscle  and  points 
externally. 

When  the  disease  ends  favorably  new  bone  is  thrown  out  around  the  dis- 
eased vertebrse,  preventing  further  bending  and  giving  stability  to  the  spine. 
If  the  abscess  do  not  discharge,  but  remain  subcutaneous,  Billroth  says : 
.  .  .  .  "  While  the  bone  disease  recovers  most  frequently,  a  large  part  of  the 
pus,  whose  cells  disintegrate  into  fine  molecules,  is  absorbed,  while  the  inner 
walls  of  the  abscess  change  to  a  cicatricial  tissue  which  in  the  shape  of  a 
fibrous  sac  contains  the  puriform  fluid.  Such  pus-sacs  often  remain  in  this 
stage  for  years." 

If  the  pus  have  escaped  externally,  the  abscesses  and  fistulae  contract  and 
finally  close,  their  site  being  occupied  by  condensed  connective  tissue.  The 
portions  of  the  diseased  vertebrte  which  have  retained  their  vitality  are  envel- 
oped and  supported  by  the  new  bone,  so  that  the  part  of  the  spine  which  was. 
the  seat  of  the  disease,  though  ankylosed  and  curved,  has  greater  firmness 
than  in  health. 

The  history  of  unfavorable  cases  varies.  The  caries  may  extend ;  pus, 
finding  no  vent,  may  accumulate  in  cavities  and  sinuses  in  which  detached 
portions  of  bone  float,  or  it  may  make  its  way  in  such  directions  that  it  pro- 
duces alarming  complications  and  impairs  or  obstructs  the  functions  of  im- 
portant organs. 

Spinal  meningitis  in  the  vicinity  of  the  caries,  and  due  to  extension  of 
the  inflammation,  is  common,  and  "  the  spinal  medulla,"  says  Billroth,  "  may 
be  endangered  by  participation  in  the  suppuration  or  by  being  so  bent  by  the 
inclination  of  the  vertebrse  that  its  function  is  destroyed."  Hence  the  paral- 
ysis of  the  lower  extremities,  bladder,  and  rectum  which  occurs  in  aggra- 
vated cases  and  which  entails  a  fatal  issue.  In  a  certain  proportion  of  cases 
the  blood  becomes  more  and  more  impoverished  from  the  continuance  of 
the  inflammation  and  suppuration,  and  death  occurs  in  a  state  of  exhaus- 
tion.    In  such  cases  post-mortem  examination  often  discloses  waxy  degen- 


SYMPTOMS— DIAGNOSIS.  639 

uration  of  important  organs,  as  the  spleen,  liver,  kidneys,  and  intestines,  for  it 
is  well  known  that  chronic  suppurative  inflauimation  of  the  bones  is  one  of 
the  two  chief  causes  of  the  waxy  disease,  sy[)hilis  beinj;  the  other. 

Symptoms. — Caries  of  the  vertebrse  is  often  preceded  by  symptoms  or 
appearances  which  are  due  to  the  strumous  cachexia.  Strumous  ailments 
have  j)robably  occurred  in  the  patient  or  in  members  of  the  family,  or  with- 
out any  clear  history  of  struma  the  child  has  jjcrhaps  for  some  time  been  in 
failing  health.  In  cases  which  I  have  observed  one  of  the  chief  symptoms, 
and  sometimes  almost  the  only  symptom  in  the  commencement  of  the  caries, 
has  been  neuralgic  pain,  usually  not  severe,  intermittent,  or  more  or  less  con- 
stant, at  some  point  in  the  anterior  aspect  of  the  body,  most  frequently  in  the 
chest,  epigastric  or  umbilical  region.  This  pain  has  been  present  in  a  larger 
proportion  of  cases  than  pain  in  the  spinal  region  at  the  seat  of  the  caries, 
though  Guersant  dwells  particularly  upon  the  latter  as  a  symptom  of  caries. 
Patients  with  this  neuralgia  are  not  infrequently  treated  for  indigestion  or 
worms,  the  true  nature  of  the  malady  not  being  suspected  and  the  spine  not 
even  being  examined.  This  neuralgia  seems  to  be  due  to  compres.sion  of  the 
spinal  nerves  by  inflammatory  exudation  at  the  points  where  they  emerge 
from  the  spinal  canal.  I  can  recall  to  mind  a  number  of  cases  in  which  I 
have  on  different  occasions  been  asked  to  prescribe  for  this  neuralgia,  which 
was  shown  by  the  sequel  to  be  undoubtedly  the  result  of  vertebral  caries, 
and  yet  with  a  careful  examination  of  the  spinal  column  I  could  discover  no 
evidences  of  disease  at  any  point.  After  a  time,  tenderness,  pain,  and  inflam- 
matory induration,  appreciable  to  the  touch,  may  occur  in  or  along  the  spine, 
but  not  usually  till  the  malady  is  well  advanced.  Lassitude,  fatigue  after 
slight  exertion,  poor  appetite,  with  slight  fever,  are  common  symptoms  in  the 
first  stage  of  the  caries. 

As  the  case  advances,  if  the  nature  of  the  disease  be  not  recognized  and 
no  artificial  support  of  the  trunk  be  provided,  the  child  instinctively  seeks 
some  way  of  supporting  the  head  and  shoulders.  He  rests  his  head  upon  his 
hands  or  his  elbows  upon  the  table.  Soon  a  gibbosity  or  angularity  appears, 
affording  clear  and  positive  proof  of  the  nature  of  the  disease.  Even  now 
there  is  little  or  no  tenderness  when  pressure  is  made  directly  on  the  spine, 
but  it  is  observed  more  when  pressure  is  made  laterally  upon  it.  If  the 
inflammation  extend  so  as  to  involve  the  meninges  and  the  cord,  pricking, 
tingling,  numbness,  or  weakness  of  the  legs  may  occur,  which  are  symptoms 
of  grave  import,  for  it  is  probable  that  the  case  will  end  in  paraplegia  and 
death.  A  state  of  emaciation  and  general  weakness,  sometimes  accompanied 
by  diarrhoea  and  oedema  of  the  limbs,  precedes  death.  But  a  very  consid- 
erable degree  of  curvature  is  not  incompatible  with  a  healthy  and  normal  per- 
formance of  all  the  functions,  and  the  number  who  recover  and  live  to  an 
advanced  age   with  deformity  is  large,  as  every  one  knows. 

Diagnosis. — This  is  often,  from  the  nature  of  the  disease,  obscure  and 
uncertain  for  a  time.  The  long  continuance  of  pain  in  the  chest  or  abdomen, 
or  perhaps  in  the  thighs,  without  any  cause  which  we  can  detect  located  at 
the  seat  of  the  pain,  should  excite  suspicion  of  spinal  disease.  Such  pain 
may  be  produced  by  spinal  irritation,  but  in  this  malady  pressure  on  the 
spine  is  badly  tolerated,  and  when  we  touch  a  certain  part  the  neuralgic  pain 
is  intensified.  In  caries,  as  we  have  seen,  firm  pressure  upon  the  spine  is 
tolerated,  and  it  does  not  increase  the  neuralgia.  At  a  later  period  in  caries 
there  may  be  spinal  pain  and  tenderness,  but  there  is  now  also  spinal  deform- 
ity, by  which  alone  the  diagnosis  is  clearly  established ;  stiffness  observed  in 
the  movements  of  the  spine,  pain  in  the  spine  on  sudden  movement  or  jarring 
the  body,  impaii'ed  appetite  and  general  health,  and  instinctive  desire  to  sit 
or  recline  in  such  a  way  as  to  relieve  the  spine  partially  of  the  weight  of  the 


640  VERTEBRAL   CARIES. 

head  and  shoulders,  are  symptoms  which,  if  they  coexist,  afford  very  strong- 
evidence  of  the  presence  of  caries,  although  there  be  as  yet  no  deformity. 

The  spinal  deformity  of  rachitis  is  distinguished  from  that  of  caries  by 
the  fact  that  it  occurs  slovply  without  pain  or  tenderness  and  is  rounded 
instead  of  angular.  Moreover,  the  rachitic  diathesis  precludes  scrofulous 
ailments,  and  the  scrofulous  diathesis  rachitic  ailments,  as  the  two  diatheses 
do  not  coexist  or  but  rarely ;  so  that  if  there  be  in  the  state  of  the  patient 
or  have  been  in  his  history  evidences  of  scrofula,  the  presumption  is  that  the 
bending  of  the  spine  occurs  from  caries.  In  a  case  of  rachitic  curvature  we 
find  also  enlargements  of  the  ankles  and  wrists,  keel-shaped  thorax,  promi- 
nent abdomen,  rachitic  head,  etc. 

Prognosis. — The  course  of  this  malady,  even  when  the  caries  is  slight 
and  the  symptoms  mild,  is  tedious.  In  the  most  favorable  cases  the  general 
health  is  but  slightly  impaired,  the  caries  is  confined  to  one  vertebra,  and  is 
early  diagnosticated  and  properly  treated.  On  the  other  hand,  if  the  general 
health  be  decidedly  poor,  the  child  anaemic  and  wasted,  the  curvature  great, 
and  an  abscess  have  occurred,  the  case  is  very  serious.  Between  these  two 
extremes  is  every  grade.  The  prognosis  is  more  favorable  in  the  child  than 
in  the  adult.  The  few  adults  whom  I  have  seen  with  it  all  died.  It  is  less 
favorable  in  the  cervical  region  than  in  the  dorsal  or  lumbar.  A  mild  case 
occurring  in  a  good  condition  of  health  may  become  grave,  and  even  fatal, 
by  neglect  and  improper  treatment.  A  majority  of  the  patients,  if  the  dis- 
ease be  not  too  far  advanced  when  recognized,  recover  if  properly  treated, 
but  the  deformity  which  results  may  prove  serious  in  after-life.  The  incom- 
plete expansion  of  the  lungs  in  the  humpbacked  greatly  increases  the  dyspnoea 
and  the  danger  in  subsequent  years  if  bi'onchitis  or  pneumonia  occur,  and  if 
the  caries  have  been  at  a  low  point  in  the  spine  and  the  patient  a  female,  the 
deformity  will  probably  present  an  obstacle  to  childbearing. 

Treatment. — The  treatment  must  be  constitutional  and  local,  hygienic, 
medical,  and  mechanical.  It  is  of  the  utmost  importance  to  improve  the 
general  health,  as  it  is  in  all  chronic  inflammations  and  scrofulous  ailments. 
Pure  air,  sunlight,  personal  cleanliness,  and  plain  but  the  most  nutritious  diet 
are  required.  Tonic  and  antistrumous  remedies  are  indicated.  To  many 
patients  I  have  prescribed,  three  times  daily,  cod-liver  oil  to  which  the  syrup  of 
the  iodide  of  iron  was  added,  giving  two  or  three  drops  of  the  latter  to  a  child 
of  one  year  and  one  additional  drop  for  each  additional  year.  The  judicious 
use  of  alcoholic  stimulants  will  often  be  found  useful  if  the  appetite  be  poor 
and  the  general  health  seriously  impaired,  as  will  also  the  vegetable  bitters. 

In  all  strumous  inflammations  of  the  bones  which  extend  to  or  involve 
joints,  and  which  are  in  their  nature  chronic,  perfect  quiet  of  the  parts,  so 
far  as  is  consistent  with  the  degree  of  exercise  which  is  required  in  order 
to  improve  the  appetite  and  general  health,  is  indispensable  for  successful 
treatment  of  the  case.  The  patient  with  this  malady  should  be  encouraged 
to  lie  much  of  the  time  in  bed,  for  the  double  purpose  of  preventing  move- 
ments of  the  inflamed  vertebrae  and  relieving  them  of  the  weight  of  the 
shoulders  and  head.  But  confinement  in  bed  is  badly  tolerated,  and  exercise 
is  necessary  for  a  healthy  functional  activity  of  the  organs ;  therefore 
mechanical  support  of  the  spine  is  required.  The  apparatuses  which  have 
been  invented  for  the  purpose  of  supporting  the  spine  and  rendering  it  im- 
movable, and  of  sustaining  the  head  if  the  caries  be  in  the  cervical  region,  or 
the  head  and  shoulders  if  it  be  in  the  dorsal  or  lumbar  region,  are  ingenious 
and  effectual.  Some  of  them  are  rather  cumbersome,  but  others  are  sufficient- 
ly light  for  the  youngest  child  who  can  walk.  The  apparatus  should  be  worn  for 
months,  care  being  taken  to  prevent  excoriation  or  undue  pressure  upon  any 
point.     I,t  may  be  removed  at  night  and  reapplied  on  rising  in  the  morning. 


SECTIOE"  II. 

DISEASES    OF    THE    RESPIRATORY    SYSTEM. 


CHAPTER   I. 
CORYZA. 

The  term  "eoryza"  is  applied  to  inflammation  of  the  Schneiderian  mem- 
brane. It  is  acute  or  chronic.  The  acute  form  is  primary  or  secondary. 
Acute  primary  eoryza  is  common  in  infancy  and  childhood.  Its  usual  cause 
is  exposure  to  currents  of  air,  to  cold,  and  especially  to  sudden  changes  of 
temperature  from  warm  to  cold.  The  cause  is  the  same  as  that  in  the  ordi- 
nary forms  of  bronchitis.  The  two  diseases  frequently  indeed  coexist,  occur- 
ring from  the  same  exposure.  The  inflammation  in  such  cases  commences 
upon  the  Schneiderian  membrane  immediately  upon  the  operation  of  the 
cause,  and  soon  after  extends  to  the  bronchial  tubes.  Acute  eoryza  may 
also  be  produced  by  the  inhalation  of  irritating  vapors,  hot  air,  or  dust, 
and  also  by  the  presence  of  a  foreign  body,  as  a  button  or  bean,  in  the 
nostril. 

Secondary  eoryza  is  commonly  due  to  a  specific  cause.  The  diseases  in 
connection  with  which  it  occurs  are  whooping  cough,  measles,  scarlet  fever, 
diphtheria,  and  constitutional  syphilis.  In  the  infant  eoryza  is  one  of  the 
first  manifestations  of  inherited  syphilitic  taint. 

Acute  primary  eoryza  ordinarily  abates  in  from  one  to  two  weeks.  The 
secondary  form  gradually  declines,  in  most  cases,  when  the  primary  afi"ection 
on  which  it  depends  is  cured.  Syphilitic  eoryza  is  more  protracted  than  the 
primary  form  or  than  that  accompanying  the  eruptive  fevers.  Some  children 
are  so  liable  to  eoryza  that  it  occurs  whenever  they  take  cold.  Occasionally 
it  is  so  frequently  renewed  in  the  winter  months  that  it  resembles  the  chronic 
form  of  the  disease. 

Chronic  eoryza  is  commonly  dependent  on  a  dyscrasia,  usually  the  syphi- 
litic or  strumous.  The  dyscrasia  is  indicated  by  pallor,  flabbiness  of  the  flesh, 
and  liability  to  glandular  swellings.  Certain  cases  take  their  origin  in  the 
nasal  catarrh  of  the  exanthematic  fevers,  the  local  affection  continuing  after 
the  constitutional  disease  has  declined.  Chronic  eoryza  sometimes  occurs  in 
children  who  appear  otherwise  in  good  health.  It  is  probable  that  in  such 
cases  there  is  a  dyscrasia  of  which  the  eoryza  happens  to  be  the  sole  mani- 
festation. 

Anatomical   Characters. — The  alterations  which  the  nasal   mucous 

membrane  undergoes  when  inflamed  vary  considerably  in  diff'erent  cases.     In 

the  simplest  and  most  common  form  of  eoryza  this  membrane  is  sometimes 

in  patches,  sometimes  generally  reddened,  thickened,  and  softened.    Its  papillae 

41  641 


642  COBYZA. 

are  prominent,  producing  an  inequality  of  tlie  surface.  Ulcerations  are  not 
common  in  simple  acute  coryza,  but  they  sometimes  occur  in  the  chronic 
form. 

In  diphtheria,  and  sometimes  in  scarlet  fever  and  variola  of  severe  type, 
the  coryza  is  pseudo-membranous,  and  when  it  presents  this  form  it  is  com- 
monly but  not  always  associated  with  pseudo-membranous  angina  or  laryn- 
gitis. A  case  of  pseudo-membranous  coryza  occurring  in  measles  is  related 
by  M.  Guibert.  The  patient  was  a  rachitic  boy  three  and  a  half  years  old. 
The  pseudo-membrane  in  grave  cases  may  cover  almost  the  entire  surface  of 
the  nostrils,  but  ordinarily  it  occurs  in  patches. 

Symptoms. — The  constitutional  symptoms  are  mild  or  severe,  according 
to  the  gravity  of  the  inflammation.  If  the  coryza  be  acute  and  pretty  gen- 
eral, there  is  febrile  movement,  with  thirst  and  loss  of  appetite.  Frontal 
headache  is  common,  from  the  proximity  of  the  inflammation  to  the  head  or 
its  extension  to  the  frontal  sinuses.  Sneezing  is  the  first  symptom  in  many 
cases  of  acute  coryza.  As  the  inflamed  membrane  swells  more  or  less  obstruc- 
tion occurs  to  respiration.  The  breathing  is  noisy,  especially  during  sleep, 
and  in  severe  cases  the  patient  is  compelled  to  breathe  mostly  through  the 
mouth.  If  there  be  much  obstruction  to  respiration  the  suffering  of  the 
patient  is  considerable,  from  the  sensation  of  fulness  in  the  nostrils,  the  head- 
ache, and  the  muscular  eff'ort  required  in  each  respiratory  act. 

In  the  commencement  of  coryza  the  patient  experiences  a  sensation  of 
dryness  in  the  nostrils,  which  is  soon  succeeded  by  a  thin  discharge  of  a  serous 
appearance.  In  the  course  of  a  few  hours  the  secretion  becomes  thicker.  It 
is  muco-purulent,  and  remains  such  till  the  disease  begins  to  decline.  Inspis- 
sated mucus  and  crusts  are  liable  to  collect  within  the  nostrils  and  around 
their  orifice  in  chronic  coryza,  and  sometimes  also  in  the  acute  disease  if  the 
discharge  be  not  abundant.  These  crusts  increase  the  difficulty  of  breathing. 
Often  the  acridity  of  the  discharge  is  such  that  the  skin  of  the  upper  lip  and 
around  the  nostrils  is  excoriated. 

Prognosis. — Uncomplicated  catarrhal  coryza  rarely  terminates  fatally. 
It  is  only  dangerous  in  young  nursing  infants,  in  whom  it  may  prevent  proper 
traction  of  the  nipples.  Coryza  accompanying  the  eruptive  fevers,  although 
it  may  increase  the  suffering,  does  not  materially  increase  the  danger.  Syph- 
ilitic coryza  subsides  when  the  system  is  sufficiently  affected  by  antisyphilitic 
remedies.  Chronic  coryza  is  sometimes  very  obstinate.  It  may  continue 
for  months  or  years,  giving  rise  to  a  constant,  but  often  not  abundant, 
discharge. 

Treatment. — Common  mild  attacks  of  coryza  require  little  treatment. 
The  bowels  should  be  kept  open,  the  feet  soaked  in  mustard-water,  and  the 
body  should  be  warmly  clothed.  Inunction  of  the  nostrils  is  a  popular  rem- 
edy, and  it  seems  to  give  some  relief.  If  coryza  commence  with  symptoms 
which  indicate  a  pi'etty  severe  attack,  and  there  are  evidences  of  extension 
of  the  disease  toward  the  bronchial  tubes,  an  emetic  of  syrup  of  ipecacuanha, 
given  at  an  early  period,  moderates  the  severity  of  the  inflammation  and  may 
prevent  the  occurrence  of  bronchitis.  Afterward  a  simple  diaphoretic  mix- 
ture, as  the  following,  should  be  given  : 

R.  Syrupi  ipecacuanha,  jij  ; 

Spirit,  aether,  nitr.,  ^}  ; 

Syrupi  simplicis,  .^ij.     Misce. 

One  teaspoonful  every  three  hours  to  a  child  of  six  months. 

In  place  of  sweet  spirits  of  nitre,  acetate  of  potassium  may  be  employed 
in  the  dose  of  one  or  two  grains  for  infants ;  and  if  there  be  considerable 


TREATMENT.  643 

fever  half  a  grain  or  one  grain,  according  to  the  age,  of  phenacetin  or  anti- 
pyrine  may  be  given. 

A  3  to  5  per  cent,  solution  of  common  salt  in  warm  water  injected  into 
the  nostrils  with  a  small  syringe  aids  materially  in  removing  the  muco-pus 
which  obstructs  the  respiration  and  in  establishing  a  healthier  state  of  the 
inflamed  surface.  The  officinal  lime-water  is  also  a  most  useful  detergent  of 
the  nasal  surface.  The  following  formulae  will  be  found  useful  in  most  cases 
of  this  form  of  coryza  : 

R.  Acidi  borici,  ^] ; 

Sodii  biborat.,  ,^ij  ; 

Aqupe,  5viij. 

R.  Sodii  chloridi,  ^}  ; 

Sodii  biborat.,  ,5ij  ; 

Aqiife,  Oj.     Misce. 

Half  a  teaspoonful,  used  warm,  should  be  injected  into  each  nostril  several  times  daily, 
with  the  head  thrown  backward. 

The  treatment  proper  for  pseudo-membranous  or  diphtheritic  coryza  is 
detailed  in  our  remarks  on  the  therapeutics  of  diphtheria.  Chronic  coryza, 
since  it  depends  upon  a  dyscrasia  of  which  it  is  one  of  the  local  manifestations, 
requires  remedies  appropriate  for  the  blood  disease.  Scrofula  needs  the 
syrup  of  the  iodide  of  iron  and  cod-liver  oil.  The  various  ferruginous  prepa- 
rations, as  wine  of  iron,  tincture  of  the  chloride  of  iron,  iron  lozenges,  and 
the  vegetable  tonics  are  also  more  or  less  useful.  The  diet  should  be  nutri- 
tious and  plain,  and  outdoor  exercise  and,  if  possible,  country  life  should  be 
enjoined. 

If  the  dyscrasia  be  syphilitic,  similar  invigorating  measures  are  required, 
and  mild  mercurial  inunctions  to  the  nasal  surface  are  especially  useful.  The 
following,  which  has  been  largely  employed  in  the  Out-door  Department  at 
Bellevue,  is  one  of  the  best  ointments  for  such  cases,  and  its  alterative  efi'ect 
renders  it  also  useful  for  strumous  coryza : 

R.  Ung.  hydrarg.  nitratis,  ^ij  ; 

Ung.  zinci  oxid.,  §ij.     Misce. 

To  be  thoroughly  applied  to  the  Schneiderian  membrane  by  a  swab  or  cam- 
el's-hair  pencil  three  or  four  times  daily.  Recently  it  has  been  modified  by 
the  substitution  of  Squibb's  5  percent,  oleate  of  mercury  in  place  of  the  citrine 
ointment.  If  the  coryza  have  a  distinctly  syphilitic  origin,  the  application 
of  a  2  or  3  per  cent,  oleate  of  mercury  will  fully  meet  the  indication  and  be 
followed  by  improvement. 

Meigs  and  Pepper  recommend  the  following  ointment  in  chronic  coryza,  to 
be  applied  at  nighi  after  the  use  of  injections  through  the  day : 

R.  Unguenti  hydrargyri  nitratis,  ^ss  ; 

Extracti  belladonnje,  gr.  x  ; 

Axungise,  §ss.    Misce. 

Astringent  injections  into  the  nostrils  are  not  often  required  in  the  treat- 
ment of  the  various  forms  of  coryza ;  but  occasionally,  if  the  discharge  be 
protracted  and  abundant,  weak  astringent  applications  may  be  beneficial,  as 
two  or  three  grains  of  nitrate  of  silver  or  of  alum  or  tannin  to  the  ounce  of 
water.  It  should  be  borne  in  mind  that  washes  for  the  nasal  surface  should, 
as  a  rule,  be  employed  tepid. 


644  LARYNGITIS. 


CHAPTER    II. 

LAKYNGITIS. 

Catarrhal  Laryngitis. 

Acute  catarrhal  larjrngitis  occurs  at  all  ages,  but  it  is  so  common  in 
infancy  and  childhood  that  it  is  proper  to  treat  of  it  in  a  work  relating  to  the 
diseases  of  these  periods.  Like  other  inflammatory  affections  of  the  air-pas- 
sages, it  is  most  common  in  the  cold  months  or  when  the  weather  is  change- 
able. Its  usual  cause  is,  therefore,  exposure  to  cold.  Protracted  and  violent 
crying  and  the  inhalation  of  acrid  vapors  are  occasional  causes.  Catarrhal — 
or,  as  it  is  sometimes  designated,  simple — laryngitis  also  occurs  in  connection 
with  certain  constitutional  diseases,  among  which  may  be  mentioned  measles, 
scarlatina,  and  variola.  Laryngitis  is  also  a  common  accompaniment  of 
bronchitis  and  broncho-pneumonia,  though  its  symptoms  are  liable  to  be 
obscured  by  those  of  the  graver  disease.  It  often  likewise  accompanies 
pharyngitis,  due  to  extension  of  the  inflammation. 

Symptoms. — Catarrhal  laryngitis  produced  by  the  impression  of  cold  is 
commonly  preceded  by  and  accompanied  by  coryza.  The  initial  symptom 
is  chilliness,  followed  by  sneezing  and  the  discharge  of  thin  mucus  from  the 
nostrils  in  consequence  of  irritation  of  the  Schneiderian  membrane. 

The  commencement  of  laryngitis  is  indicated  by  hoarseness,  which  is 
apparent  when  the  child  cries  or,  if  old  enough,  when  it  attempts  to  speak. 
There  is  often  in  severe  cases  complete  loss  of  voice,  so  that  speech  above  a 
whisper  is  impossible.  I  have  noticed  this  most  frequently  in  the  laryngitis 
which  accompanies  measles.  A  cough  occurs  which  is  at  first  dry  and  husky, 
but  becomes  loose  in  the  course  of  a  few  days.  Expectoration  is  scanty, 
unless  the  inflammation  have  extended  to  the  trachea  and  bronchial  tubes. 

This  disease  is  often  accompanied  by  soreness  of  the  throat,  noticed  in  the 
act  of  coughing  or  when  the  larynx  is  pressed  with  the  finger.  In  laryngeal 
catarrh,  when  uncomplicated,  the  respiration  remains  nearly  natural  and  the 
pulse  is  but  little  accelerated.  In  mild  cases  the  nature  of  the  disease  is 
often  not  apparent,  as  long  as  the  child  remains  quiet,  in  consequence  of  the 
absence  of  symptoms,  but  the  character  of  the  voice  when  it  cries  or  speaks, 
or  of  the  cough,  reveals  at  once  the  nature  of  the  affection. 

Acute  laryngeal  catarrh  subsides  in  from  one  to  two  weeks.  Occasion- 
ally it  lasts  three  or  four  weeks  before  the  symptoms  entirely  disappear. 
Death,  which  is  rare,  is  due  to  some  complication. 

Chronic  laryngitis  is  much  less  frequent  than  the  acute  form.  Its 
anatomical  characters  are  similar  to  those  in  other  chronic  inflammations 
affecting  mucous  surfaces — to  wit,  thickening  and  more  or  less  infiltration 
of  the  mucous  membrane,  increased  pi'oliferation  and  exfoliation  of  the  epi- 
thelial cells,  and  increased  functional  activity  of  the  muciparous  follicles. 

In  the  adult,  chronic  laryngitis  is  common  as  one  of  the  lesions  of  the 
syphilitic  or  tubercular  disease.  In  the  child,  syphilitic  and  tubercular  laryn- 
gitis is  more  rare,  but  the  latter  sometimes  occurs  in  connection  with  pulmo- 
nary or  bronchial  tuberculosis.  Such  patients  are  emaciated  and  have  the 
ordinary  symptoms  of  the  tubercular  disease.  Chronic  laryngitis  also  occurs 
in  young  children,  usually  infants,  as  one  of  the  manifestations  of  the  stru- 
mous diathesis.     I  have  records  of  several  such  cases,  mostly  nursing  infants. 


CATARRHAL  LARYNGITIS.  645 

Some  of  these  patients  had  mild  bronchitis,  but  it  was  obviously  subordinate 
to  the  laryngitis.  Their  respiration  was  noisy  and  harsh,  continuing  of  this 
character  several  weeks  and  even  months.  The  cough  was  also  harsh  and 
loud,  conveying  the  idea  of  thickening  and  relaxation  of  the  mucous  mem- 
brane covering  the  vocal  cords.  Their  respiration  was  not  notably  accelerated 
and  the  blood  was  apparently  fully  oxygenated,  though  the  friends  were  often 
alarmed  by  the  noisy  breathing  and  cough. 

In  this  form  of  chronic  laryngitis  expectoration  is  scanty,  the  fever  slight 
or  absent,  the  appetite  remains  unimpaired,  and  the  general  condition  of  the 
child  is  good.  From  time  to  time  exacerbations  occur,  and  occasionally 
improvement  is  such  as  to  encourage  the  hope  of  speedy  cure ;  but  in  the 
cases  which  I  have  seen  there  has  not  been  complete  intermission  in  the  dis- 
ease till  the  final  recovery.  Those  patients  whom  I  have  been  able  to  follow 
through  the  disease  have  recovered  in  from  three  or  four  months  to  one  year. 

Chronic  laryngitis  is  to  be  distinguished  from  frequent  attacks  of  acute 
laryngitis  which  are  due  to  fresh  exposures,  and  also  from  the  laryngitis 
which  is  associated  with  bronchial  phthisis.  It  is  to  be  distinguished  from 
protracted  acute  laryngitis,  which  sometimes  does  not  entirely  subside  in  less 
than  a  month  or  six  weeks,  by  its  longer  duration,  the  greater  thickening  of 
the  inflamed  membrane,  and  more  noisy  respiration.  Often  chronic  laryngitis 
results  from  the  acute  disease,  the  inflammation  being  perpetuated  by  the 
struma  or  dyscrasia  of  the  patients. 

Anatomical  Characters. — In  acute  catarrhal  laryngitis  the  mucous 
membrane  of  the  larynx  presents  the  usual  appearances  of  mucous  surfaces 
when  inflamed — namely,  redness  and  thickening.  It  is  also  more  or  less  soft- 
ened. Ulcerations  rarely,  perhaps  never,  occur  in  primai'y  acute  laryngitis. 
When  present  in  chronic  laryngitis  the  ulcers  are  small  and  situated  upon  or 
near  the  vocal  cords.  Tubercular  and  syphilitic  ulcers  of  the  larynx  are  much 
more  rare  in  children  than  in  adults.  The  inflammation  in  simple  acute  laryn- 
gitis usually  extends  over  the  whole  surface  of  the  larynx  and  also  to  the 
upper  part  of  the  trachea.  It  may  be  pretty  uniform  or  more  intense  in  one 
place  than  another,  and,  like  other  mucous  inflammations,  it  is  accompanied 
by  more  or  less  proliferation  and  exfoliation  of  epithelial  cells.  In  most  cases 
of  simple  laryngitis,  whether  acute  or  chronic,  the  inflammation  extends  to  the 
pharynx,  producing  redness  and  thickening,  though  generally  moderate,  of 
the  mucous  membrane  which  covers  it.  Examination  of  the  fauces  therefore 
aids  in  diagnosis. 

In  the  adult  oedema  glottidis  occasionally  results  from  laryngitis.  In  the 
child  there  is  little  danger  that  this  will  occur,  in  consequence  of  the  anatom- 
ical character  of  the  larynx,  since  in  early  life  the  larynx  contains  but  little 
submucous  connective  tissue,  and  therefore  less  submucous  infiltration  or 
exudation  occurs  during  the  inflammation.  The  structural  changes  occurring 
in  catarrhal  laryngitis  of  infancy  and  childhood  relate  almost  exclusively  to 
the  mucous  membrane. 

Treatment. — Primary  and  uncomplicated  catarrhal  laryngitis  requires 
little  treatment.  Most  cases  do  well  by  the  employment  of  suitable  hygienic 
measures,  without  medicines.  Benefit  is,  however,  derived  from  the  use  of 
demulcent  drinks  and  an  occasional  laxative.  A  mixture  of  paregoric  and 
syrup  of  ipecacuanha  or  the  mist,  glycyr.  comp.  or  a  small  Dover's  powder 
will  relieve  the  cough.  For  restlessness  a  warm  foot-bath  is  also  useful. 
Inhalation  of  the  spray  of  glycerin  and  water  from  the  atomizer,  or  of  steam, 
plain  or  medicated,  is  also  useful.  Mildly  stimulating  embrocations,  as  by 
camphorated  oil  with  or  without  a  little  turpentine,  also  aid.  It  should  be 
rubbed  several  times  daily  over  the  throat,  or  a  strip  of  flannel  soaked  with  it 
may  be  applied  around  the  neck.     Chronic  laryngitis  dependent  on  syphilis 


646  LARYNGITIS. 

or  tuberculosis  requires  the  constitutional  treatment  which  is  appropriate  for 
that  disease.  Measures  not  specific  have  little  effect  upon  this  form  of  inflam- 
mation. The  chronic  laryngitis  which  I  have  described  as  occurring  chiefly 
in  infancy,  and  which  appears  to  be  of  a  strumous  character,  is  in  most  cases 
obstinate.  The  patient  should  be  warmly  clothed,  and  constant  care  should 
be  taken  that  there  be  no  exposure  which  would  endanger  taking  cold,  as  this 
would  produce  an  exacerbation  of  the  disease  and  tend  to  counteract  what  had 
been  gained  by  remedial  measures.  This  form  of  chronic  laryngitis  is  most 
satisfactorily  treated  by  the  application  of  tincture  of  iodine  upon  the  neck 
directly  over  the  larynx,  and  the  internal  use  of  cod-liver  oil  and  the  syrup 
of  the  iodide  of  iron. 

Spasmodic  Laryngitis. 

This  is  a  common  disease.  It  is  also  called  false  croup,  in  contradistinc- 
tion to  true  or  pseudo-membranous  croup,  and  by  some  continental  writers 
stridulous  angina  or  stridulous  laryngitis.  It  should  not  be  confounded  with 
spasm  of  the  glottis,  which  is  a  form  of  internal  convulsions  and  is  not 
inflammatory.  It  occurs  ordinarily  between  the  ages  of  two  and  five  years. 
It  is  commonly  a  sporadic  affection,  but  Rilliet  and  Barthez  state  that  "  it  is 
incontestable  that  it  may  prevail  epidemically."  They  express  this  opinion, 
not  from  their  own  observations,  but  chiefly  from  those  of  Jurine,  made  in 
the  commencement  of  the  present  century. 

Causes. — Children  in  some  families  are  more  liable  to  false  croup  than  in 
others,  so  that  an  hereditary  tendency  to  it  must  be  admitted.  The  exciting 
cause  in  most  cases  is  exposure  to  cold.  False  croup  is  not  uncommon  in  the 
commencement  of  measles.  Narrowness  of  the  rima  glottidis  and  an  excita- 
ble state  of  the  nervous  system,  both  of  which  are  common  in  early  childhood, 
are  predisposing  causes. 

Symptoms. — Spasmodic  laryngitis  is  ordinarily  preceded  for  a  day  or  two 
by  a  slight  cough  and  fever,  by  symptoms  of  mild  nasal  catarrh,  such  as  all 
children  are  liable  to  on  taking  cold.  In  exceptional  cases  these  symptoms 
are  absent  and  the  disease  begins  abruptly.  Singularly,  it  commences  in 
most  patients  at  night  after  the  first  sleep,  between  ten  and  twelve  o'clock. 
The  sleep  is  usually  quiet  and  natural,  but  the  child  awakens  with  a  loud, 
barking  cough.  There  is  great  dyspnoea,  and  the  respiration  is  harsh  or 
whistling,  on  account  of  the  narrowing  of  the  chink  of  the  glottis  from  the 
swelling  and  tension  of  the  vocal  cords.  The  face  is  flushed  and  expressive 
of  suffering.  The  child  cries,  moves  from  one  position  to  another,  wishes  to 
be  held  or  carried,  seeking  in  vain  for  relief.  The  skin  is  hot,  pulse  acceler- 
ated, the  voice  hoarse  or  even  whispering.  After  a  variable  period,  usually 
from  half  an  hour  to  two  or  three — not  more  than  half  an  hour  with  proper 
treatment — these  symptoms  abate.  The  patient  is  then  somewhat  exhausted 
and  falls  asleep.  The  face  is  less  flushed  or  even  pallid,  the  heat  abates,  and 
the  pulse  is  less  accelerated.  The  cough,  though  less  frequent,  remains  for 
a  time  barking  or  sonorous,  and  respiration,  though  greatly  relieved,  is  not  at 
once  entirely  natural,  but  it  gradually  becomes  so.  In  many  cases  the  spas- 
modic respiration  and  cough  do  not  recur,  but  sometimes  the  attack  is  repeated 
once  or  more,  especially  during  the  subsequent  nights.  The  symptoms  vary 
greatly  in  intensity  in  different  patients. 

As  the  attack  declines  the  disease,  losing  its  spasmodic  character,  becomes 
a  simple  inflammation.  In  some  patients  the  abatement  of  the  cough  and 
restoration  of  health  are  rapid,  but  oftener  the  inflammation  extends  not  only 
into  the  trachea,  but  also  into  the  larger  bronchial  tubes,  and  a  tracheo-bron- 
chitis  remains,  which  gradually  declines. 


SPASMODIC  LARYNGITIS.  647 

The  termination  is  not  always  so  favorable.  Spasmodic  laryngitis  is,  in 
exceptional  instances,  the  precursor  of  other  serious  affections,  which  may 
prove  fatal.  It  has  been  stated  that  measles  often  begins  with  spasmodic 
laryngitis.  Bronchitis,  becoming  capillary,  may  occur  in  connection  with  it, 
as  may  also  pneumonia,  and  by  either  of  these  severe  inflammations  the 
prognosis  may  be  rendered  doubtful.  A  few  cases  have  been  recorded  in 
which  it  was  believed  that  spasmodic  laryngitis  was  of  itself  fatal.  In  some 
of  these  the  dyspnoea  was  ex'treme  and  persistent  and  was  the  cause  of  death. 
In  a  case  reported  by  Ilogery,  on  the  other  hand,  the  respiration  became  easy 
before  death  and  the  pulse  more  and  more  frequent  and  feeble.  Death 
apparently  occurred  from  exhaustion.  It  is  not  improbable  that  had  careful 
post-mortem  examinations  been  made  in  those  cases  of  spasmodic  laryngitis 
which  have  ended  fatally,  other  lesions  would  have  been  discovered  besides 
those  located  in  the  larynx,  perhaps  tracheo-bronchitis,  with  an  accumulation 
of  mucus  in  the  larynx,  producing  sufi'ocation,  or  perhaps  in  some  of  the  cases 
congestion  of  the  brain  or  lungs  and  serous  effusion. 

Anatomical  Characters  ;  Pathology. — The  opportunity  does  not 
often  occur  of  determining  the  anatomical  characters  of  spasmodic  laryngitis. 
I  have  witnessed  but  one  post-mortem  examination.  A  little  girl  nine  years 
old  was  taken  on  Frida}'^  night  with  cough  and  dyspnoea,  indicating  a  pretty 
severe  attack.  The  mother,  acting  through  the  advice  of  a  friend,  gave 
kerosene  oil  to  her  in  considerable  quantity.  This  was  succeeded  by  obstinate 
vomiting  and  purging,  which  continued  during  Saturday  and  Sunday  and 
terminated  fatally  on  Monday.  At  the  autopsy  we  found  uniform  and 
intense  injection  throughout  the  whole  extent  of  the  larynx  and  trachea  and 
in  the  bronchial  tubes,  but  there  was  no  pseudo-membrane  on  the  inflamed 
surface  and  but  little  mucus  and  pus.  The  solitary  follicles  of  the  intestines 
and  Peyer's  patches  were  tumefied,  and  the  gastro-intestinal  surface  vpas 
injected  in  places.  The  cause  of  death  was  obviously  the  diarrhoea,  appar- 
ently of  an  inflammatory  character,  and  probably  produced  by  the  kerosene 
oil.  The  condition  of  the  mucous  membrane  of  the  larynx  was  that  which 
is  ordinarily  present  in  spasmodic  laryngitis,  though  in  some  cases  in  which 
post-mortem  examinations  have  been  made  the  evidences  of  laryngeal  inflam- 
mation were  slight.  Guersant  relates  a  ease  in  which  the  surface  of  the 
larynx  seemed  to  be  nearly  in  its  normal  state.  Death  in  cases  of  slight 
laryngitis  is  due  to  causes  which  are  independent  of  the  larynx.  In  Guer- 
sant's  case  tuberculosis  was  present. 

There  is,  as  has  already  been  intimated,  another  and  a  more  important  ele- 
ment besides  the  inflammation  in  the  pathology  of  spasmodic  laryngitis — 
an  element  producing  those  phenomena  which  render  it  a  disease  distinct  from 
simple  laryngitis.  I  refer  to  spasm  of  the  laryngeal  muscles.  This  element 
pertains  to  the  nervous  system,  so  that  spasmodic  laryngitis  is  allied  both  to 
the  neuroses  and  to  inflammation. 

Diagnosis. — The  disease  for  which  spasmodic  laryngitis  is  most  fre- 
quently mistaken  is  pseudo-membranous  croup.  The  friends,  indeed,  usually 
make  this  mistake  in  forming  their  opinion  of  the  case  before  the  physician 
arrives  ;  and  there  can  be  no  doubt  that  many  of  the  cases  which  have  been 
published  in  medical  journals  as  true  croup  were  examples  of  this  aff'ection. 
The  points  of  diff"erential  diagnosis  are  the  following  :  True  croup  begins 
with  symptoms  which  at  first  are  slight,  so  as  scarcely  to  arrest  attention, 
but  which  gradually  increase  in  intensity.  The  cough  becomes  more  harsh 
and  the  respiration  more  difficult  by  degrees.  This  increase  in  the  gravity  of 
the  symptoms  occurs  by  day  as  well  as  by  night.  On  the  other  hand,  false 
croup,  though  preceded  by  symptoms  of  nasal  catarrh,  commences  abruptly. 
The  symptoms  have  from  the  first  their  maximum  intensity,  and  the  time  at 


648  LARYNGITIS. 

which  it  commences  is  at  night.  Again,  the  cough  in  spasmodic  laryngitis 
possesses  a  loud,  sonorous  character,  while  in  true  croup  it  is  harsh  or  rough 
from  the  presence  of  the  membrane,  and  having,  therefore,  less  fulness. 
The  voice  in  spasmodic  laryngitis  may  be  hoarse,  but  it  is  not  lost  or  is  lost 
only  for  a  short  time.  It  afterward  becomes  natural  or  is  slightly  hoarse. 
On  the  other  hand,  in  true  croup  the  voice,  from  being  natural  at  first,  is 
gradually  extinguished.  In  fatal  cases  it  soon  becomes  whispering,  and  con- 
tinues such  till  the  close  of  life ;  in  those  that  recover  the  voice  remains 
hoarse  several  days.  These  differences  are  important,  and  if  fully  appre- 
ciated are  in  most  instances  sufficient  to  establish  the  diagnosis.  Besides,  in  a 
large  proportion  of  eases  of  true  croup  portions  of  the  pseudo-membrane  may 
be  discovered  on  inspecting  the  fauces,  and  the  faucial  surface  is  deeply 
injected,  while  in  spasmodic  laryngitis  there  is,  with  rare  exceptions,  no 
false  membrane  upon  the  surface  of  the  fauces  and  but  a  moderate  amount 
of  congestion. 

Laryngismus  stridulus  or  internal  convulsions  must  not  be  confounded 
with  this  disease.  It  is  not  inflammatory,  but  purely  spasmodic,  suddenly 
commencing  and  abating — identical,  it  is  believed,  in  character  with  tonic 
convulsions  of  the  external  muscles,  but  affecting  the  internal  muscles  of 
respiration.     This  disease  has  already  been  fully  described. 

Prognosis. — Little  need  be  added,  as  regards  prognosis,  to  what  has 
already  been  stated.  While  a  favorable  opinion  in  reference  to  the  result 
may  ordinarily  be  expressed,  the  physician  should  not  forget  the  fact  that 
death  may  occur.  Symptoms  indicating  an  unfavorable  termination  are — 
great  and  continued  dyspnoea,  not  diminished  by  the  proper  remedial  mea- 
sures ;  stridulous  expiration  as  well  as  inspiration ;  lividity  of  the  prolabia 
and  fingers ;  pallor  and  coldness  of  surface ;  pulse  progressively  more 
frequent  and  feeble.  Convulsions  and  coma  mav  also  occur  near  the  close 
of  life. 

Treatment. — The  indications  of  treatment  are  twofold :  first,  to  relieve 
the  spasmodic  action  of  the  laryngeal  muscles ;  secondly,  to  cure  the  laryn- 
gitis. To  meet  the  first  indication  a  warm  bath  of  the  temperature  of  about 
100°  should  be  employed  as  soon  as  possible  after  the  commencement  of  the 
attack.  The  patient  should  be  kept  in  it  ten  or  fifteen  minutes,  in  order  to 
obtain  its  full  relaxing  effect.  In  mild  cases  a  warm  foot-bath  may  be  suf- 
ficient. A  second  means  is  the  use  of  an  emetic,  which  should  be  simulta- 
neous with  the  bath.  To  children  under  the  age  of  three  years  syrup  of 
ipecacuanha  should  be  given,  in  doses  of  one  teaspoonful  repeated  in  twenty 
minutes,  till  vomiting  occurs.  Children  over  the  age  of  three  years,  unless 
of  feeble  constitution,  are  best  treated  by  the  compound  syrup  of  squills  in 
teaspoonful  doses,  or  a  mixture  of  this  with  syrup  of  ipecacuanha.  It  is  not 
often  necessary  to  give  more  than  three  or  four  doses,  and  sometimes  one  or 
two  are  sufficient  to  produce  vomiting. 

In  most  cases  by  the  use  of  the  warm  bath  and  the  emetic  the  symptoms 
are  rendered  milder,  and  convalescence  soon  commences. 

Dr.  R.  R.  Livingstone  ^  reports  a  case  of  laryngitis  treated  by  Squibb 's 
ether.  It  is  stated  that  portions  of  pseudo-membrane  from  one-eighth  to 
three-fourths  of  an  inch  in  length  were  expectorated ;  but  the  symptoms 
certainly  indicated  a  spasmodic  element  as  decided  as  in  spasmodic  croup, 
and  the  benefit  from  the  ether  was  apparently  due  to  the  relaxation  of 
the  laryngeal  muscles  which  it  produced.  The  treatment  of  the  patient, 
who  was  two  years  old,  was  commenced  by  the  administration  by  the  mouth 
of  half  a  teaspoonful  of  the  ether,  and  followed  by  its  inhalation.  "  In  pre- 
cisely eight  minutes  from  the  time  the  patient  commenced  the  inhalation  the 

^  American  Journal  of  the  Medical  Sciences,  April,  1867. 


SPASMODIC  LARYNGITIS.  649 

abnormal  muscular  exertion  ceased ;  a  general  relaxation  took  place ;  the 
pulse  (which  had  numbered  150)  fell  to  100."  Kther,  judiciously  employed, 
will  probably  prove  to  be  a  useful  remedial  agent  in  spasmodic  forms  of 
laryngitis,  whether  or  not  it  have  any  effect  on  pseudo-membranous  forma- 
tions. A  large  majority  of  cases,  however,  recover  speedily  without  its  em- 
ployment or  by  the  other  measures    recommended. 

Attention  should  always.be  given  to  the  state  of  the  bowels  in  spasmodic 
laryngitis ;  if  they  arc  not  well  open  a  purgative  should  be  administered. 
For  those  that  are  robust  and  with  considerable  febrile  movement  the  saline 
cathartics  are  ordinarily  preferable,  as  Rochelle  salts,  or  a  purgative  dose 
of  calomel  may  be  administered.  The  cathartic  should  not  be  prescribed 
till  the  nausea  from  the  emetic  has  subsided.  By  its  derivative  effect  it 
tends  to  diminish  the  laryngitis,  and  in  severe  cases  it  may  obviate  the 
need  of  depletion  by  leeches. 

Inhalation  of  the  vapor  of  hot  water  and  the  application  of  a  sinapism 
over  the  neck  and  upper  part  of  the  sternum,  followed  by  an  emollient  poul- 
tice, are  useful  adjuvants  to  treatment. 

The  most  convenient  and  effectual  way  of  employing  vapor  is,  however, 
by  the  atomizer,  and  as  the  chief  danger  is  that  the  inflammation  may 
become  pseudo-membranous,  I  am  in  the  habit  of  using  in  the  atomizer  the 
ofiicinal  lime-water,  its  solvent  action  being  increased  by  the  addition  of  the 
sodium  bicarbonate,  two  drachms  to  the  pint. 

When  the  spasmodic  element  in  the  disease  is  relieved  the  case  becomes 
one  of  simple  laryngitis,  and  the  general  plan  of  treatment  I'ecommended  for 
that  malady  is  proper  for  this.  Small  doses  of  ipecacuanha  or  of  one  of  the 
antimonial  preparations,  as  the  compound  syrup  of  squills,  not  sufficient  to 
cause  nausea,  should  now  be  given  at  regular  intervals.  Antipyrine  or  phen- 
acetin,  given  every  third  hour  in  doses  of  half  a  grain,  one  grain,  or  one  and 
a  half  grains,  is  a  useful  remedy  if  the  temperature  reach  103°.  Its  effect 
should  be  watched,  and  it  should  be  discontinued  when  its  sedative  influence 
on  the  circulation  begins  to  be  apparent. 

If,  however,  the  disease  do  not  speedily  terminate  by  recovery,  or  more 
rarely  by  death,  there  is  nearly  always  tracheo-bronchitis  or  a  more  serious 
affection  coexisting  with  the  laryngitis  or  following  it,  so  that  depi'essing 
measures  should  not  be  long  continued.  Expectorants  of  a  stimulating 
character,  as  carbonate  of  ammonium,  are  required  in  the  course  of  a  few 
days,  and  in  young  and  feeble  children  they  should  be  given  at  an  early 
period. 

The  mode  of  treatment  recommended  above  is  appropriate  for  that  large 
class  in  whom  the  inflammatory  element  predominates.  In  a  smaller  number 
of  cases  the  nervous  element  predominates  over  the  inflammatory,  and  the 
treatment  should  be  in  some  respects  different.  Such  children  are  usually 
pallid  and  of  spare  habit,  having,  indeed,  the  nervous  temperament.  They 
are  liable  to  attacks  of  this  disease,  though  generally  of  a  mild  form,  on 
slight  exposure  to  cold,  and  with  a  very  moderate  amount  of  inflammation. 
The  treatment  in  these  cases  should  be  directed  more  to  the  nervous  system. 
My  plan  has  been  in  the  treatment  of  such  patients,  after  perhaps  the  use  of 
a  mild  emetic,  to  give  quinine,  one  grain  three  or  four  times  daily,  to  a  child 
from  three  to  five  years  old,  prescribing  at  the  same  time  a  simple  expector- 
ant and  a  mildly  irritating  application  to  the  throat.  The  symptoms  in  these 
cases  are  not  severe  and  active  measures  are  not  required,  though  the  peculiar 
cough  continues  longer  than  in  the  more  inflammatory  forms  of  the  malady. 
The  patient  with  spasmodic  laryngitis  should  be  kept  in  a  warm  room 
during  the  paroxysms,  and  should  inhale  an  atmosphere  loaded  with 
moisture. 


650  MEMBRANOUS  CROUP. 

Trousseau  recommends  a  mode  of  treatment  of  spasmodic  laryngitis  which 
was  first  suggested  by  Graves  of  Dublin.  It  consists  in  the  application 
underneath  the  chin,  so  as  to  cover  the  larynx,  of  a  sponge  soaked  in  water 
as  hot  as  can  be  borne ;  in  ten  or  fifteen  minutes  it  is  repeated.  This  red- 
dens the  skin,  producing  revulsion  from  the  larynx.  The  hoarseness, 
dyspnoea,  and  cough  diminish  with  this  treatment,  and  some  recover  without 
other  measures. 

In  rare  cases  of  spasmodic  laryngitis  the  dyspnoea  becomes  so  great,  not- 
withstanding active  treatment,  that  the  life  of  the  patient  is  in  danger 
whether  oedema  glottidis  or  thickening  and  infiltration  of  the  laryngeal 
mucous  membrane  be  present.  In  these  cases  intubation  with  O'Dwyer's 
tubes  will  give  prompt  relief.  Spasmodic  contraction  of  the  laryngeal  mus- 
cles probably  also  occurs  in  these  cases,  increasing  the  dyspnoea.  Recently, 
in  the  case  of  a  child  of  about  three  years,  the  dyspnoea  was  so  great  in 
about  three  hours  from  the  commencement  that  intubation  was  performed 
with  immediate  relief. 

Guersant  and  others  speak  of  the  importance  of  prophylactic  management 
of  children  who  are  liable  to  this  disease.  Attention  should  be  given  to  the 
dress,  so  that  there  may  be  sufiicient  protection  from  atmospheric  changes, 
and  there  should  be  an  equable  temperature  of  the  apartments  in  which  they 
reside.  Children  of  a  decidedly  nervous  temperament,  in  whom  the  slightest 
laryngitis  is  liable  to  be  spasmodic,  require  additional  prophylactic  measures. 
They  are  pallid  and  in  a  moi'e  or  less  cachectic  state.  Such  children  are 
benefited  by  chalybeate  and  vegetable  tonics  and  by  exercise  in  suitable 
weather  in  the  open  air. 


CHAPTER    III. 

MEMBEANOUS  CEOUP  (DIPHTHEEITIC  CEOUP ;  TEUE  CEOUP). 

The  term  pseudo-membranous  laryngitis  or  laryngo-tracheitis  or  true 
croup  is  applied  to  a  common  and  fatal  disease,  the  essential  anatomical 
character  of  which  is  inflammation  of  the  larynx  or  larynx  and  trachea,  with 
the  formation  of  a  pseudo-membrane  upon  its  surface.  It  occurs  most  fre- 
quently between  the  ages  of  two  and  twelve  years,  but  infancy  after  the  age 
of  six  months  and  early  manhood  are  not  exempt  from  it.  For  brevity  I 
shall  use  the  term  croup  in  the  following  pages  to  indicate  this  form  of 
inflammation,  although  recognizing  another  form  of  croup,  the  spasmodic  or 
catarrhal,  in  which  no  pseudo-membrane  occurs. 

Etiology. — Wherever  diphtheria  prevails  as  an  endemic  or  epidemic  it  is 
well  known  that  a  large  majority  of  the  cases  of  membranous  croup  are  local 
manifestations  of  this  disease,  and  this  inflammation  is  therefore  in  such 
localities  commonly  designated  diphtheritic  croup.  Physicians  have  endeav- 
ored to  discriminate  between  croup  due  to  diphtheria  and  that  from  other 
causes  ;  but,  whatever  the  cause,  the  anatomical  characters,  the  clinical  history, 
and  the  required  treatment  are  so  nearly  identical  that  attempts  to  diff"eren- 
tiate  the  disease  when  produced  by  other  agencies  than  diphtheria  from  that 
due  to  diphtheria  have  proved  futile  and  unsatisfactory  in  localities  where 
diphtheria  occurs,  except  in  a  few  instances ;  as,  for  example,  when  croup 
has  been  manifestly  caused  by  swallowing  or  inhaling  some  irritating  agent. 

Inflammation  of  the  laryngeal  and  tracheal  surface,  whatever  its  cause, 


ETIOLOGY.  G51 

whenever  it  reaches  a  certain  grade  of  severity  may  be  attended  by  the 
exudation  of  fibrin  and  the  formation  of  a  pseudo-membrane ;  but  sucli  a 
result  more  frecjuently  occurs  in  the  inflammation  caused  by  diphtheria  tlian 
in  that  produced  by  other  agencies.  In  diplitheria  a  moderate  laryngo- 
tracheitis  is  attended  by  the  pseudo-membranous  formation. 

The  percentage  of  cases  of  diphtheria  in  whicli  the  larynx  becomes 
implicated  and  croup  occurs  varies  in  different  epidemics  and  in  different 
seasons  and  localities.  In  epidemics  of  a  mild  type  the  cases  appear  to  be 
fewer  in  which  the  larynx  is  involved  than  in  epidemics  of  a  severe  form. 
In  New  York  the  percentage  is  large.  From  December  1,  1875,  to  July, 
1878,  I  preserved  records  of  all  the  cases  of  diphtheria  which  came  under 
my  notice.  The  number  was  104,  and  in  25  of  these,  or  about  1  in  4,  croup 
occurred,  producing  the  usual  obstructive  symptoms  and  constituting  the 
chief  source  of  danger.  During  the  two  and  a  half  years  embraced  in  these 
statistics  the  disease  was  usually  severe.  Subsequently  amelioration  occurred 
in  the  type  of  diphtheria  in  this  city,  and  the  proportion  of  croup  cases  has 
not  been  so  large. 

So  commonly  is  membranous  croup,  when  occurring  in  a  locality  where 
•diphtheria  is  endemic  or  epidemic,  a  local  manifestation  of  diphtheria  that 
physicians  in  such  localities  come  to  regard  every  case  of  this  disease  of  the 
larynx  as  produced  by  the  diphtheritic  poison.  In  New  York  physicians 
scarcely  recognize  any  other  form  of  membranous  croup.  It  is  well,  there- 
fore, briefly  to  recall  the  evidences  that  croup  in  a  certain  proportion  of  cases 
results  from  other  causes  than  diphtheria.  The  occurrence  of  croup  in  locali- 
ties where  diphtheria  is  unknown  of  course  indicates  the  operation  of  some 
other  agency  than  the  diphtheritic  poison.  Thus,  in  1842,  before  diphtheria 
was  established  in  this  country,  Dr.  John  Ware  of  Boston  published  his  well- 
known  paper  on  croup,  and  in  74  of  the  75  cases  embraced  in  his  statistics 
the  membranous  exudation  was  present  upon  the  faucial  surface.  The  sta- 
tistics relating  to  the  introduction  of  diphtheria  into  New  York  City  and  the 
recorded  death-statistics  of  this  city  have  been  annually  published,  and  each 
year  more  or  fewer  deaths  from  croup  have  been  reported.  The  first  death 
from  diphtheria  in  this  century  within  the  city  limits,  certified  by  a  physician, 
was  that  of  a  German  woman  at  638  Hudson  street  on  February  15,  1852. 
Two  other  fatal  cases  occurred  in  1857,  and  since  then  the  deaths  from  croup 
and  diphtheria  have  been  as  presented  in  the  following  table  : 

Year.                           Croup.  Diphtheria.  Year.                            Croup.  Diphtheria. 

1858 478  5  1867 338  251 

1859 622  53  1868 342  276 

1860 599  422  1869 483  328 

1861 460  453  1870 421  308 

1862 685  594  1871 466  238 

1863 908  981  1872 675  446 

1864 754  781  1873 732  1151 

1865 449  534  1874 594  1665 

1866 368  435  1875 758  2329 

Since  1875  weekly  bulletins  have  been  issued  instead  of  the  annual  reports. 

Thus,  in  the  first  years  after  the  introduction  of  diphtheria  the  deaths 
assigned  to  croup  so  greatly  outnumbered  those  of  diphtheria,  as  in  1858, 
when  5  died  of  diphtheria  and  478  of  croup,  that  it  is  evident  that  most  of 
the  cases  of  croup  in  those  years  were  attributable  to  other  causes  than  diph- 
theria. Since,  as  we  have  stated,  any  inflammation  of  the  surface  of  the 
larynx  and  trachea,  if  sufficiently  intense,  may  produce  a  pseudo-membrane, 
croup  may  occur  as  a  primary  disease  and  as  a  complication  of  various  mal- 


652  MEMBRANOUS  CROUP. 

adies.  According  to  my  observations  in  New  York  City,  the  chief  causes  of 
croup,  arranged  in  the  order  of  frequency,  would  be  about  as  follows :  Diph- 
theria, "  taking  cold,"  measles,  pertussis,  scarlatina,  typhoid  fever,  irritating 
inhalations.  I  have  elsewhere  related  cases  of  scarlet  fever  of  severe  type  in 
which  a  thin  film  of  pseudo-membrane  was  found  upon  the  surface  of  the 
larynx  and  trachea,  and  there  was  no  other  lesion  to  indicate  that  diphtheria 
had  supervened.  The  croup  was,  to  all  appearances,  caused  by  the  scar- 
latinous and  not  the  diphtheritic  poison.  The  following  was  a  case  in  which 
croup  was  apparently  idiopathic,  and  produced  by  that  common  cause  of 
inflammations  of  mucous  surfaces — to  wit,  exposure  to  sudden  atmospheric 
changes. 

Case. — At  midnight  on  October  22,  1884,  I  was  summoned  to  a  child  aged 
twenty-five  months  who  had  been  in  the  street  till  nearly  nightfall,  when  the 
weather  suddenly  became  much  cooler  and  he  was  brought  home.  At  11.45  P.  M. 
he  awoke  with  a  harsh  voice  and  croupy  cough,  so  as  to  alarm  the  family.  I 
found  the  axillary  temperature  normal,  but  the  fauces  were  injected,  and  the 
diagnosis  was  made  of  spasmodic  or  catarrhal  croup.  Emesis  was  produced  by 
syrup  of  ipecacuanha ;  the  croup  kettle  and  a  mixture  of  potassium  chlorate  and 
ammonium  chloride  were  ordered. 

On  the  following  day  he  walked  around  the  room  and  seemed  better,  but  the 
inhalation  of  the  vapor  of  lime  from  the  croup  kettle  was  continued.  At  7  P.  M. 
the  symptoms  became  aggravated,  the  cough  was  frequent  and  hoarse,  tempera- 
ture (axillary)  102|^°,  pulse  120,  and  respiration  noisy.  At  my  visit  the  post- 
clavicular,  suprasternal,  inframammary,  and  epigastric  regions  were  depressed  in 
each  inspiration,  though  only  to  a  moderate  degree ;  face  flushed ;  fauces  injected,, 
but  without  pseudo- membrane.  The  aspect  was  now  more  serious  on  account  of 
the  increasing  dyspnoea.  The  pulse  was  strong  and  no  pseudo-membrane  was 
visible ;  the  temperature  in  the  groin  was  scarcely  100°.  Emesis  had  been  pro- 
duced before  my  arrival,  and  in  the  matter  vomited  was  a  pseudo-membrane  with 
ragged  edges  and  about  one-half  an  inch  in  length ;  examined  within  an  hour 
subsequently  under  the  microscope,  it  was  found  to  consist  of  fibrillse,  evidently 
fibrinous,  some  of  them  wavy,  and  enclosing  many  pus-cells.  Ten  grains  of  cal- 
omel were  placed  on  the  tongue,  and  inhalations  of  the  following  were  almost 
constantly  employed  by  the  steam-atomizer: 

B.  Liq.  potassse,  .^ij  ; 

Aq.  calcis,  ^^ij-     Misce. 

On  the  following  day  the  respiration  was  easier,  and  within  twenty  hours  the 
patient  had  so  far  convalesced  as  to  be  out  of  danger.  There  had  been  no  case 
of  diphtheria  in  the  house,  nor  recently,  so  far  as  I  could  learn,  in  the  immediate 
neighborhood. 

That  this  was  a  local  disease,  non-specific  and  quite  distinct  from  the 
croup  of  diphtheria,  cannot,  I  think,  be  doubted. 

In  considering  the  etiology  of  croup,  and  recognizing  diphtheria  as  by  far 
its  most  common  cause  wherever  the  latter  disease  prevails,  an  interesting 
theory  is  suggested  to  which  Heubner  alludes,  who  affirms  that  infiamma- 
tions,  even  with  the  characteristic  membranous  exudation,  may  be  set  up  with- 
out the  specific  microbe  of  diphtheria,  and  then  inoculation  by  the  microbe 
occurs  and  "induces  the  general  disease.'"  The  point  alluded  to  is  that 
inflammations  arising  from  other  causes  than  diphtheria  now  and  then  become 
intensified  and  are  rendered  more  protracted  and  dangerous  by  the  reception  of 
the  diphtheritic  virus  after  the  infiammations  are  established.  In  support  of 
this  opinion  it  is  well  known  by  all  who  have  had  much  experience  with  diph- 
theria that  those  surfaces  are  prone  to  be  attacked  by  the  specific  inflamma- 

^  "Die  experimentelle  Diphtheria,"  Leipzig,  1883,  quoted  in  Ziegler's Po<Ao/.  Anat, 
part  11.  paragraph  444,  1884. 


ETIOLOGY.  653 

tion  that  are  already  irritated  or  inflamed  when    diphtheria   is    contracted. 
(This  subject  is  alluded  to  in  our  remarks  on  Diphtheria.) 

Scarlatina  is  so  often  complicated  by  diphtheria  that  there  seems  to  be  a 
close  affinity  between  the  two  disea.ses.  It  is  a  very  common  observation  in 
New  York  City  that  scarlet  fever  continues  two  or  three  days  in  its  usual 
form,  when  the  symptoms  become  suddenly  aggravated  and  the  a.spect  of  the 
disease  more  severe.  On  inspecting  the  fauces  a  pseudo-membrane  is  dis- 
covered covering  this  region,  and  it  probably  appears  also  upon  the  nasal 
surface.  Although  severe  scarlatinous  inflammation  may  cause  a  fibrinous 
exudation,  yet  that  diphtheria  has  supervened  upon  scarlet  fever  in  a  consid- 
erable proportion  of  cases  which  have  the  above  history  cannot,  I  think,  be 
doubted.  In  a  few  instances  in  my  practice  (four)  the  fact  that  scarlet  fever 
was  complicated  by  true  diphtheria,  and  the  scarlatinous  inflammations,  fir.st 
in  order,  were  intensified  by  the  presence  and  influence  of  the  diphtheritic 
poison,  was  shown  by  the  occurrence  of  diphtheria  without  scarlet  fever  in 
other  members  of  the  family. 

In  accordance  with  the  above  law  we  may  assume  that  a  child  who  has 
laryngo-tracheitis,  so  common  from  taking  cold  and  manifested  by  cough  and 
hoarseness,  is  more  prone  to  have  diphtheritic  croup  than  is  one  whose  air- 
passages  are  in  their  normal  state  when  diphtheria  commences.  A  supposed 
error  of  diagnosis  is  often  made  by  physicians,  always  to  their  discredit,  who 
diagnosticate  catarrhal  laryngitis,  but  find  after  two  or  three  days  that  their 
patients  really  have  diphtheritic  croup.  A  considerable  number  of  such 
instances  have  come  to  my  notice,  always  with  the  ill-will  of  families  toward 
their  physicians.  Now,  it  seems  to  me  that  in  many  of  these  cases  the  phy- 
sicians have  been  right  in  their  first  diagnosis,  and  diphtheritic  croup  super- 
vened on  the  catarrhal   inflammation. 

Another  point  relating  to  the  etiology  of  diphtheritic  croup  requires 
notice.  Many  physicians  who  have  had  ample  opportunities  to  observe 
diphtheria  believe  that  the  common  way  in  which  diphtheritic  croup  begins 
is  as  follows ;  The  faucial  or  nasal  surface  is  first  aff"ected,  becoming  covered 
by  the  peculiar  exudation,  and  during  inspiration  particles  of  the  pseudo- 
membrane  Containing  the  specific  principle,  being  detached,  lodge  in  the 
larynx.  At  the  point  of  inoculation  the  specific  inflammation  arises  and 
extends.  This  may  be  the  manner  in  which  the  croup  of  diphtheria  begins 
in  certain  cases,  but  it  certainly  does  not  apply  to  a  considerable  number  of 
patients.  Thus  both  the  faucial  and  nasal  pseudo-membranes  may  be  treated 
every  second  or  third  hour  from  the  time  of  their  formation  with  the  best 
disinfectants  which  we  possess,  so  as  to  destroy  all  the  micrococci  in  them 
and  render  them  an  inert  mass,  and  yet  croup  not  infrequently  occurs  during 
the  progress  of  the  case.  Again,  in  certain  cases  croup  begins  at  the  com- 
mencement of  the  diphtheritic  attack.  The  laryngitis  commences  as  early 
as  the  pharyngitis,  and  therefore  does  not  result  from  it.  Sometimes  the 
inflammation  of  the  air-passages  is  from  the  first  the  predominant  lesion,  the 
pharyngitis  being  subordinate  or  even  trivial.  Thus,  a  boy  of  two  years  ten 
months  whom  I  attended  died  of  croup  lasting  about  four  days.  He  lived  in 
the  subui'bs  of  the  city,  where  the  houses  were  scattered  and  where  there 
had  been  no  recent  diphtheria.  The  attack  began  with  hoarseness,  which 
gradually  increased  to  a  fatal  obstruction  in  the  air-passages.  Close  and 
repeated  inspection  of  the  fauces  revealed  only  redness  and  some  swelling  of 
the  parts  that  were  visible,  and  the  symptoms  indicated  but  slight  coryza. 
The  diphtheritic  nature  of  the  disease  was  rendered  certain  by  the  occur- 
rence of  diphtheria  in  its  usual  form  in  the  two  nurses  immediately  after  the 
death  of  the  child.  In  this  case  croup  began  at  the  beginning  of  the  sick- 
ness, and  it  is  evident  from  the  history  of  the  lesions  that  the  contagium  was 


654  MEMBRANOUS  CROUP. 

not  transferred  to  the  larynx  from  any  of  the  other  surfaces.  In  view  of  the 
number  of  such  cases  I  see  no  propriety  in  assigning  to  diphtheritic  croup  a 
mode  of  origin  different  from  that  of  other  diphtheritic  inflammations.  But 
the  possibility,  and  perhaps  probability,  in  some  instances  of  an  auto-infec- 
tion we  will  not  deny. 

Anatomical  Characters. — It  is  important  to  acquaint  ourselves  with 
the  anatomical  characters  of  croup,  especially  with  the  nature  of  the  pseudo- 
membrane,  that  we  may  know  what  measures  to  employ  in  order  to  remove  it 
and  prevent,  so  far  as  possible,  the  laryngeal  stenosis  from  which  so  many 
perish.  The  surface  of  the  larynx,  trachea,  and  in  severe  cases  that  of  the 
bronchial  tubes,  is  hyperaemic  and  swollen,  and  the  inflammatory  action 
involves  more  or  less  the  submucous  connective  tissue,  causing  infiltration 
or  oedema.  The  relation  of  the  exudation  to  the  mucous  surface  varies 
according  to  the  kind  of  epithelium  present.  Where  the  epithelium  is  of 
the  flat  or  squamous  variety  the  fibrinous  exudation  from  the  blood-vessels  is 
poured  out  around  the  epithelial  cells,  which  perish.  If  the  inflammation 
extend  more  deeply,  the  underlying  connective  tissue  is  also  embraced  in  the 
coagulation  and  perishes.  Prof.  Ziegler  of  Tubingen,  who  has  made  repeated 
microscopic  examinations  of  the  pseudo-membrane,  says  :  "  It  sometimes  hap- 
pens that  the  dead  epithelial  cells  become  saturated  with  the  exuded  liquid, 
and  then  pass  into  a  peculiar  condition  of  rigidity  akin  to  coagulation.  The 
seat  of  this  change  appears  to  the  naked  eye  as  a  dull,  raised,  grayish  patch 
surrounded  by  red  and  swollen  mucous  membrane.  The  exudation  is  rich  in 
albumen,  and  the  transformed  cells  take  on  the  appearance  of  a  kind  of 
coarse  meshwork  almost  or  altogether  devoid  of  nuclei."  This  is  superflcial 
inflammation,  and  Prof.  Ziegler  next  describes  deep  or  parenchymatous, 
inflammation,  as  follows  :  "  It  is  characterized  by  the  coagulation  not  merely 
of  the  epithelium,  but  also  of  the  underlying  connective  tissue.  The  afiected 
patch  is  swollen  and  assumes  a  whitish  or  grayish  tint,  the  discoloration 
extending  through  the  epithelium  to  the  connective-tissue  structures.  The 
epithelium  in  some  cases  is  lost  altogether,  and  then  the  diphtheritic  patch 

consists  of  dead  connective  tissue  only The  dead  tissue  is  separated 

from  the  living  by  a  zone  of  cellular  inflammation.  Fibrinous  filaments  are 
seen  here  and  there  through  the  mass.  The  lymphatics  in  the  neighborhood 
contain  coagula  and  leucocytes." 

Squamous  epithelium  covers  the  nostrils,  buccal  cavity,  fauces,  and 
larynx  upon  and  above  the  superior  vocal  cord,  with  the  exception  of  its 
anterior  aspect.  The  pseudo-membrane,  therefore,  upon  all  these  surfaces 
lined  with  this  form  of  epithelium  consists  of  the  exudate  from  the  blood 
which  surrounds  and  permeates  the  epithelium  or  epithelium  and  subjacent 
connective  tissue.  These  two  distinct  elements,  that  poured  out  from  the 
blood-vessels,  and  the  normal  tissue  of  the  mucous  surface  now  dead,  incor- 
porated in  one  mass,  constitute  the  pseudo-membrane.  Its  intimate  relation 
with  the  surrounding  living  tissue  is  such  that  we  cannot  detach  it  without 
lacerating  the  latter  and  causing  hemorrhage. 

The  anterior  aspect  of  the  larynx  from  the  middle  of  the  epiglottis  down- 
ward, all  that  part  of  the  larynx  below  the  superior  vocal  cord,  the  entire 
trachea,  and  the  bronchial  tubes,  are  lined  by  columnar  epithelium.  When- 
ever this  variety  of  epithelium  is  present  the  exudate  from  the  blood  does 
not  become  incorporated  with  the  mucous  membrane,  but  escapes  to  the  sur- 
face and  coagulates  in  a  layer  over  it.  It  is,  therefore,  loosely  adherent  to 
the  underlying  tissues,  being  attached  to  it  by  some  fibrinous  threads,  and  when 
it  is  peeled  off"  the  hyperaemic  and  swollen  mucous  membrane  is  seen  under- 
neath in  its  entirety,  unless,  as  is  commonly  the  case,  a  considerable  part  of 
its  epithelium  has  been  shed  and  been  expectorated.     The  loose  attachment 


SYMPTOMS.  655 

of  the  pseudo-membrane  in  the  trachea  and  bronchial  tubes  is  of  the  greatest 
significance  in  its  relation  to  intubation  and  tracheotomy. 

In  this  connection  it  is  proper  to  call  attention  again  to  the  confusion 
which  occurs  in  the  use  of  the  terms  diphtlieritic  and  croupous  as  employed 
by  pathologists  on  the  one  hand  and  clinical  observers  or  practitioners  on  the 
other.  Pathologists,  following  Virchow,  designate  the  inflammation  "  diph- 
theritic "  when  the  epithelium  and  underlying  tissues  remaining  la  situ  are 
blended  with  the  exudate  and  become  a  part  of  the  pseudo-membrane,  what- 
ever may  be  the  cause  of  the  inflammation  ;  and  they  designate  the  inflamma- 
tion "  croupous,"  whatever  its  cause,  when  the  exudate  escapes  to  the  sur- 
face of  the  mucous  membrane,  as  in  the  trachea  and  bronchial  tubes,  and 
coagulates  upon  it.  Therefore,  in  all  cases  of  pseudo-membranous  inflamma- 
tion of  the  air-passages,  even  that  due  to  "  taking  cold  "  or  to  inhalation  of  an 
irritating  vapor,  they  term  the  laryngitis  diphtheritic,  since  in  the  larynx  the 
exudate  is  incorporated  with  the  mucous  membrane,  while  the  pseudo-mem- 
branous tracheitis  or  bronchitis  in  the  same  patient  is  termed  croupous,  since 
the  exudate  lies  upon  the  surface.  Practitioners,  on  the  other  hand,  apply 
the  term  diphtheritic  to  all  inflammations  which  occur  as  local  manifestations 
of  the  specific  disease,  diphtheria,  and  to  only  such  inflammations,  whatever 
may  be  their  form,  whether  pseudo-membranous  or  catarrhal. 

The  epithelial  cells  embraced  in  the  pseudo-membrane  undergo  a  histolog- 
ical change.  We  have  stated  Ziegler's  remark  that  they  are  permeated  by 
the  exudate  of  the  blood.     Cornil  and  Ranvier  say  :  "  Wagner  admits  the 

fibrinous  degeneration  of  the  cells We  have  verified  the  description 

given  by  Wagner,  but  we  would  conclude  that  the  cells  are  filled  with  a 
material  which  approaches  mucin  rather  than  fibrin."  In  the  first  week  the 
pseudo-membrane  forms  more  rapidly,  and  is  usually  thicker  and  more  ex- 
tended, producing  dyspnoea  more  quickly  than  when  it  forms  in  the  declining 
stage  of  the  disease.  If  the  membrane  be  detached  by  the  forcible  coughing 
of  the  patient,  it  is  usually  quickly  reproduced,  unless  the  diphtheria  be  in 
its  advanced  stage  and  abating.  If  the  croup  continue  from  four  to  six  days, 
the  pseudo-membrane  begins  to  soften  from  commencing  decomposition  and 
to  disintegrate.  The  minute  fibres  which  attach  it  to  the  membrane  give  way, 
and  in  favorable  cases  by  the  effort  of  coughing  or  vomiting  it  is  thrown  off. 
Separation  is  aided  by  the  muco-pus  which  collects  underneath. 

Symptoms. — Whenever  croup  is  one  of  the  local  manifestations  of  diph- 
theria, such  general  or  constitutional  symptoms  are  present  as  commonly  per- 
tain to  this  blood  disease,  such  as  fever,  anorexia,  thirst,  and  progressive  loss 
of  flesh  and  strength.  The  temperature  in  the  commencement  in  croup  from 
this  cause  is  usually  higher  than  at  an  advanced  period,  unless  some  compli- 
cation occur,  as  pneumonia,  which  increases  the  heat  of  the  system.  The 
temperature  is  not,  however,  in  the  beginning  ordinarily  above  103°  or  104°, 
and  as  the  croup  continues  and  the  systemic  blood-poisoning  becomes  more 
marked,  the  temperature  usually  falls,  so  that  even  in  the  gravest  cases  it  is 
often  at  or  below  100°.  Most  patients  also  have  those  inflammations  which 
commonly  attend  diphtheria — i.  e.  pharyngitis  and  more  or  less  coryza,  but 
they  are  relatively  unimportant  in  comparison  with  the  croup,  for,  unlike  the 
croup,  they  do  not  in  themselves  involve  immediate  danger  to  life. 

Croup  commonly  begins  gradually  and  insidiously,  revealed  at  first  to  the 
physician  by  hoarseness  or  huskiness  of  the  voice  and  a  hoar.se  or  harsh  cough. 
Both  voice  and  cough  are  feeble,  lacking  the  fulness  and  sonorousness  present 
in  spasmodic  laryngitis.  In  grave  cases  approaching  a  fatal  termination  the 
voice  becomes  more  and  more  indistinct,  and  finally  is  suppressed.  The 
cough  also,  which  in  the  beginning  of  the  croup  was  strong  and  expulsive, 
becomes  feeble  and  ineffectual,  and  less  frequent  as  the  fatal  result  draws  near. 


656  MEMBRANOUS  CROUP. 

The  amount  of  sputum  varies  considerably  in  different  cases.  If  the 
inflammation  extend  no  farther  downward  than  the  trachea  it  is  scanty,  but 
if  there  be  coexisting  bronchitis  it  is  more  abundant,  consisting  of  muco-pus 
with  occasional  flakes  of  pseudo-membrane.  By  vomiting  a  larger  quantity 
is  expelled  than  by  the  cough.  Occasionally  masses  of  pseudo-membrane  of 
considerable  size  are  expectorated,  even  moulds  of  some  part  of  the  respira- 
tory passage,  always  with  great  temporary  relief  to  the  patient.  A  pseudo- 
membrane  of  considerable  thickness  and  extent  obstructs  the  expectoration 
of  muco-pus,  which,  collecting  in  the  lower  part  of  the  trachea  and  in  the 
bronchial  tubes,  greatly  increases  the  dyspnoea.  The  respiration  is  somewhat 
more  frequent  than  in  health,  but  it  is  not  notably  increased  except  when 
bronchitis  or  broncho-pneumonia  is  present.  At  an  advanced  stage,  when 
stupor  supervenes  from  non-oxygenation  of  the  blood,  the  respiration  may  be 
slower  than  in  health. 

Croup  in  its  commencement  and  in  the  active  period  of  diphtheria  without 
treatment  almost  never  remains  stationary  or  abates.  Little  by  little,  or  often 
quite  rapidly,  the  laryngeal  stenosis  increases,  and  soon  the  patient  begins  to 
experience  the  want  of  air.  He  becomes  restless,  has  an  anxious  expression 
of  the  face,  seeks  change  of  position,  reaching  out  his  arms  to  the  nurse  or 
mother  to  obtain  relief.  In  some  patients  only  a  few  hours  elapse  and  in 
others  a  day  or  more  of  gradual  increase  in  the  obstruction,  when  it  becomes 
evident  that  death  must  soon  occur  unless  relief  be  afforded.  In  this  stage 
the  post-clavicular,  infraclavicular,  suprasternal,  and  inframammary  regions 
are  depressed  during  inspiration,  and  the  larynx  is  drawn  with  each  inspira- 
tory act  toward  the  sternum.  While  there  is  constant  suffering,  there  are  also 
occasionally  most  distressing  attacks  of  dyspnoea,  attended  by  an  increase  in 
the  lividity  of  the  features  and  extremities,  which  now  have  an  habitual  dusky 
pallor.  Sometimes  these  attacks  are  perhaps  due  to  the  doubling  of  a  de- 
tached end  of  the  pseudo-membrane  on  itself,  or  perhaps  to  a  movement  of 
the  muco-pus  by  which  bronchial  tubes  are  occluded.  With  the  ear  applied 
over  the  larynx  or  upper  part  of  the  sternum,  a  loud  rhonchus  is  heard  both 
on  inspiration  and  expiration,  produced  by  the  passage  of  the  air  over  the 
obstruction,  and  obscuring  to  a  great  extent  the  other  sound.  Moist  bronchial 
rales  are  also  common. 

Those  who  recover  from  membranous  croup  without  intubation  or  trache- 
otomy and  by  the  use  of  inhalations — and  thus  far  they  constitute  only  a 
small  minority — usually  improve  gradually,  the  obstruction  diminishing  by 
the  softening  and  detaching  of  portions  of  the  pseudo-membrane,  the  cough 
becoming  looser  and  the  voice  less  hoarse.  After  the  detachment  of  the 
pseudo-membrane  several  days  elapse  before  the  thickening  and  infiltration 
of  the  mucous  membrane  disappear  and  the  epithelial  cells  are  restored. 

Diagnosis. — Catarrhal  laryngitis  with  an  unusual  amount  of  thickening 
and  infiltration  of  the  mucous  membrane  and  of  the  underlying  connective 
tissue,  so  as  to  produce  stenosis  and  obstruct  respiration,  may  be  mistaken  for 
pseudo-membranous  laryngitis.  In  the  New  York  Foundling  Asylum  two 
children  have  at  different  times  died  with  the  symptoms  of  membranous 
laryngitis,  and  the  obstruction  was  found  to  be  due  entirely  to  the  thicken- 
ing and  infiltration  of  the  mucous  and  submucous  tissues  of  the  larynx  by 
newly-formed  corpuscular  elements.  Of  course,  death  from  catarrhal  laryn- 
gitis is  rare,  but  that  this  disease  may  produce  such  an  amount  of  laryngeal 
stenosis  as  to  cause  even  fatal  dyspnoea,  like  that  from  the  presence  of  pseudo- 
membrane,  these  two  cases  show.  In  most  instances  the  diagnosis  of  mem- 
branous laryngitis  from  catarrhal  laryngitis  is  easy  by  the  presence  of  patches 
of  pseudo-membrane  on  the  fauces  or  by  the  history  of  the  case,  which  evi- 
dently points  to  diphtheria  as  the  cause.     In  the  case  alluded  to  above  a  child 


PROGNOSIS.  657 

in  my  practice  died  with  the  symptoms  of  acute  laryngeal  stenosis,  with- 
out any  pseudo-membrane  upon  visible  parts  and  with  only  a  moderate  phar- 
yngitis. This  case,  which  might  have  passed  as  one  of  catarrhal  laryngitis 
accompanied  by  an  unusual  amount  of  cellular  and  serous  infiltration,  as  there 
was  no  known  diphtheria  in  the  vicinity,  was  really  due  to  diphtheria,  and 
was  a  local  manifestation  of  that  disease,  for  immediately  after  the  death  of 
the  patient  the  two  nurses  had  une(juivocal  symptoms  of  diphtheria.  The 
difficulty  in  using  the  laryngoscope  in  young  children  is  such  when  their 
fauces  are  swollen  that  it  has  not  heretofore  afforded  much  aid  in  the  differ- 
ential diagnosis  of  the  various  forms  of  acute  laryngeal  stenosis  in  young 
children,  at  least  when  employed  by  the  general  practitioner. 

Procjnosis. — The  mortality  from  croup  obviously  depends  to  a  great  extent 
on  the  prevalence  and  the  type  of  diphtheria.  From  what  has  been  stated 
above,  it  follows  that  croup  is  more  frequent  and  more  fatal  when  a  grave  form 
of  diphtheria  is  prevailing  than  in  mild  epidemics  Avith  less  blood-poisoning. 
In  New  York  City,  during  the  fifteen  years  ending  with  1878,  the  percentage 
of  recoveries  was  very  small,  both  under  medicinal  treatment  and  tracheot- 
omy. During  this  long  period,  surgeons,  not  saving  more  than  3  to  5  per 
cent,  of  their  cases  by  tracheotomy,  performed  this  operation  reluctantly. 
But  since  1878  the  percentage  of  recoveries  after  tracheotomy  has  been  much 
greater.  The  mortality  from  croup  is  greater  the  younger  the  patients  ;  for 
the  younger  the  child  the  less  the  diameter  of  the  air-passages  and  the  more 
quickly  laryngeal  stenosis  results.  The  younger  the  child,  also,  the  more 
difficult  is  the  use  of  the  proper  remedies,  and  the  less  the  time  for  their  use 
before  fatal  dyspnoea  occurs.  We  have  already  said  that  croup  appearing  in 
the  declining  stage  of  diphtheria  is  less  severe  and  more  easily  controlled  or 
cured  than  when  it  occurs  in  the  commencement  of  this  disease.  Much 
depends  also  upon  whether  the  physician  is  summoned  at  the  beginning  of 
croup  and  appropriate  remedies  are  early  and  persistently  employed.  In 
many  instances  the  friends  do  not  take  alarm  and  the  physician  is  not  sum- 
moned till  the  disease  is  well  under  headway  and  there  is  not  the  requisite 
time  for  the  action  of  inhalations.  Obviously,  also,  croup,  beyond  all  other 
diseases,  requires  faithful  and  intelligent  nurses,  for  without  the  co-operation 
of  such  nurses  night  and  day  in  the  care  of  the  patient  the  most  judicious 
measures  are  often  inefficient. 

Exact  statistics  are  lacking  to  show  what  proportion  of  cases  of  croup 
recover  by  strictly  medicinal  treatment.  If  we  regard  as  incipient  croup 
those  cases  in  which  the  voice  becomes  hoarse  or  harsh,  but  no  dyspnoea 
occurs,  and  the  lungs  are  fully  and  normally  inflated,  a  considerable  number 
— I  think  more  than  50  per  cent,  in  my  practice — recover.  There  may  be 
in  these  cases  a  catarrhal  laryngitis,  or  there  may  be  a  thin  film  of  pseudo- 
membrane  upon  the  laryngeal  surface,  not  sufficient  to  embarrass  respiration. 
Slight  laryngitis,  thei'efore,  occurring  in  the  course  of  diphtheria,  unaccom- 
panied by  any  increase  in  temperature  or  change  in  the  freedom  or  rhythm  of 
respiration,  and  whose  only  symptom  is  a  huskiness  of  voice,  if  treated  early 
and  properly  by  inhalations  passes  off  in  a  few  days  in  a  large  proportion  of 
cases.  It  possesses  little  importance,  except  that  it  might  be  the  initial  stage 
of  croup  if  neglected.  It  is  obviously  improper  to  consider  this  trivial  form 
of  laryngitis  as  membranous  croup,  although  by  neglect  it  might  become  such. 
In  the  statistics  of  croup  those  cases  only  should  be  included  in  which  the 
symptoms  are  so  pronounced  that  it  is  evident  that  more  or  less  laryngeal  ste- 
nosis is  present,  although  there  may  as  yet  be  no  marked  dyspnoea. 

In  determining  the  percentage  of  recoveries  in  croup  it  is  proper  to  arrange 
cases  in  two  groups  :  1st.  cases  which  have  received  only  medicinal  treatment ; 
2d,  cases  in  which  intubation  or  tracheotomy  has  been  performed.  Having 
42 


658 


MEMBRANOUS  CROUP. 


been  in  almost  continuous  practice  since  diphtheria  began  in  New  York,  in  a 
section  of  the  city  where  this  disease  has  always  been  prevalent,  and  having 
witnessed  all  kinds  of  treatment — that  by  emetics,  by  depletion,  by  stimula- 
tion, by  inhalation  and  insufflation — it  is  my  opinion  that  not  more  than  one 
in  eight  has  recovered  by  medicinal  treatment  in  this  long  period,  of  cases  of 
croup  which  began  in  the  first  week  of  diphtheria,  and  in  which  the  symp- 
toms were  so  pronounced  as  to  indicate  more  or  less  laryngeal  stenosis.  The 
exudation  in  the  first  week  of  diphtheria,  or  in  its  active  period,  occurs  so 
rapidly  and  in  such  large  quantity  that  no  one  of  the  medicinal  agents  or 
modes  of  treatment  which  physicians  commonly  prescribe  is  sufficiently 
prompt  in  its  action  to  prevent  the  formation  of  the  pseudo-membrane  to  an 
extent  that  soon  endangers  life.     I  allude  to  what  has  hitherto  been  the  result. 

Perhaps  we  may  yet  discover  a  mode  of  treatment  that  more  effectually 
controls  the  formation  of  pseudo-membranes. 

Croup  occurring  in  the  second  or  third  week  of  diphtheria,  since  it  is 
attended  by  less  abundant  and  less  rapid  exudation  than  when  it  occurs 
during  the  acute  stage,  can  be  more  successfully  treated  under  the  persever- 
ing use  of  solvent  inhalations,  and,  according  to  my  observations,  a  larger 
proportion  of  such  cases  than  1  in  8 — perhaps  1  in  4 — recovers  by  the  early 
and  continuous  or  almost  continuous  use  of  inhalations. 

Still  the  mortality  is  so  large  and  the  suffering  so  great  in  croup,  at  what- 
ever stage  of  diphtheria  it  occurs,  that  we  cannot  rely  on  the  slow  action  of 
medicines  or  inhalations,  and  surgical  treatment  is  in  most  instances  required 
to  diminish  the  suffering  and  afford  the  best  chances  for  saving  life.  Intuba- 
tion of  the  larynx  by  O'Dwyer's  tubes  is  rapidly  coming  into  use  as  a  prompt 
and  efficient  method  of  relieving  laryngeal  stenosis.  The  percentage  of 
recoveries  after  intubation  will  be  considered  hereafter,  but  enough  is  known 
to  render  it  certain  that  this  simple  and  painless  operation  will  soon  be  per- 
formed as  a  substitute  for  tracheotomy  in  every  part  of  the  world  where  there 
is  a  medical  profession  worthy  of  the  name.  The  following  statistics  show 
the  result  of  tracheotomy  when  skilfully  performed : 

Cases. 
Jacobi,  Krackowizer,  and  Voss  {Amer.  Jour,  of  Obstet, 

May,  1868) 166 

J.  H.  Riplev,  iV.  Y.  Med.  Rec,  1880 56 

Parisian  Children's  Hospital,  1851-75  (Tennd)  .    .    .  4663 

Bethanien  in  Berlin,  1861-72  (Bartels) 330 

Berliner  Chirurg.  Klinik,  1870-76  (Kronlein)  ...  504 

St.  Annenspital,  Wien  (Monti) 210 

Table  of  Monti  from  various  sources 2608 

Hofraohl's  statistics 3760 

Kiister's  statistics 1556 

C.  Hospital,  Trousseau,  Paris,  during  1883  (per  Dr. 

L'Enfance) 359 

Clinic  of  the  Zurich  Kantonspitals,  under  Eose  and 

F.  Kronlein,   1868,   March,  1882  (11   under  two 

years,  1  of  eight  months) 238 

Deutsche  Zeitschrijt  fiir  Ckirurg.,  1882,  Bd.  xvii.   (H. 

Lindner) 101 

Statistik    der    Tracheotomie    per    Croup,    Deutsche 

Chirurger  Lieferung,  37  Stuttgard,  1880,  by  Kiihn  .  277 

H6pital  des  Enfants  Malad.,  Paris,  1850-57  ....  389 

Hopital  des  Enfants  Malad.,  Paris,  1860-67  ....  813 

Trousseau,  according  to  Kiihn 466 

Guersant  (Sedillot),  Med.  Oper.,  ii.,  page  480  ....  171 

Barthez,  Hospital  St.  Eugenie,  1855-68 573 

Cases  in  the  Parisian  Hospitals  and  in  the  Provinces, 

Fascher  et  Bricheteau 1011 

Eoser  (Lissard)  C.  C,  1854-61 42 


Recov- 

Per cent,  of 

eries. 

recoveries. 

39 

127 

16 

24 

103 

31.2 

147 

29 
33 
25 
27 
32 

115 

244 

32 

92 

39 

371 

125 

152 

86 

22 

208 

126 

25 

36 

21 

160 

28 
25 

19 

45.4 

PROGNOSIS.  659 


Opemtions. 


Recov- 

Per cent,  of 

eries. 

recoveneB. 

2\ 

25 

lo 

33 

46 

35.6 

119 

31.75 

1 

5 

Vhde,  Arcliiv  f.  klin.  Chlr.,  18^d,  1S20-69   ■;■■    ■  «1 

Max.  Muller  (Langenh.  Arch./,  /din.  Chir.,  vii.).    .    .  4") 

Hardenheiier  (<  oilier  Biirgerhospitals,  187o-7G)  .  .  1'29 
Krankenhause  Bethanien,  1873,  and  following  (H. 

Settegast) 375 

Billroth,  C'hirurg.  klinik.   Wien,  1871-76 18 

Reisz,  Broncliotomiens  Indicat.,  1858 17 

Wansher    f  Copenhagcner   Kommuni   Hospitals,    Sept., 

1863-Dec.,  1876) 400               170                42.5 

The  result  of  tracheotomy  in  infants  is  much  less  favorable  than  in  older 
children.  Dr.  Gustav  Chagin '  has  published  the  statistics  of  cases  in  infancy. 
These  cases,  977,  occurred  since  1874,  and  of  this  number,  832,  or  85  per 
cent.,  died.  In  the  Copenhagener  Kommuni  Hospital,  in  which,  as  stated 
above,  there  was  the  remarkably  good  general  result  of  170  recoveries  in  400 
tracheotomies,  only  5  per  cent,  recovered  of  children  under  one  year ;  of  76 
operated  on  between  the  ages  of  one  and  two  years,  22  recovered,  or  29  per 
cent. ;  while  of  296  operated  on  between  the  ages  of  two  and  ten  years,  146 
recovered,  or  49.3  per  cent.  In  the  Krankenhause  Bethanien  the  results  of 
tracheotomy  from  the  beginning  of  1861  to  the  close  of  1876,  tabulated 
according  to  the  age,  were  as  follows  (H.  Settegast)  : 

Years.  Tracheotomies.      Eecovered.  Per  cent. 

2  to  3  years 93  22  23.65 

3  "    4  "  165  47  28.45 

4  "    5  "  175  54  30.85 

5  "    6  "  107  39  35.45 

6  "    7  "  90  34  37.77 

7  "    8  "  59  17  38.86 

8  "    9  "  24  11  45.83 

9  "  10  "  15  6  40.00 

The  statistics  show  that  the  older  the  patient  upon  whom  tracheotomy  is 
performed,  other  things  being  equal,  the  greater  the  percentage  of  recoveries. 
Prof.  Abraham  Jacobi  has  probably  performed  tracheotomy  for  croup  in  as 
many  cases  as  any  other  physician  or  surgeon  in  this  country — not  fewer,  he 
thinks,  than  four  hundred  times.  His  opinion  corresponds  with  the  common 
belief  that  in  recent  years  the  percentage  of  recoveries  after  tracheotomy 
in  New  York  City  has  been  larger  than  in  previous  years,  and  the  operation 
is  performed  more  frequently  by  the  attending  physician  than  formerly.  The 
result  of  tracheotomy  during  a  long  series  of  years,  ending  with  1878  or 
1879,  was  so  unfavorable,  on  account  of  the  type  of  the  disease,  that  Dr. 
Jacobi  thinks  that  in  the  aggregate  of  his  cases  of  tracheotomy  since  1858 
only  about  12  per  cent,  recovered. 

Although  at  present  in  this  city  the  percentage  of  recoveries  after 
tracheotomy  is  larger  than  formerly,  yet  the  statistics  of  some  of  the 
prominent  physicians  and  surgeons  show  nearly  as  large  a  proportion  of 
deaths  as  in  former  years,  probably  because  the  operation  has  been  deferred 
till  the  patients  were  nearly  moribund.  Thus,  one  surgeon  records  only  4 
recoveries  in  21  operations  during  three  or  four  years,  and  a  physician  of 
large  experience  connected  with  one  of  the  institutions  where  children  are 
treated  has  been  equally  unsuccessful  in  his  tracheotomies,  but  he  has  oper- 
ated only  when  the  dyspnoea  was  extreme  and  death  momentarily  expected. 
Earlier  operation  might  have  given  better  results. 

The  statistics  of  recent  tracheotomies,  which  seem  to  me  to  indicate  most 

'  Archil' filr  Kinderheilkunde,  Bd.  iv. 


660  MEMBRANOUS  CROUP. 

accurately  the  results  of  this  operation  when  skilfully  performed,  and  not  at 
too  late  a  stage  in  the  type  of  diphtheria  now  prevailing  in  this  city,  I  have 
obtained  from  Drs.  J.  H.  Ripley  and  Fred.  Lange.  The  operations  embraced 
in  their  statistics  were  performed  since  January  1,  1879,  and  before  intuba- 
tion came  into  general  use,  with  the  following  result : 

Tracheotomies.  Died.  Recovered.  Per  cent,  of  recoveries. 

66  44  22  33J 

These  surgeons  did  not  select  cases  for  the  operation,  but  operated  on 
nearly  every  patient  with  croup  to  whom  they  were  summoned,  provided  that 
death  appeared  inevitable  without  tracheotomy.  They  operated  even  if  serious 
complications  were  present,  as  nephritis  or  pneumonia,  or  the  blood  were  pro- 
foundly poisoned. 

Some  physicians  in  this  city  make  greater  discrimination  in  cases,  and  do 
not  operate  if  the  condition  of  the  patient  be  such  that  death  will  in  all 
probability  occur  after  tracheotomy.  They  do  not,  therefore,  advise  the 
operation  if  the  patient  have  profound  blood-poisoning  or  severe  local  disease 
elsewhere  than  in  the  air-passages.  Such  physicians  by  the  early  perform- 
ance of  tracheotomy  and  by  careful  attention  to  the  after-treatment,  making 
frequent  visits  and  supervising  the  details  of  the  management,  furnish  more 
favorable  statistics  of  the  operation  than  those  published  above.  Thus,  Dr. 
A.  E,.  Robinson,  who  carefully  considers  the  indications  and  contraindications 
of  tracheotomy,  who  operates  early,  does  not  insert  the  canula  until  all  loose 
muco-pus  and  shreds  of  pseudo-membrane  are  expelled  by  the  cough  from 
the  trachea  and  bronchial  tubes,  and  who  supervises  by  frequent  visits  the 
after-management,  has  saved,  since  1880,  11  in  13  consecutive  cases  of 
undoubted  membranous  croup.  It  is  seen  from  the  above  statistics  that  we  can 
claim  from  tracheotomy,  judiciously  performed  and  at  a  sufl&ciently  early 
stage,  the  cure  of  1  in  every  3  patients  on  the  average.  The  statistics  in 
Boston  show  that  the  results  obtained  in  that  city  in  hospital  practice  have 
been  about  the  same  as  those  in  New  York  and  in  European  cities.  In  an 
interesting  paper  on  tracheotomy  in  croup,  published  in  the  Medical  JVews, 
July  12,  1884,  the  writer  says :  "  Tracheotomy  for  this  disease  has  been  per- 
formed 118  times  at  the  Boston  City  Hospital  during  the  past  twenty  years : 
39,  or  1  in  3,  were  successful.  That  the  cases  were  not  selected  is  shown  by 
the  fact  that  3  patients  died  during  the  operation  from  shock  and  exhaustion, 
not  from  hemorrhage ;  34  died  within  twenty-four  hours ;  and  56,  or  more 
than  one-half  of  the  fatal  cases,  within  forty-eight  hours ;  4,  if  not  5,  of  the 

successful  cases  were  practically  moribund  at  the  time  of  the  operation 

The  ages  of  these  patients  ranged  from  nine  months  to  forty-one  years. 
The  youngest  to  recover  was  eleven  months,  the  oldest  sixteen  years ;  4 
aged  two  years  and  5  aged  three  years  got  well.  Membrane  was  visible  in 
the  fauces  or  trachea  in  a  large  proportion  of  both  the  successful  and  unsuc- 
cessful cases.  Its  absence  was  noted  in  only  3  of  each  class.  It  need  not 
be  said  that  in  every  instance  there  was  present  severe,  constant,  and  increas- 
ing dyspnoea,  exhausting  the  strength  and  threatening  suffocation." 

Treatment — Preventive. — In  attending  a  case  of  diphtheria  the  phy- 
sician should  notice  at  each  visit  whether  the  patient  have  any  hoarseness  or 
other  signs  indicating  implication  of  the  larynx,  since  if  the  danger  be  recog- 
nized at  its  inception  it  may  perchance  be  averted.  Ineffectual  as  inhalations 
may  be  for  fully-declared  croup,  we  have  seen,  in  speaking  of  the  prognosis, 
that  experience  fully  justifies  the  belief  that  they  are  sufficient  in  a  large 
proportion  of  cases  to  relieve  that  degree  of  laryngitis  which  is  indicated  by 
simple   hoarseness,    and    which  if  it   continue   might    eventuate  in    serious 


TREATMENT.  6G1 

obstructive  disease.  If  the  pliysician  observe  such  symptoms,  he  should 
immediately  recommend  that  the  air  in  the  apartment  be  kept  moist  by  the 
croup  kettle  or  pans  of  hot  water  over  the  fire,  into  each  of  which  a  lump 
of  lime  is  placed.  I  frequently  surround  the  bed  with  a  tent  made  with  a 
clothes-horse,  over  which  blankets  are  thrown,  and  place  the  croup  kettle 
underneath.  Frequently  stirring  the  water  in  the  kettle  adds  to  its  efficiency. 
I  prefer,  however,  in  most  instances,  to  employ  the  steam-atomizer  either  with 
or  without  the  croup  kettle.  It  should  be  so  constructed  that  it  throws  a 
heavy  spray  of  rather  turbid  lime-water,  and  should  be  almost  continuously 
used  as  long  as  the  premonitory  symptoms  of  croup  continue.  It  obviates 
the  necessity  of  heating  the  apartment,  which  in  hot  weather  is  very  uncom- 
fortable. 

It  is  proper,  in  this  connection,  to  consider  which  is  the  most  efficient  and 
the  best  agent  for  inhalation  in  croup.  Have  we  an  agent  that  can  be  safely 
used,  which  will  prevent,  when  inhaled,  the  formation  of  the  pseudo-mem- 
brane, or  which  will  dissolve  it  when  it  has  already  formed  ?  The  agents 
which  have  been  most  employed  for  this  purpose  are  lime-water,  lactic  acid, 
pepsin,  and  trypsin. 

In  selecting  the  one  that  is  safest  and  most  efficient,  the  important  fact 
should  be  borne  in  mind  that  anything  which  irritates,  so  as  to  increase  the 
inflammation  of  the  mucous  surface,  is  injurious.  Whatever  intensifies  the 
inflammation  evidently  augments  the  thickening  and  infiltration  of  the  mucous 
membrane  and  increases  the  area  as  well  as  thickness  of  the  pseudo-mem- 
brane. It  is  therefore  harmful  instead  of  beneficial.  In  my  opinion,  the 
teachings  of  Bretonneau  and  Trousseau  did  immense  harm  in  the  fact  that 
they  brought  into  use  agents  far  too  irritating  to  the  sensitive  mucous  sur- 
face. Since  the  pressing  danger  in  croup  arises  from  the  obstruction  pro- 
duced by  the  pseudo-membrane  and  by  the  thickening  and  infiltration  of  the 
mucous  membrane  underneath,  that  agent  is  indicated,  if  it  can  be  found, 
which  loosens  and  dissolves  the  pseudo-membrane,  and  at  the  same  time  tends 
to  diminish,  or  at  least  does  not  increase,  the  inflammation  of  the  underlying 
tissues  by  its  irritating  action.  Alkalies  exert  a  solvent  action  on  fibrin  and 
mucin,  and  as  the  pseudo-membrane  consists  of  the  exudate  from  the  blood 
largely  fibrinous,  and  of  epithelium  and  connective  tissue  which  have  under- 
gone degeneration  into  a  substance  resembling  fibrin  (Wagner),  or  perhaps 
mucin  (Cornil  and  Ranvier),  their  employment  seems  to  rest  on  a  sound  ther- 
apeutic basis.  Lime-water  slightly  turbid,  but  not  so  turbid  as  to  clog  the 
point  of  the  steam-atomizer,  with  its  alkalinity  increased  by  the  addition  of 
an  unirritating  alkali,  should  be  employed  almost  continuously  by  inhalation. 
Dr.  E.  M.  Moore'  of  Rochester  recommends  insufflation  of  sodium  bicarbonate 
as  an  active  solvent  of  the  pseudo-membrane.  It  possesses  this  advantage — 
that  it  is  but  slightly  irritating,  so  that  it  can  be  used  in  substance  or  with 
but  little  dilution.  For  this  reason  it  should  be  preferred  to  lime-water, 
which  is  in  more  common  use. 

Recently  I  have  employed  in  the  steam-atomizer  the  following  formula, 
with  good  results  ■ 

Sodii  bicarbonat.,         .^ij ; 
Aquse  calcis,  Oj.     Misce. 

Trypsin  may  be  advantageously  used  with  this  liquid,  but  trypsin  in  pow- 
der is  very  likely  to  clog  the  atomizer.  The  liquid  trypsin,  as  prepared  by 
Fairchild,  should  therefore  be  employed  with  the  lime-water.  Pepsin,  as  we 
have  stated  elsewhere,  is  incompatible  with  an  alkali. 

By  the  persistent  and  timely  use  of  such  inhalations  as  soon  as  hoarse- 
'  Transactions  of  the  N.  Y.  Medical  Association,  1885. 


662  MEMBRANOUS  OROVP. 

ness  appears  croup  can  be  often  prevented.  But  we  all  know  how  fre- 
quently, notwithstanding  our  best  endeavors,  croup  occurring  in  the  first 
week  of  diphtheria  grows  hourly  worse.  In  these  acute  and  rapid  cases 
inhalations  of  the  best  agents  which  physicians  have  hitherto  used  act  too 
slowly  to  prevent  the  growth  of  the  pseudo-membrane,  and  in  a  few  hours  it 
becomes  painfully  evident  that  something  more  must  be  done  or  the  life  of 
the  child  is  lost.  In  those  many  cases  in  which  diphtheria  is  ushered  in  with 
croupous  symptoms,  and  in  which  within  a  few  hours  laryngeal  stenosis 
begins  to  occur,  the  experienced  physician  sees  at  a  glance,  often  at  his  first 
visit,  that  inhalations,  however  faithfully  employed,  will  be  inadequate,  and 
that  sufi"ocation,  the  most  painful  of  all  modes  of  death,  will  be  inevitable 
unless  other  and  energetic  measures  are  used. 

On  the  other  hand,  in  the  milder  forms  of  croup,  in  which  the  exudation 
has  but  moderate  thickness  and  forms  slowly,  inhalations  are  of  the  greatest 
service,  and  aided  by  internal  remedies  they  not  infrequently  arrest  the  dis- 
ease and  save  life.     The  following  was  such  a  case :   "  M.  J ,  a  girl  of 

two  years  and  five  months,  took  diphtheria  on  January  6,  1884.  I  first  saw 
her  on  the  9th,  when  a  considerable  amount  of  pseudo-membrane  covered  the 
fauces.  The  temperature  was  but  moderately  elevated,  and  a  slight  discharge 
occurred  from  the  nostrils.  Under  the  usual  treatment  the  pharyngitis 
abated,  and  she  seemed  to  be  convalescing  until  Januar}"^  14th,  when  her 
respiration  began  to  be  noisy  and  embarrassed.  On  inspecting  the  fauces  a 
pseudo-membrane  was  seen  upon  the  aperture  of  the  glottis,  apparently  dip- 
ping down  into  it.  The  steam-atomizer  was  employed  almost  constantly, 
throwing  a  spray  of  lime-water  with  about  1  per  cent,  of  liquor  potassse. 
Each  inspiration  was  accompanied  by  marked  depression  of  the  post-clavicu- 
lar, epigastric,  and  inframammary  regions,  and  the  respiration  was  noisy 
and  embarrassed  till  the  17th,  when  it  began  to  improve,  and  the  patient  was 
soon  out  of  danger.  It  will  be  observed  that  the  croup  commenced  in  the 
second  week  or  in  the  declining  stage  of  diphtheria.  Had  it  been  earlier, 
when  the  inflammation  was  more  active  and  the  exudation  more  rapid,  in  all 
probability  the  patient  would  have  perished  unless  saved  by  tracheotomy. 
The  slowness  of  the  exudative  process  afforded  time  for  the  action  of  solvent 
inhalations. 

Nearly  at  the  same  time  that  this  case  occurred  a  patient  in  my  practice 
who  had  recovered  from  croup  by  tracheotomy  was  seized  with  dyspnoea  a 
month  after  the  operation,  when  the  opening  had  healed,  and  a  flapping  sound 
could  be  distinctly  heard,  produced  probably  by  a  pseudo-membrane  which 
was  partially  detached.  This  obstruction,  which  for  a  time  apparently 
involved  great  danger  from  the  dyspnoea  which  it  caused,  was  removed  by 
the  third  day  under  alkaline  inhalations.  In  such  cases,  in  which  the  inflam- 
mation is  mild  and  the  exudation  at  a  standstill  or  slow,  the  benefit  from 
inhalations  is  most  apparent.  I  am  confident  that  one  good  result  from  alka- 
line inhalations  is  not  fully  appreciated  by  the  profession :  I  refer  to  the  fact 
that  they  render  the  muco-pus,  which  collects  in  large  quantity  in  the  bron- 
chial tubes,  and  is  expectorated  with  difficulty  on  account  of  its  viscidity  and 
the  obstacle  above  it,  thinner  and  more  easily  expelled. 

Now  that  diphtheria  has  become  so  prevalent  in  this  country,  and  so  many 
children  perish  of  the  croup  which  it  produces,  it  is  to  be  hoped  that  some 
more  efficient  and  at  the  same  time  unirritating  substance  may  be  discovered 
for  inhalation  than  those  at  present  in  use. 

Since  my  attention  has  been  called  to  the  fact  by  Dr.  Van  Syckel  of  New 
York  that  trypsin,  one  of  the  digestive  ferments  secreted  by  the  pancreas,  is 
a  rapid  solvent  of  fibrin,  he  having  observed  its  action  in  the  laboratory  of 
Prof.  Ktihne  of  Heidelberg,  I  have  employed  this  agent  in  the  usual  form  of 


TREATMENT.  663 

diphtheria  in  several  instances  with  such  result  as  to  encourage  the  hope  that 
the  solvent  which  we  have  so  long  needed  has  been  found.  I  have  never 
seen  pseudo-membranes  disappear  from  the  fauc(js  more  rapidly  than  in  cases 
in  which  the  following  mixture  was  applied  every  half  hour  with  a  large 
camel's-hair  pencil,  whether  the  good  effect  was  due  to  the  trypsin  contained 
in  the  extract  or  to  the  alkali,  or  to  the  combination  of  the  two  : 

p]xtracti  pancreatis  (Fairchild's),  3j  ; 

Hodii  i)icarl)i)nat.,  giij.     Misce. 

A<ld  one  teaspoonfiil  of  tlii.s  to  six  teaspoonfuls  of  water. 

Thus  recently,  in  a  child  of  about  five  years  a  thick  pseudo-membrane 
over  each  tonsil  had  disappeared  by  the  third  day,  without  apparently  any 
ii'ritating  effect  from  the  application.  Mr.  Fairchild  has  recently  prepared 
trypsin  in  a  liquid  form  in  order  that  its  efficacy  can  be  more  readily  and 
conveniently  tested  as  a  solvent  for  the  membranes  in  croup ;  and  different 
observers  state  that  this  liquid  employed  in  spray  has  in  certain  cases  exerted 
a  marked  solvent  action  on  pseudo-membranes.  Additional  clinical  observa- 
tions will  determine  the  value  of  trypsin  as  a  solvent.  That  it  requires  an 
alkaline  medium  for  its  activity  renders  it  compatible  with  alkaline  inhala- 
tions, as  we  have  stated  above. 

Intc.r)iid  Ti-t'dfment. —  (JaJomrl. — This  was  long  regarded  as  the  most 
important  internal  remedy  for  membranous  croup,  as  well  as  for  diphtheritic 
exudations  elsewhere  than  in  the  larynx.  In  the  belief  that  it  had  a  tend- 
ency to  prevent  the  formation  of  pseudo-membranes,  and  aided  in  detaching 
and  removing  those  already  formed,  it  was  in  common  use  until  about 
twenty-five  years  ago.  It  was  sometimes  prescribed  for  croup  in  large  doses, 
but  more  frequently  in  doses  of  one-half,  one,  or  one  and  a  half  grains, 
repeatedly  evei-y  second  or  third  hour,  and  often  in  combination  with  an 
opiate,  as  Dover's  powder.  However  useful  a  remedy  it  may  be  when  judi- 
ciously employed  in  ci'oup  as  well  as  in  certain  other  diseases,  it  fell  into  dis- 
use on  account  of  its  ill-advised  use  in  diseases  which  did  not  require  it,  often 
to  the  extent  of  producing  unpleasant  and  even  dangerous  symptoms.  'When 
diphtheria  was  established  in  this  country  calomel  was  in  a  few  years  dis- 
carded by  most  physicians  as  a  remedy  for  croup,  on  account  of  the  growing 
belief  that  nearly  all  cases  of  this  disease  were  local  manifestations  of  diph- 
theria and  required  less  depressing  and  more  sustaining  measures  than  mer- 
cury. Moreover,  it  was  easy  to  point  out  cases  in  the  writings  of  such  mas- 
ters of  the  profession  as  Bretonneau  and  Trousseau  in  which  calomel  was 
improperly  employed,  doing  harm  by  causing  not  only  severe  salivation,  but 
also  gangrene.  Nevertheless,  cases  occurred  in  those  days  which  seemed 
to  show  that  this  agent,  properly  employed,  is  a  potent  and  useful  remedy 
for  croup.  One  in  the  Astor  House  of  New  York  attracted  attention.  A 
child  of  about  two  years  stopping  at  this  hotel  had  pseudo-membranous 
laryngitis,  with  constantly  increasing  dyspnoea.  -Prominent  physicians  sum- 
moned to  him  expressed  the  opinion  that  he  could  not  live,  when,  through 
the  advice  of  a  physician  from  an  inland  city  who  was  temporarily  sojourn- 
ing in  the  hotel,  twenty  grains  of  calomel  were  placed  on  his  tongue.  From 
this  time  the  dyspnoea  began  to  abate  and  the  patient  recovered. 

The  medical  journals  from  time  to  time  have  published  reports  of  eases 
of  croup  in  which  calomel  has  apparently  been  beneficial.  Dr.  J.  P.  Klin- 
gensmith  ^  of  Blairsville,  Pennsylvania,  states  that  physicians  in  his  locality 
prescribe  calomel  in  large  doses  for  croup,  and  with  greater  success  than  that 
achieved  by  other  modes  of  treatment,  and  he  relates  three  cases  showing  the 
result  in  his  own  practice  : 

^Med.  Record,  July  12,  1884. 


064  MEMBRANOUS  CROUP. 

Case. — A  child  aged  twenty-eight  months  took  twenty  grains  of  calomel 
placed  on  the  tongue  in  the  commencement  of  croup,  and  afterward  ten  grains 
every  hour  till  the  third  day,  when  seven  hundred  and  twenty  grains  had  been 
taken.  It  was  now  discontinued,  and  on  the  sixth  day  the  pseudo-membranes 
had  disappeared.     Recovery  was  rapid  and  without  any  untoward  symptoms. 

Case. — The  second  patient,  aged  three  and  a  half  years,  had  been  sick 
forty-eight  hours,  with  a  temperature  of  102°  F.  He  had  a  croupy  cough  and  a 
pseudo-membranous  exudation.  Twenty  grains  of  calomel  were  administered, 
and  afterward  ten  grains,  every  hour  for  fifteen  hours,  so  that  one  hundred  and 
seventy  grains  were  administered.  The  child,  which  had  previously  been  restless, 
fell  into  a  quiet,  natural  sleep.  The  calomel  was  discontinued,  and  a  mixture  of 
potassium  chlorate  and  ammonium  chloride  given  in  its  place.  On  the  fifth  day 
convalescence  was  fully  established  without  any  unfavorable  symptoms. 

Case. — The  third  patient,  a  girl  of  four  years,  had  been  sick  twenty-four 
hours,  with  "  high  temperature,  painful  croupy  cough,  labored  respiration,  dry 
skin,  flushed  face,  and  some  diphtheritic"  exudation.  Twenty  grains  of  calomel 
were  administered,  and  followed  by  hourly  ten-grain  doses  till  twelve  doses 
were  given.  No  other  remedy  was  employed,  and  in  three  or  four  days  the  patient 
recovered. 

These  appear  to  have  been  genuine  cases,  and  that  they  recovered  tends 
to  confirm  the  belief  that  calomel  does  exert  a  beneficial  action  on  pseudo- 
membranous inflammations,  either  diminishing  the  exudation  or  promoting 
the  liquefaction  and  detachment  of  the  pseudo-membrane. 

A  mode  of  treatment  commonly  accepted  and  practised  by  the  profession 
through  a  long  series  of  years  usually  does  some  good,  in  at  least  a  certain 
portion  of  cases,  even  if  it  be  abused,  else  it  would  not  be  likely  to  gain 
general  acceptance.  We  know  how  quickly  calomel  cures  the  mucous  patches 
of  syphilis  even  when  they  are  of  large  size.  These  are  produced  by  inflam- 
matory changes  in  the  tegumentary  system,  and  they  consist  largely  of 
epithelial  or  epidermic  cells.  They  therefore  contain  elements  similar  to  the 
pseudo-membrane  in  ei'oup,  but  without  the  fibrin.  We  know  also  how 
readily  fibrinous  opacities  on  the  cornea  yield  to  calomel  dusted  on  them. 
We  may  admit  that  calomel  probably  exerts  a  salutary  action  either  on  the 
exudative  process  or  the  pseudo-membrane,  without  being  able  to  state  pre- 
cisely how  it  acts.  Bouchut  says  of  calomel  in  his  article  on  croup  :  ''  This 
medicine  promotes  the  expectoration  and  the  rejection  of  the  false  mem- 
brane." Trousseau  believed  that  the  beneficial  eff"ects  of  the  mercurial 
preparations  were  due  mainly  to  their  local  action.  He  states  that  "  wher- 
ever they  can  be  applied  locally  "  they  "  modify  most  powerfully  the  diph- 
theritic inflammation."  He  dusted  the  inflamed  surface,  if  accessible,  with 
calomel  or  with  a  powder  of  the  red  precipitate,  one  part  to  twelve  of  pul- 
verized sugar.  The  use  of  the  mercurial  collar  for  the  neck  in  the  treatment 
of  croup,  employed  and  recommended  by  Bretonneau,  is  familiar  to  those 
who  have  read  his  memoirs.  Professor  Jacobi  also,  who  has  probably  given 
more  attention  to  diphtheria  than  any  other  physician  in  America,  apparently 
believes  that  mercury  used  locally  is  beneficial  in  croup,  for  he  has  recently 
recommended  inunction  with  the  oleate  of  mercury  upon  the  neck  whenever 
the  bichloride  of  mercury  administered  internally  disagrees.  It  has  seemed 
to  me  that  one  or  two  large  doses  of  calomel  administered  in  the  commence- 
ment of  croup,  when  there  is  no  decided  cachexia,  do  exert  a  beneficial  action 
on  the  course  of  the  disease,  as  in  the  following  case : 

Case. — R ,  male,  aged  three  years,  began  to  be  croupy,  but  without  any 

marked  impairment  of  the  voice,  on  November  7,  1884,  The  mother  states  that 
he  has  had  sore  throat  nearly  one  week,  but  without  medical  attendance.  His 
respiration  gradually  became  more  noisy  and  difficult  till  the  evening  of  the  8th, 
when  I  was  asked  to  see  him. 

His  temperature  was  99°.     The  dyspnoea  was  such  that  the  post-clavicular. 


TREATMENT.  665 

suprasternal,  and  inframammary  regions  were  depressed  on  inspiration,  and  his 
breathing  was  noisy,  but  the  voice  liad  nearly  the  usual  clearness.  The  i'auces, 
though  red,  were  not  notably  swollen,  and  a  psmdo-nienibranous  patch  of  the 
size  of  the  little  finger-nail  lay  over  the  right  tonsil.  The  diagnosis  was  there- 
fore made  of  mild  di[)litlK'ria,  but  with  dangerous  laryngeal  stenosis,  probably 
from  the  presence  of  a  jjseudo-membrane ;  general  condition  of  the  child  good. 
8i.\  grains  of  calomel  were  i)laced  on  the  tongue,  and  inhalation  was  ordered 
by  the  steam-atomizer  of  the  following: 

li.  Liquor  potassse,  5j  ; 

A(juitf  calcis,  ()j.     Misce. 

The  record  of  November  10th  states:  Resp.  38  per  minute,  still  noisy,  but  no 
increase  of  dyspncea;  pulse  126;  temperature  in  groin  993°;  slight  discharge 
from  nostrils ;  uses  the  inhalation  almost  constantly.  From  this  date  the  pseudo- 
membrane  and  redness  of  the  fauces  gradually  disappeared,  and  two  days  later 
the  patient  was  out  of  danger. 

The  results  of  the  treatment  of  diphtheria  and  of  the  inflammations  which 
accompany  this  disease  are  liable  to  produce  an  erroneous  opinion  in  regard 
to  the  value  of  therapeutic  agents,  since  cases  differ  so  greatly  in  type  or 
severity.  But  the  expei'ience  of  many  physicians  justifies  the  belief  that 
mercury,  and  especially  calomel,  employed  within  certain  limits  in  the  com- 
mencement of  a  pseudo-membranous  inflammation,  does  exert  some  control- 
ling action  on  this  disease.  That  it  did  much  harm  formerly,  when  physicians 
prescribed  it  freely  to  the  extent  in  many  instances  of  increasing  the  cachexia 
and  causing  mercurialism,  should  not  deter  from  its  judicious  use.  In  the 
ordinary  form  of  diphtheria  I  would  not  advise  the  use  of  calomel,  or  would 
limit  its  employment  to  one  or  two  doses  of  six  or  ten  grains  in  the  commence- 
ment of  the  disease  in  robust  cases.  But  in  croup,  since  the  danger  is  not 
from  the  cachexia  or  blood-poisoning  so  much  as  from  the  lai'yngeal  stenosis 
which  usually  develops  rapidly,  that  medicine  is  indicated,  and  should  be  pre- 
scribed, which  most  strongly  retards  the  exudative  process  and  aids  in  lique- 
fying and  removing  the  pseudo-membrane  ;  provided  that  it  produce  no  dele- 
terious effect  which  renders  its  use  inadmissible.  Hence  it  is  proper  to 
prescribe  calomel  in  larger  doses  and  for  a  longer  time  in  the  treatment  of 
croup  than  in  other  forms  of  membranous  inflammation,  if  it  fulfil  the  indica- 
tion, as  it  seems  to  in  a  measure.  In  my  own  practice,  however,  calomel  is 
not  prescribed  after  the  first  or  second  day,  since  I  prefer  the  use  of  other 
remedial  measures  which  are  efficient  and  are  less  likely  to  produce  injurious 
effects.  It  is  certainly  the  opinion  of  the  majority  of  New  York  physicians. 
in  which  I  concur,  that  after  the  first  day  corrosive  sublimate  is  preferable 
to  other  forms  of  mercury  for  internal  use,  inasmuch  as  most  cases  of  mem- 
branous croup  occur  as  a  manifestation  or  complication  of  the  microbic  dis- 
ease diphtheria. 

Emetics. — These  have  been  largely  used  in  all  forms  of  croup,  and  in 
catarrhal  or  spasmodic  croup  they  usually  produce  marked  relief.  Formerly, 
emetics  were  much  employed  in  the  treatment  of  membranous  croup,  but 
now  that  diphtheria  has  spread  throughout  the  country,  and  most  cases  of 
this  form  of  croup  occur  in  patients  suffering  from  diphtheritic  blood-poison- 
ing, depressing  emetics,  as  ipecacuanha  and  antimony,  have  fallen  into  disuse, 
since  they  were  found  to  be  badly  tolerated.  In  my  practice  a  child  of  ten 
years  with  severe  diphtheria  and  with  commencing  croupy  symptoms  sank 
rapidly  and  died  between  two  of  my  visits,  from  exhaustion  produced  by  a 
single  large  dose  of  ipecacuanha  administered  by  anxious  parents  without  my 
advice. 

But  an  emetic  gives  partial  relief  to  the  dyspncea  in  certain  cases,  since  it 
assists  in  expelling  the  muco-pus  which  blocks  up  the  tubes  below  the  pseudo- 


mQ  MEMBRANOUS  CROUP. 

membranes,  and  sometimes  portions  of  pseudo-membrane,  which  are  easily 
detached.  If  an  emetic  be  employed,  one  should  be  selected  which  acts 
promptly  with  little  depression,  and  as  a  rule  it  should,  I  think,  only  be  used 
at  the  commencement  of  croup.  If  after  the  initial  period  there  be  that 
degree  of  dyspnoea  which  suggests  its  use,  intubation  is  preferable  as  more 
likely  to  give  relief  and  save  the  patient.  Of  the  emetics  which  are  admissi- 
ble in  the  commencement  of  croup,  sulphate  of  copper  is  one  of  the  best. 
Several  years  since,  in  one  case  in  which  there  were  at  my  first  visit  dyspnoea, 
croupy  cough,  and  a  pseudo-membrane  over  each  tonsil,  and  in  regard  to  which 
I  had  made  an  unfavorable  prognosis,  the  parents,  observing  the  good  effects 
of  two  grains  of  sulphate  of  copper,  repeated  the  dose  every  two  to  four  hours 
till  the  following  day,  and  the  patient  recovered.  Such  a  result,  however,  I 
regard  as  exceptional.  Probably  in  ordinary  cases  the  best  emetic  is  the 
yellow  sulphate  of  mercury  or  turpeth  mineral  in  a  powder  of  two  or  three 
grains.  The  use  of  this  emetic  in  croup  was  prominently  brought  to  the 
notice  of  the  profession  by  Prof.  Fordyce  Barker,  who  administered  this 
agent  immediately  after  being  summoned  to  a  case,  and,  he  alleges,  with 
remarkable  benefit  to  his  patient.  It  has,  however,  been  recently  stated  on 
apparently  good  authority  that  turpeth  mineral,  when  it  enters  the  stomach, 
although  it  causes  vomiting,  is  not  itself  ejected  unless  in  small  quantity,  so 
that  a  considerable  part  of  its  action  may  be_ through  its  absorption,  its  mode 
of  action  being  like  that  of  calomel. 

Internal  Disinfectants  or  Germicides. — The  theory  which  happens  to  pre- 
vail regarding  the  nature  of  a  disease  necessarily  influences  the  treatment. 
The  theory  is  now  accepted  that  diphtheria  is  produced  by  a  microbe,  and 
hence  the  use  of  antiseptic  internal  remedies  is  proper  in  the  treatment  of 
croup  when  it  supervenes  as  one  of  the  manifestations  of  diphtheria.  There- 
fore the  most  active  of  the  germicides,  corrosive  sublimate,  is  commonly 
employed  in  New  York,  as  we  have  stated  above,  in  the  treatment  of  diph- 
theritic croup,  in  the  same  manner  as  in  other  forms  of  diphtheria. 

Since  membranous  croup  in  localities  where  diphtheria  prevails  is  in  most 
instances  a  local  manifestation  of  this  disease,  the  same  sustaining  general 
treatment  is  required  which  is  proper  in  ordinary  cases  of  diphtheria.  The 
tincture  of  the  chloride  of  iron,  administered  every  second  hour  in  liberal 
doses,  potassium  chlorate,  quinine,  brandy  or  other  form  of  alcohol  in  large 
and  frequent  doses,  long  used  in  diphtheria  as  tonics  and  blood-restorers,  are 
indicated.  Medicines  of  this  kind  may  be  given  between  those  which  are 
designed  to  correct  the  exudative  process  and  aid  in  removing  the  laryngeal 
obstruction,  which  have  been  described  above.  The  diet  should  be  nutri- 
tious and  easily  digested,  consisting  largely  of  milk  and  the  meat  teas.  For 
those  with  poor  appetite  and  feeble  digestion  peptonized  milk  and  the  pep- 
tonized meat  juices  may  often  be  advantageously  prescribed. 

Surgical  Trefl.tment. — Although  the  best  possible  treatment  by  inhala- 
tions and  internal  medication  be  early  employed  and  without  intermission, 
yet  it  is  the  common  experience  in  all  countries  that  such  treatment  is  in  a 
large  proportion  of  cases  inadequate,  and  that  many  perish  from  suffocation 
unless  relieved  by  surgical  interference.  We  have  stated  above  that  if 
croup  occur  at  the  commencement  of  diphtheria,  when  the  exudative  process 
is  active  and  the  pseudo-membranes  form  rapidly  and  abundantly,  death  is 
the  common  result  if  the  medicinal  treatment  only  be  employed.  But  if 
the  inflammation  be  less  intense  or  subacute,  as  in  the  second  week  in  diph- 
theria, so  that  there  is  more  time  for  the  action  of  medicines  and  inhalations, 
and  if,  as  is  sometimes  the  case,  the  stenosis  appear  to  be  at  a  standstill, 
without  any  marked  sufi"ering  from  want  of  air,  resort  to  surgical  measures 
may  be  judiciously  postponed. 


INTUBATION.  667 

The  indications  for  surgical  interference  are  a  gradual  increase  of  the 
stenosis  and  consequent  dyspnoea,  notwithstanding  the  constant  and  judicious 
use  of  remedial  agents,  and  a  manifest  suffering  from  want  of  air  as  shown 
by  restlessness  of  the  child  and  the  expression  of  suffering  in  his  features, 
with  or  without  lividity  of  the  surface.  We  adults  may  have  some  faint 
conception  of  the  suffering  which  children  with  acute  laryngeal  stenosis 
undergo  when  we  have  sevei'e  nasal  catarrh  and  attempt  to  breathe  with  the 
mouth  closed ;  and  the  paramount  duty  of  the  physician  to  relieve  suffering 
should  prompt  to  a  resort  to  other  measures  when  medicines  prove  inade- 
■Cjuate,  even  if  we  leave  out  of  account  the  important  object  of  saving  life. 
When,  therefore,  membranous  croup  is  found  to  be  progressive  after  having 
been  observed  and  properly  treated  from  six  to  twenty-four  hours,  and  the 
child  begins  to  suffer  from  want  of  air,  the  propriety  of  surgical  measures 
should  be  considered. 


CHAPTER   lY. 
INTUBATION. 

The  most  important  improvement  made  in  recent  years  in  the  treatment 
of  croup  is  intubation,  for  which  the  profession  are  indebted  entirely  to  the 
genius  and  perseverance  of  Dr.  Joseph  O'Dwyer.  Intubation  is  destined 
in  the  future  to  prevent  an  immense  amount  of  suffering  in  the  various  forms 
of  laryngeal  stenosis.  It  has  rescued,  and  will  rescue,  multitudes  of  chil- 
dren from  a  most  painful  death  by  suffocation.  It  is  an  operation  of  remark- 
able simplicity,  quickly  performed,  without  the  use  of  aneestheties  and  with- 
out pain  to  the  patient.  In  this  respect  it  contrasts  strikingly  with  laryn- 
gotomy  or  tracheotomy,  which  is  a  painful  and  bloody  operation,  and  which, 
for  its  proper  performance,  requires  more  or  less  delay.  Those  who  have 
witnessed  the  slow  suffocation  of  children  in  membranous  croup  and  catarrh- 
al croup  when  accompanied  by  oedema  and  infiltration  can  best  appreciate  the 
value  of  intubation. 

In  1858,  Bouchut  published  a  paper  on  the  treatment  of  croup  by  intu- 
bation of  the  larynx.  He  employed  a  straight  cylindrical  tube  nearly  an 
inch  long.  The  tube  was  introduced  by  means  of  a  male  catheter  open  at  its 
two  ends.  Intubation  excited  some  attention  and  discussion  at  the  time  in 
the  Parisian  capital,  and  M.  G-ros  related  a  case  of  its  successful  employment. 
But,  performed  with  such  rude  instruments,  it  met,  as  might  be  expected, 
with  strong  opposition  from  the  first  by  such  men  as  Barthez  and  Trousseau, 
who  were  bringing  forward  tracheotomy,  and  it  soon  fell  into  disuse  and  was 
forgotten.  It  was  reserved  for  American  surgery  to  achieve  the  honor  of  its 
succes.sful  employment.  Dr.  O'Dwyer,  wholly  ignorant  of  the  previous  his- 
tory of  intubation,  after  many  measurements  of  the  larynx  of  the  cadaver, 
many  discouragements,  and  many  modifications  in  the  tubes  to  facilitate 
their  introduction  and  retention,  has  so  improved  them  that  the  objection  to 
their  use  strongly  urged  by  Trousseau  thirty  years  ago,  that  they  caused 
ulceration,  is  inapplicable  to  the  tubes  now  in  use.  Dr.  O'Dwyer  has  kindly 
contributed  the  following  paper  descriptive  of  this  operation : 


668  im'UBATIOK 

Intubation. 
By  Joseph  O'Dwyer,  M.  D. 

In  the  following  pages  I  will  confine  myself  to  the  practical  details  of  this 
operation,  as  applicable  to  those  forms  of  stenosis  of  the  larynx  that  occur 
almost  exclusively  in  children.  The  reader  is  referred  to  the  appropriate  sec- 
tions of  this  book  for  information  in  regard  to  the  diagnosis,  medical  treat- 
ment, etc.  of  croup  and  kindred  diseases. 

A  very  serious  impediment  to  the  success  of  intubation,  and  one  for  which 
there  is  no  remedy,  arises  from  the  large  number  of  grossly-imperfect  instru- 
ments that  are  constantly  being  made  and  sold  as  the  latest  improvements.  I 
will  therefore  first  endeavor  to  point  out  some  of  the  grosser  defects  referred 
to,  in  order  that  every  one  who  uses  these  tubes  may  be  able  to  distinguish 
the  good  from  the  bad. 

The  most  common  defect,  and  at  the  same  time  the  one  attended  with  the 
most  serious  consequences,  is  apparently  so  insignificant  that  it  is  often  over- 
looked by  the  manufacturers,  even  after  their  attention  has  been  repeatedly 
called  to  it.  It  results  from  filing  the  metal  so  thin  on  the  anterior  surface 
of  the  distal  extremity  as  to  produce  a  cutting  edge  at  this  point.  It  should 
be  remembered  that  this  part  of  the  tube  is  not  only  in  contact  with  the  ante- 
rior wall  of  the  trachea,  but  that  it  also  moves  up  and  down  over  a  space  of 
about  half  an  inch  during  every  act  of  swallowing.  This  position  is  pro- 
duced by  the  backward  pressure  of  the  base  of  the  tongue,  which  pushes  the 
epiglottis  and  the  upper  extremity  of  the  tube  before  it  with  considerable 
force,  tilting  the  lower  extremity  forward,  which  glides  upward  as  the  larynx 
is  raised  and  the  trachea  stretched,  to  fall  back  to  what  may  be  called  its  res- 
piratory position  as  soon  as  the  act  of  swallowing  is  completed. 

If  sharp,  or  even  in  the  slightest  degree  rough,  at  the  point  indicated,  a 
proportionate  degree  of  injury  will  be  inflicted  on  the  mucous  membrane, 
sometimes  amounting  to  a  deep  ulcer,  which  adds  to  the  danger  of  systemic 
infection  and  gives  rise  to  painful  deglutition  and  bloody  expectoration. 

In  the  perfect  tube  the  metal  on  the  anterior  surface  is  left  quite  thick 
and  smoothly  rounded  off  like  the  runner  of  a  sled,  so  that  it  will  glide  up 
and  down  over  the  tissues  without  injuring  them.  As  the  distal  extremity 
of  the  tube  seldom  impinges  on  the  posterior  wall  of  the  trachea,  and  never 
touches  the  sides,  the  metal  at  these  points  should  be  comparatively  thin,  to 
avoid  increasing  the  size,  but  the  whole  should  form  a  perfectly  smooth  probe- 
point  when  the  obturator  is  in  position.  If  the  obturator  do  not  project  far 
enough  beyond  the  end  of  the  tube,  or  if  it  fit  imperfectly,  the  sharp  edges 
will  be  left  unprotected,  which  will  injure  the  tissues  while  passing  through 
the  narrowed  glottis. 

The  metal  is  also  left  thick  on  the  anterior  surface  of  the  upper  extrem- 
ity in  order  to  prevent  the  formation  of  a  cutting  edge  under  the  epiglottis. 
The  head  or  shoulder  of  the  tube  which  rests  in  the  vestibule  of  the  larynx, 
and  which  is  compressed  by  the  action  of  the  constrictor  muscles  in  every 
act  of  swallowing,  should  be  absolutely  free  from  any  roughness  or  projecting 
angles  or  edges.  This  portion  of  the  tube,  about  a  quarter  of  an  inch  in 
length,  has  a  backward  curve  to  carry  it  away  from  the  base  of  the  epiglottis, 
where  a  perfectly  straight  tube  would  be  liable  to  produce  ulceration. 

Another  very  common  defect  is  the  imperfect  fitting  of  the  obturator, 
which  allows  the  tube  to  wabble  when  attached  to  the  introducer,  and  causes 
it  to  slip  off  if  the  operation  fail  to  place  it  in  the  larynx  on  the  first 
attempt.  The  instrument-makers  find  it  very  difiicult  to  overcome  this  defect, 
owing  to  the  joint  in  the  shank  of  the  obturator  and  the  backward  curve  that 
exists  in  the  upper  portion  of  the  tube. 


INTUBATION. 


669 


If  properly  made,  the  tube  when  attached  to  the  introducer  and  ready  for 
use  should  be  as  free  from  motion  as  if  constructed  of  one  piece. 

I  have  also  noticed  in  many  of  the  sets  of  instruments  otherwise  imper- 
fect that  the  lines  indicating  the  years  on  the  scale  do  not  correspond  to  the 
length  of  the  tubes,  which  renders  it  difficult  lor  a  beginner  to  select  the 
proper  size.  By  observing  the  following  rule  the  scale  can  be  dispensed 
with  :  The  smallest  size  is  suitable  for  the  first  year  of  life,  the  second  for 
the  second  year,  and  the  third  size  for  from  two  to  four  years,  and  the  others 
for  two  years  each. 

A  set  of  intubation  instruments  suitable  fur  children  up  to  the  age 
of  puberty  consists  of  sis  tubes  (r),  an  introducer  (a)  and  extractor 
('•),  a  mouth-gag  (h),  and  a  scale  of  years  ('/)  ;  /',  introducer  and  tube ; 
g,    a  large    round  tube  used  for  the  expulsion  of  membrane.     Each  tube  is 

1  Fig.  41. 


Intubation  Instruments. 


supplied  with   a    separate    obturator,   one    end  of   which   screws    on  to   the 

introducer,  while  the  other  extends  sufficiently  beyond  the  distal  extremity 

1  Geo.  Ermold,  204-206  East  Twenty-third  Street,  New  York. 


670  INTUBATION. 

of  the  tube  to  convert  the  whole  into  a  probe-point.  The  numbers  on  the 
scale  represent  years,  and  indicate  approximately  the  ages  for  which  the 
corresponding  tubes  are  suitable.  For  example,  the  smallest  size  when 
applied  to  the  scale,  including  the  head  or  shoulder,  will  reach  the  line 
marked  1,  and  is  suitable  for  the  first  year  of  life,  but  may  be  used  up  to 
fifteen  or  eighteen  months  if  the  child  be  small  for  its  age. 

The  next  size,  which  reaches  the  line  marked  2,  is  intended  for  children 
between  one  and  two  years,  but  may  be  used  up  to  three  years,  the  only 
objection  being  that  it  is  liable  to  be  coughed  out.  The  third  size,  marked 
3-4  on  the  scale,  should  be  used  between  the  ages  of  two  and  four  years ; 
and  so  on. 

The  largest  tube  in  the  set  may  be  used  in  the  early  years  of  adolescence 
by  having  a  string  attached,  but  is  of  no  use  in  the  adult  larynx,  as  it  would 
either  be  expelled  immediately  or  pass  through  into  the  trachea. 

When  the  proper  tube  for  the  age  is  coughed  out,  there  is  always  room  for 
the  next  larger  size.  In  one  case,  of  an  infant  aged  twenty  months,  in  which 
the  two-year-old  tube  was  twice  expelled,  I  was  obliged  to  insert  the  3-4  size. 

Indications  for  Intubation. — As  the  indications  for  this  operation  are  the 
same  as  for  tracheotomy,  the  reader  is  referred  to  the  proper  section  of  this 
work  for  information  on  this  subject. 

Method  of  Operating. — A  tube  of  proper  size  for  the  age  is  first  selected, 
and  strong  silk  or  linen  thread  passed  through  the  eyelet  intended  for  this 
purpose.  In  case  the  tube  is  placed  in  the  oesophagus  instead  of  the  larynx, 
it  quickly  passes  into  the  stomach,  drawing  the  string  with  it,  unless  the 
latter  be  held.  To  guard  against  this  accident,  therefore,  the  thread  should 
be  left  long  enough  to  reach  the  stomach  and  still  protrude  from  the  mouth. 

The  obturator  is  then  screwed  tightly  to  the  introducer  and  passed  into 
the  tube  when  it  is  ready  for  use.  The  antero-posterior  or  long  diameter  of 
the  tube  should  then  be  in  a  line  with  the  handle  of  the  introducer.  If  the 
obturator  be  found  to  turn  too  far  to  bring  it  in  this  position,  which  usually 
occurs  after  having  been  used  for  some  time,  a  washer  of  writing-paper  of 
one  or  more  thicknesses  can  be  added. 

It  is  always  advisable  to  push  the  tube  off  once  or  twice  before  inserting 
it,  to  be  certain  that  it  works  easily.  The  person  who  holds  the  child  should 
be  seated  on  a  solid  chair  with  low  back,  and  the  patient  placed  on  the  lap 
with  its  head  resting  on  the  left  shoulder  of  the  nurse,  to  avoid  interference 
with  the  gag.  The  hands  may  either  be  held  or  secured  by  the  sides  by  pass- 
ing a  towel  or  napkin  around  the  body,  and  retained  in  that  position  until  the 
tube  is  inserted  and  the  string  removed.  Failure  to  pay  particular  attention 
to  this  precaution  is  often  the  cause  of  much  annoyance  to  the  operator,  for 
if  the  child  gets  its  hands  free  for  an  instant,  it  seizes  the  thread  and  removes 
the  tube.  Fastening  the  hands  in  front  of  the  chest  or  thick  garments  in 
the  same  location  are  objectionable,  as  they  render  it  difiicult  to  depress  the 
handle  of  the  introducer  sufiiciently  to  carry  the  tube  over  the  dorsum  of 
the  tongue. 

The  gag  should  be  inserted  in  the  left  angle  of  the  mouth,  well  back, 
between  or  behind  the  teeth  if  practicable,  and  opened  as  widely  as  possible 
without  using  too  much  force.  In  children  who  have  not  at  least  one  double 
tooth  on  the  left  side  the  gag  should  not  be  used,  as  it  slides  forward  on  the 
gums,  and,  besides  being  in  the  way,  is  likely  to  injure  the  incisor  teeth. 
There  is  little  difficulty  in  keeping  the  mouth  sufficiently  open  with  the  finger, 
and  no  danger  of  being  bitten  if  it  be  kept  well  to  the  patient's  right.  The 
necessity  of  using  force  is  obviated  by  allowing  the  child  to  compress  the 
finger  for  a  few  seconds  until  the  jaws  relax,  before  carrying  back  into  the 
pharynx.     The  Denhard  gag,  which  is  shown  in  the  cut,  holds  better  than 


INTUBATION.  671 

the    one    originally   devised    by   the    author,   and    seldom    slips   if   properly 
placed. 

An  assistant,  standing  behind,  holds  the  head  firmly  by  placing  one  hand 
on  either  side,  and,  if  without  exp(!ricnce,  should  be  requested  not  to  touch 
the  gag.  The  operator,  either  standing  or  sitting  in  front  of  the  patient,  the 
former  position  being  preferable,  holds  the  introducer  lightly  between  the 
thumb  and  fingers  of  the  right  haiul,  with  the  thumb  resting  just  behind  the 
button  that  serves  to  detach  the  tube,  and  the  index  finger  in  front  of  the 
trigger-support  underneath.  Held  in  this  position,  it  is  impossible  to  use 
force  enough  to  make  a  false  passage,  while  if  firmly  grasped  in  the  hand  the 
beginner  is  very  liable  to  lacerate  the  tissues. 

The  index  finger  of  the  left  hand  is  now  quickly  passed  well  down  in  the 
pharynx  or  beginning  of  the  oesophagus,  and  then  brought  forward  in  the 
median  line,  raising  and  fixing  the  epiglottis,  while  the  tube  is  guided  beside 
the  finger  into  the  larynx. 

If  any  difficulty  be  experienced  in  feeling  the  epiglottis,  it  is  better  to 
seek  the  cavity  of  the  larynx,  a  cul-de-sac  into  which  the  tip  of  the  finger 
readily  enters,  and  which  cannot  be  mistaken  for  anything  else.  Once  in  this 
cavity,  the  epiglottis  must  be  in  front  of  the  finger,  and  the  latter  is  then 
raised  and  carried  to  the  patient's  right  in  order  to  leave  room  for  the  tube 
to  pass  beside  it.  As  the  larynx  contracts  when  touched,  thereby  diminish- 
ing its  aperture,  it  is  necessary  to  keep  the  distal  extremity  of  the  tube  close 
to  the  finger,  or  even  directing  it  a  little  obliquely  to  the  right  in  order  to  get 
inside  the  left  aryepiglottic  fold.  This  is  particularly  important  in  very  young 
children,  in  whom  the  tip  of  the  finger  completely  covers  the  larynx. 

In  the  beginning  of  the  operation  the  handle  of  the  introducer  is  held 
close  to  the  patient's  chest,  and  rapidly  raised  as  the  lower  end  of  the  tube 
passes  behind  the  epiglottis ;  otherwise,  it  slips  over  the  larynx  into  the 
oesophagus. 

When  the  tube  is  inserted,  it  is  slipped  off  by  pressing  forward  the  button 
on  the  upper  surface  of  the  handle  with  the  thumb,  while  counter-pressure 
is  made  by  the  index  finger  underneath.  In  removing  the  obturator  the  tube 
must  be  held  down  by  placing  the  finger  either  on  the  side  or  posterior  por- 
tion of  the  shoulder.  The  tube  should  be  carried  well  down  before  being 
detached,  otherwise  it  is  liable  to  become  occluded  with  false  membrane  when 
subsequently  pushed  home  with  the  finger.  When  the  tube  is  in  place  the 
gag  is  removed,  but  the  string  is  allowed  to  remain  for  about  ten  minutes, 
or  until  it  is  ascertained  with  certainty  that  the  dyspnoea  is  relieved  and  that 
no  loose  membrane  is  pi'esent  in  the  lower  portion  of  the  trachea. 

In  removing  the  thread  the  finger  must  be  reinserted  to  hold  the  tube 
down,  but  the  reinsertion  of  the  gag  is  rarely  necessary  for  this  purpose. 
The  extraction  of  the  tube  is  much  the  most  difficult  operation,  and  at  the 
same  time  the  most  dangerous  as  far  as  injury  to  the  larynx  is  concerned. 
The  patient  is  held  in  the  same  position  as  for  insertion,  and  the  extractor  is 
guided  along  beside  the  finger,  which  is  first  brought  in  contact  with  the  head 
of  the  tube,  and  then  carried  to  the  right  in  order  to  uncover  the  aperture  and 
leave  room  for  the  instrument  to  enter  beside  it. 

Before  inserting  the  extractor  it  should  be  ascertained  with  certainty  that 
the  tube  is  still  in  the  larynx.  This  can  be  determined  by  the  tubal  charac- 
ter of  the  cough,  which  is  characteristic,  the  difficulty  of  swallowing,  and, 
lastly,  by  the  sense  of  touch  if  necessary. 

Difficulties  of  the  OjK'ratlon. — Few  who  have  not  practised  intubation 
recognize  the  fact  that  it  is  a  difficult  operation  to  perform,  and  that  it  is 
difficult  simply  because  it  must  be  done  quickly  and  at  the  same  time  gently. 
Sufficient  dexterity  to  fulfil  both  of  these  requii'ements  can  only  be  acquired 


672  INTUBATION. 

by  a  great  deal  of  practice,  and  if  this  be  gained  on  the  living  sixbject  it  must 
be  at  the  expense  of  a  great  deal  of  unnecessary  suffering  and  the  sacrifice 
of  many  lives  as  well.  It  is  the  sense  of  touch  alone  that  is  to  be  relied 
upon,  and  that  requires  to  be  educated ;  consequently,  the  accomplished 
larjmgologist  who  has  only  educated  his  sense  of  sight  is  no  more  competent 
to  perform  the  operation  than  one  who  has  never  seen  the  larynx  in  its  nor- 
mal position. 

The  operator  has  so  many  movements  to  make,  involving  both  hands,  in 
such  a  brief  space  of  time,  that  unless  he  have  had  sufficient  practice  to  make 
some  of  these  movements  to  a  certain  extent  automatic,  he  cannot  operate 
with  safety  to  his  patient  nor  with  credit  to  himself.  The  epiglottis  must  be 
found,  raised,  and  held  in  this  position  as  the  tube  is  glided  down  in  contact 
with  the  finger,  otherwise  the  operator  does  not  know  where  it  is ;  it  has  to 
be  slipped  off  at  the  right  moment,  and  held  down  while  the  obturator  is 
being  removed  ;  and  to  be  safe  all  these  movements  must  be  completed  in  less 
than  ten  seconds. 

Intubation  should  therefore  never  be  attempted,  except  in  case  of  emer- 
gency, without  some  preliminary  practice,  either  on  the  cadaver,  on  one  of  the 
smaller  animals,  or  on  a  larynx  removed  from  the  body.  Let  the  beginner 
who  has  never  performed  either  opei'ation  choose  tracheotomy  rather  than 
intubation  as  being  the  safer,  because  in  the  former  he  can  see  what  he  is 
doing  and  his  patient  can  bi'eathe  during  the  progress  of  the  operation.  Prac- 
tice on  a  child's  cadaver  is  within  the  reach  of  comparatively  few,  but  it  can  be 
done  on  that  of  one  of  the  smaller  animals,  such  as  a  cat  or  dog,  with  prac- 
tically the  same  result — viz.  education  of  the  sense  of  touch  and  automatism 
in  some  of  the  movements. 

In  addition  to  a  moderate  amount  of  this  kind  of  practice,  every  young 
operator  should  keep  a  small  larynx  in  preservative  fluid  on  which  he  can 
continue  to  practise  at  frequent  intervals  by  placing  it  upright  in  the  neck 
of  a  bottle  or  other  receptacle  in  the  same  relative  position  which  it  occupies 
in  the  body. 

There  is  no  doubt  that  dexterity  in  the  use  of  these  instruments  can  be 
acquired  in  this  manner ;  and  this  is  particularly  important  in  extracting  the 
tube,  which  is  so  difficult  to  do  without  injuring  the  larynx. 

The  difficulty  sometimes  experienced  in  intubating  older  children  who 
offer  resistance  is  to  a  great  extent  obviated  by  placing  their  legs  between 
the  knees  of  the  person  acting  as  nurse  and  holding  them  firmly  in  that 
position. 

Accidents  and  Dangers  of  Intuhation. — The  most  serious  of  the  avoidable 
accidents  attending  this  operation  is  asphyxia,  from  holding  the  finger  too 
long  in  the  throat.  It  should  be  remembered  that  when  intubation  is  called 
for  the  patient  is  getting  very  little  air,  and  can  afford  to  dispense  with  this 
little  only  for  a  very  short  time  without  danger  to  life.  After  the  insertion 
of  the  gag  an  expert  can,  as  a  rule,  place  a  tube  in  the  larynx  in  five  seconds 
or  less,  and  without  any  shock  worth  considering.  The  novice,  on  the  con- 
trary, having  so  many  other  things  to  occupy  his  attention,  is  very  liable 
to  forget  how  long  his  finger  has  been  in  the  throat,  and  that  during  this 
time  respiration  is  practically  suspended.  A  fatal  issue  under  these  circum- 
stances is  almost  invariably  attributed  to  pushing  down  membrane,  which 
is  not  a  common  accident,  and  has  never  proved  immediately  fatal  in  my 
hands. 

There  is  seldom  any  danger  from  repeated  failures  to  intubate,  pro- 
vided the  finger  be  not  retained  in  the  pharynx  longer  than  ten  seconds 
at  a  time,  and  the  child  be  given  a  chance  to  get  its  breath  between  the 
attempts. 


INTUBATION.  673 

It  is  well  for  the  beginner  always  to  have  another  physician  present, 
who  while  holding  the  head  will  wateli  the  patient  closely  and  be  prepared 
to  give  some  prearranged  signal  to  stop  when  he  thinks  there  is  danger  of 
asphyxia. 

The  ventricles  of  the  larynx  seldom  offer  any  obstruction  to  the  entrance 
of  the  tube,  as  they  are  usually  obliterated  by  the  swollen  mucous  mem- 
brane and  covered  over  by  the  fibrinous  deposit  in  croup  ;  but  this  should  be 
remembered  if  any  resistance  be  encountered,  as  it  does  not  require  much 
force  to  make  a  false  passage   at  these  points. 

Pushing  down  a  mass  of  pseudo-membrane  before  the  tube  is  the  most 
serious  of  the  unavoidable  accidents  attending  intubation  in  croup.  In  the 
majority  of  cases  the  offending  membrane  is  expelled  on  the  withdrawal  of 
the  tube,  if  the  latter  be  inserted  quickly  and  as  quickly  removed  when  the 
respiration  is  found  to  be  suspended ;  and  even  if  none  be  expelled  the 
patient   is   in   no   worse   condition   than   he   was   in  before   the   operation. 

I  have  devised  and  tried  vai'ious  instruments  for  the  removal  of  pseudo- 
membrane  from  the  ti'achea,  but  I  have  found  short  cylindrical  tubes  of  large 
calibre  the  most  successful.  Being  short,  they  do  not  accumulate  masses  of 
membrane  before  them,  and,  while  overcoming  the  obstruction  in  the  glottis, 
afford  relief  to  the  dyspnoea  where  the  long  tubes  fail.  They  are  only 
intended  for  temporary  use,  as.  owing  to  their  large  size,  extensive  ulcera- 
tion would  result  if  long  retained.  The  string  should  be  left  attached  and 
secured  behind  the  ear,  by  which  the  tube  can  be  removed  at  the  end  of  four 
or  five  hours  whether  any  false  membrane  be  expelled  or  not.  The  amount 
of  dilatation  from  the  pressure  accomplished  in  this  time  will  usually  secure 
several  hours  of  relief  from  dyspnoea  and  give  ample  time  for  the  physician 
to  reach  the  patient  and  reintubate,  if  necessary.  Should  the  offending 
membrane  still  be  retained,  it  is  better  to  use  the  same  tube  on  the  recur- 
rence of  dyspnoea  than  to  again  run  the  risk  of  producing  apnoea  by  insert- 
ing the  long  one  ;  othei'wise  the  latter  is  preferable. 

These  tubes  (Fig.  41,  ^)  have  no  retaining  swell,  the  size  alone  being 
sufficient  to  retain  them.  The  metal  of  which  they  are  constructed  is  made 
very  thin,  in  order  to  have  as  large  a  lumen  as  possible,  and  they  can  also  be 
used  to  facilitate  the  expulsion  of  foreign  bodies  from  the  lower  air-passages. 
Under  these  circumstances  they  can  be  left  in  position  for  a  much  longer 
time  without  danger  from  pressure,  because  the  mucous  membrane  of  the 
larynx  is  in   the  normal   condition. 

A  separate  introducer  with  long  curve  is  necessary  for  these  tubes  in 
order  to  carry  them  well  through  the  subglottic  division  of  the  larynx  before 
removing  the  obturator. 

Danger  of  Asph^/xia  from  Loose  Membrane  heloio  the  Tube. — The  ex- 
istence of  loose  membrane  below  the  tube — that  is,  in  the  lower  portion  of 
the  trachea — usually  gives  rise  to  the  following  signs  :  A  flapping  sound  with 
the  respiratory  movements,  a  hoarse  or  croupy  character  of  the  cough,  and 
obstructed  aspiration,  especially  when  forced,  as  in  the  act  of  coughing.  In 
some  cases  there  is  no  difficulty  while  the  breathing  is  quiet,  but  the  egress 
of  air  is  completely  cut  off  with  the  first  attempt  at  coughing.  The  vis  a 
tergo  thus  developed  is  often  sufficient  to  cause  the  expulsion  of  both  tube 
and  pseudo-membrane,  but  this  does  not  always  occur,  and  precautions  should 
be  taken  to  avoid  the  danger  of  sudden  death  from  this  cause. 

The  safest  plan  is  to  leave  a  string  attached,  by  which  any  one  who  is  pres- 
ent can  remove  the  tube  in  case  of  threatened  asphyxia.  Should  this  not  be 
practicable,  owing  to  the  age  or  from  other  causes,  a  smaller  tube  than  that 
indicated  by  the  scale  of  years  should  be  used,  which  would  be  more  likely  to 
be  coughed  out  in  the  event  of  its  sudden  occlusion.  Either  of  these  methods 
43 


674  INTUBATION. 

should  be  resorted  to  if  the  symptoms  of  loose  membrane  in  the  lower  part 
of  the  trachea,  absent  at  the  time  of  operation,  subsequently  show  them- 
selves. 

Premature  expulsion  of  the  tube  seldom  occurs  when  the  proper  size  has 
been  used,  and  is  rarely  attended  with  danger,  provided  the  patient  be  within 
easy  reach. 

Dangers  of  Extraction. — Cases  have  been  reported  in  which  the  tubes  as 
now  made,  with  large  heads,  have  passed  through  into  the  trachea.  This 
accident  can  only  occur  when  the  tissues  of  the  larynx,  cartilages  included, 
have  been  extensively  lacerated  by  the  extractor  by  passing  it  down  on  the 
outside  of  the  tube  and  withdrawing  it  with  force.  This  danger  has  been 
minimized  to  a  great  extent  by  the  addition  of  a  regulating  screw  to  the 
extractor,  which  prevents  the  blades  from  opening  any  wider  than  is  necessary 
to  hold  the  tube  firmly. 

No  force  is  necessary  to  remove  a  tube  from  the  larynx,  and  if  any 
appreciable  resistance  be  encountered,  it  is  pretty  certain  that  the  instrument 
is  caught  in  the  tissues.  Severe  hemorrhage  often  results  from  a  very  moder- 
ate laceration  produced  in  this  manner. 

When  the  Tube  should  he  Removed. — In  a  large  number  of  recoveries 
following  intubation  in  croup  the  average  time  the  tube  was  retained 
amounted  to  five  days.  The  longest  time  in  my  own  practice  was  twenty- 
nine  days.  The  older  the  child,  as  a  rule,  the  sooner  it  can  be  dispensed 
with.  In  very  young  children,  when  progressing  favorably  or  if  the  patient 
be  not  within  easy  reach,  it  is  better  to  leave  it  in  position  for  seven  or  eight 
days.  The  frequent  removal  of  the  tube,  unless  specially  indicated  by  a 
recurrence  of  the  dyspnoea  or  for  other  cause,  is  bad  practice,  principally 
because  of  the  irritation  produced  on  each  occasion.  In  protracted  cases,  in 
which  the  dyspnoea  returns  soon  after  the  second  or  third  removal  at  regular 
intervals  of  four  or  five  days,  it  is  safer  to  leave  it  in  position  continuously 
for  two  or  three  weeks,  unless  some  special  indication  for  its  removal  arises 
in  the  interim.  If  the  tube  be  properly  constructed  and  well  plated,  it  will 
do  no  harm  when  retained  for  this  length  of  time. 

Management  after  Intubation. — One  of  the  greatest  advantages  of  intuba- 
tion over  tracheotomy  is  the  fact  that  no  skilled  nursing  is  required  after  the 
operation.  The  most  important  part  of  the  after-treatment  consists  in  getting 
the  patient  to  take  a  sufficient  amount  of  nourishment.  The  difficulty  here- 
tofore experienced  in  this  matter  has  been  greatly  reduced  by  the  method 
suggested  by  Dr.  W.  E.  Casselberry  of  Chicago.  It  consists  in  feeding  while 
the  patient's  head  is  lower  than  the  body.  By  this  means  advantage  is  taken 
of  gravitation,  thus  allowing  any  fluid  that  may  have  entered  the  tube  to 
escape  without  the  act  of  coughing.  The  little  patient  soon  learns  this,  and 
ceases  to  object  to  the  uncomfortable  position.  For  very  young  children  at 
least  the  best  position  is  lying  on  the  back  across  the  lap,  with  the  head 
hanging  well  below  the  level  of  the  body,  and  feeding  from  a  spoon  or  bottle. 
Older  children  may  be  allowed  to  assume  any  position  they  wish,  provided 
the  head  be  lower  than  the  chest. 

Feeding  in  the  upright  position  should  always  be  by  spoon,  at  least  for 
the  first  two  or  three  days,  and  the  patient  be  given  time  and  encouraged  to 
cough  between  the  acts  of  swallowing.  By  this  means  any  danger  from  the 
entrance  of  food  is  obviated.  Nourishment  in  the  solid  and  semi-solid  forms 
— which  are  swallowed  better  than  liquids — should  be  given  the  preference 
when  children  can  be  induced  to  take  them. 

Rectal  feeding  is  rarely  necessary,  but  when  resorted  to  should  be  given 
in  small  quantities — not  over  two  ounces — and  at  intervals  of  three  or  four 
hours. 


TEA  CHEOTOMY.  675 

No  food  or  medicine  should  be  given  for  two  or  three  hours  after  intuba- 
tion, unless  the  presence  of  the  tube  fail  to  excite  sufficient  cough  to  get  rid 
of  accumulated  secretions.  It  is  principally  by  the  act  of  coughing  that  the 
tube  is  kept  clear,  and  if  this  does  not  occur  voluntarily,  it  may  be  excited 
by  giving  some  irritating  substance,  such  as  carbonate  of  ammonia,  brandy 
strong  or  slightly  diluted,  etc.  If  this  plan  be  adopted  and  the  air  of  the 
room  be  kept  well  saturated  with  warm  vap(jr,  it  will  rarely  be  found  neces- 
sary to  remove  a  tube  for  the  purpose  of  cleaning  it.  The  presence  of  a 
tube  in  the  larynx  does  not  contraindicate  the  use  of  an  emetic,  which  i.s 
sometimes  necessary  when  the  bronchi  are  loaded  with  secretions. 

Tracheotomy. 

Prior  to  the  employment  of  intubation  by  O'Dwyer,  tracheotomy  was 
one  of  the  most  important  operations  in  surgery.  Properly  performed  and 
at  the  proper  time,  with  judicious  after-treatment,  it  has  rescued  many  chil- 
dren from  a  most  painful  death.  The  details  of  this  operation  are  given  in 
surgical  treatises,  but  some  general  remarks  relating  to  it  will  not  be  inap- 
propriate here. 

Sanne  says  that  the  operator  should  have  three  assistants,  at  least  one  of 
them  a  physician.  One  should  administer  chloroform,  one  use  the  sponge, 
and  the  third,  a  physician,  should  be  ready  to  assist  in  handing  instruments, 
ligating  vessels,  etc.  The  operation  is  simple  and  devoid  of  danger,  or 
difficult  and  dangerous,  according  to  circumstances.  The  younger  the  child, 
the  greater  the  danger,  other  things  being  equal.  The  greatest  difficulty  and 
risk  attend  tracheotomy  in  fleshy  infants  with  thick  and  short  necks  and  ia 
patients  who  have  extreme  dyspnoea  and  are  nearly  moribund,  so  that  the 
operator  is  compelled  to  hurry  in  the  operation  through  fear  that  death  will 
occur  before  the  trachea  is  opened.  The  operator  should  have  time  for  slow 
and  cautious  dissection,  that  he  may  avoid  wounding  vessels  and  other  import- 
ant parts. 

The  patient  to  be  operated  on  should  be  placed  on  his  back  on  a  table 
covered  by  a  blanket,  and  a  bottle  or  block  about  four  inches  in  diameter 
should  be  placed  under  his  neck,  so  that  the  head  is  thrown  back  at  an  angle 
of  forty-five  degrees  and  the  anterior  surface  of  the  neck  rendered  prominent. 
Chloroform  is  then  administered.  An  incision  should  be  made  through  the 
skin  in  the  median  line  one  and  a  half  to  two  inches  in  length,  according  to 
the  age,  and  extending  to  within  half  an  inch  of  the  sternum.  Thi'ough  the 
connective  tissue  to  the  trachea  the  dissection  should  be  slowly  and  cautiously 
made  with  the  point  of  the  knife,  the  scissors,  and  the  blunt  hooks  which  are 
used  to  tear  the  connective  tissue  and  draw  aside  vessels.  The  tip  of  the 
finger  occasionally  pressed  upon  the  trachea  aids  in  determining  its  location 
and  serves  to  guide  the  dissection,  which  should  always  be  in  the  median 
line.  Little  cutting  is  required  after  the  skin  has  been  divided,  but  when 
fibres  of  connective  tissue  resist  the  blunt  hooks  they  should  be  cut  either 
by  the  point  of  the  knife  or  the  scissors.  A  grooved  director  is  also  useful 
in  the  dissection,  since  by  it  the  operator  is  enabled  to  raise  and  tear  resisting 
fibres  or  detach  them  from  parts  underneath  so  that  they  can  be  more  readily 
divided. 

Some  surgeons  prefer  the  high,  others  the  low  operation.  In  the  high 
operation  the  trachea  is  found  nearer  the  surface,  and  the  vessels  in  the  way 
are  less  numerous  than  in  the  low  operation.  In  the  operation,  however,  the 
trachea  is  usually  opened  at  that  point,  whether  high  or  low,  which  is  most 
readily  reached  and  laid  bare.  When  this  tube  is  exposed  a  longitudinal 
incision  is  made  through  its  anterior  wall  sufficiently  long  to  allow  the  canula 


676  INTUBATION. 

to  be  inserted.  To  facilitate  opening  the  trachea  it  may  be  held  by  a  tenaculum 
constructed  for  the  purpose,  with  the  hook  bent  so  as  to  be  at  right  angles 
with  the  handle.  The  length  of  the  incision  through  the  trachea  should  be 
about  five-eighths  of  an  inch.  The  canula  should  not  be  immediately  intro- 
duced, but  the  patient  should  be  made  to  cough  by  inserting  a  pigeon's  quill 
down  the  trachea  into  the  bronchial  tubes.  Blood,  muco-pus,  and  shreds  of 
fibrin,  if  any  be  present,  are  expelled  through  the  opening  by  the  cough  which 
the  quill  produces.  The  canula  is  now  introduced,  with  or  without  the  aid 
of  the  tracheal  dilator.  The  one  which  is  in  common  use  is  that  devised  by 
Trousseau,  with  some  subsequent  improvements.  It  consists  of  two  concen- 
tric cylinders,  the  external  fenestrated,  and  the  disc  or  plate  which  supports 
the  tubes  is  movable  upon  them. 

The  result  depends  to  a  great  extent  on  the  subsequent  treatment.  The 
common  result  is  immediate  relief  to  the  dyspnoea,  but  unfortunately,  in  a 
large  proportion  of  cases,  the  temperature  rises  about  the  third  day  after  the 
operation  and  pseudo-membranes  begin  to  form  in  the  bronchial  tubes,  and  in 
some  instances  broncho-pneumonia  results.  Surgeons  have  endeavored  to 
prevent  the  formation  of  membrane's  in  the  bronchial  tubes  after  tracheot- 
omy by  allowing  lime-water  to  trickle  through  the  aperture  into  the  tubes. 
Perhaps  some  other  solvent  of  pseudo-membranes,  as  bicarbonate  of  soda  or 
trypsin,  might  be  preferable  for  this  purpose.  No  surgical  operation  more 
imperatively  requires  intelligent  and  attentive  after-nursing  than  tracheotomy, 
since  the  canula  needs  to  be  frequently  removed  and  cleaned  whenever  ob- 
structed by  muco-pus.  No  certain  time  can  be  foretold  for  the  removal  of 
the  canula  if  the  patient  live.  If  on  withdrawing  the  inner  tube  and  apply- 
ing the  finger  over  the  end  of  the  remaining  canula  the  patient  breathe  easily 
through  the  fenestra,  the  laryngeal  stenosis  has  probably  so  far  abated  that 
the  tube  can  be  safely  removed. 

The  following  is  a  description  of  the  instruments  in  the  ti'acheotomy  case 
of  one  of  the  most  skilful  operators  in  New  York  City,  Dr.  Fred.  Lange ;  all 
of  them  have  small  handles  like  those  of  dental  instruments : 

1.  a.  A  scalpel  with  cutting  edge  convex,  the  blade  IJ  inches  in  length 
and  its  greatest  width  |  inch.  The  scalpel  is  employed  in  dividing  the  skin 
and  in  subsequent  dissection,  h.  A  scalpel  of  same  length,  but  with  narrower 
blade  and  straight  cutting  edge,  used  for  opening  the  trachea. 

2.  Two  blunt  hooks,  with  the  hook  straight,  \  inch  in  length,  extending 
at  a  right  angle  from  the  handle,  having  a  diameter  scarcely  larger  than  a 
carpet  needle.  The  end  of  the  hook  is  slightly  bulbous.  A  considerable 
part  of  the  dissection  is  performed  by  the  blunt  hooks,  which  are  used  in 
tearing  the  connective  tissue. 

3.  Three  artery  clamps,  by  which  bleeding  vessels  or  oozing  surfaces  are 
seized,  and  the  instruments  with  their  points  attached  to  the  bleeding  surfaces 
are  dropped  upon  the  sides  of  the  neck.  They  thus  aid  in  drawing  open  the 
wound. 

4.  Tenacula :  Two  with  hooks  in  line  with  the  handle ;  two  others  with 
hooks  at  right  angles  to  the  handle  ;  the  diameter  of  the  curves  in  the  hooks 
-4-  inch.  Those  with  hooks  at  right  angles  are  employed  for  transfixing  and 
holding  the  treachea  when  it  is  to  be  opened. 

5.  Two  grooved  directors,  one  with  the  end  smaller  and  more  pointed  than 
that  of  the  other. 

6.  A  common  artery-forceps,  also  forceps  with  fine  teeth. 

7.  The  spring  hook  of  the  oculist,  employed  by  him  in  separating  the  eye- 
lids ;  it  holds  apart  the  edges  of  the  wound. 

8.  The  tracheotomy-tube,  consisting  of  two  concentric  cylinders,  described 
above. 


BRONCHITIS.  677 

9.  Pigeon's  quills  ;  these  are  important  for  removing  muco-pus  and  fibrin- 
ous shreds  from  the  trachea  and  bronchial  tubes.  An  instance  has  come  to 
my  knowledge  in  which  the  physician  who  assumed  charge  of  the  case  after 
the  operation  attempted  to  use  for  this  purpose  a  small  piece  of  sponge  held 
by  forceps  ;  he  unfortunately  loosened  his  hold,  and  the  sponge,  drawn  in  with 
the  breath,  produced  immediate  death  by  suffocation.  This  would  not  have 
happened  with  the  pigeon's  quill. 

When  the  operation  is  completed  and  the  canula  introduced,  iodoform 
should  be  dusted  upon  the  wound,  and  two  thicknesses  of  linen  soaked  with 
the  solution  of  bichloride  of  mercury,  1  part  to  2000,  notched  so  as  to  sur- 
round the  canula  and  pass  under  its  plates,  should  be  applied  over  the  wound, 
and  every  hour  moistened  with  the  bichloride  solution.  With  such  treatment 
the  wound  preserves  a  healthy  appearance  and  heals  readily. 


CHAPTER   V. 

BRONCHITIS. 

Inflammation  of  the  bronchial  tubes,  or  bronchitis,  is  probably  the  most 
frequent  disease  of  early  life.  It  is  usually  associated  with  more  or  less 
inflammation  of  the  mucous  membrane  of  the  nostrils,  larynx,  and  trachea. 
We  designate  the  disease  coryza,  laryngitis,  or  bronchitis,  according  as  one  or 
the  other  inflammation  predominates.  Sometimes  bronchitis  occurs  with  but 
slight  inflammation  elsewhere,  and  often  the  coryza  and  laryngitis  abate  while 
the  bronchitis  is  still  active. 

Bronchitis  occurs  both  as  a  primary  and  secondary  disease.  The  secondary 
form  is  common  in  connection  with  measles,  whooping  cough,  pneumonia,  and 
pulmonary  phthisis,  and  it  is  not  uncommon  in  remittent  and  continued  fevers. 
Bronchitis  is  acute,  subacute,  or  chronic,  and  according  to  its  extent  it  is  mild 
or  severe.  If  the  smallest  bronchial  tubes  are  involved,  the  inflammation  is 
designated  capillary  bronchitis — a  term  not  well  chosen,  but  which  is  conve- 
niently employed  in  a  description  of  the  malady.  Bronchitis  is  commonly 
bilateral,  afi'ecting  the  tubes  on  the  two  sides  with  about  equal  intensity. 
"When  due  to  tubercles  or  to  pneumonia  it  is  often  unilateral,  being  confined 
to  those  tubes  or  nearly  to  those  which  lie  in  the  tubercular  or  inflamed  pul- 
monary tissue. 

Causes. — The  causes  of  secondary  bronchitis  are  obviously  the  diseases 
in  connection  with  which  it  occurs.  The  cause  of  primary  bronchitis  is  the 
same  as  that  of  simple  acute  laryngitis  or  coryza — namely,  sudden  change  of 
temperature  from  warm  to  cold,  exposure  to  currents  of  air,  the  practice  of 
sending  children  without  sufficient  clothing  from  heated  rooms  into  the  open 
air,  the  throwing  off  of  bedclothes  at  night,  etc. 

Anatomical  Characters. — In  the  most  common  form  of  bronchitis  the 
larger  bronchial  tubes  only  are  affected.  They  are  the  seat  of  the  inflamma- 
tion in  most  of  those  cases  which  are  designated  "colds"  by  families,  and 
which  are  often  treated  without  the  aid  of  the  physician.  The  lining  mem- 
brane of  the  bronchial  tubes  presents  the  ordinary  anatomical  characters  of 
mucous  inflammations.  It  is  reddened  uniformly  or  in  patches,  intensely  or 
in  that  milder  degree  known  as  arborescence,  according  to  the  severity  of  the 
inflammation. 

The  secretion  of  the  muciparous  follicles  is  at  first  arrested  and  the  sur- 


678  BRONCHITIS. 

face  of  the  membrane  is  dry.  In  the  course  of  a  day  or  two  the  secretory 
function  is  re-established,  and  the  surface  is  covered  with  thin  ,and  transpa- 
rent mucus.  A  day  or  two  later  the  secretion  becomes  thicker,  consisting  of 
mucus  and  pus.  Mixed  with  these  substances  are  epithelial  cells,  which  are 
exfoliated  in  abundance  from  the  inflamed  surface.  At  the  same  time  the 
mucous  membrane  becomes  thickened  and  more  or  less  softened.  If  the 
inflammation  be  severe  the  vessels  of  the  submucous  connective  tissue  are 
also  injected. 

Usually,  in  about  a  week  in  the  young  child,  in  from  one  to  two  weeks  in 
older  children,  the  inflammation  begins  to  abate.  Gradually  the  inflamed 
membrane  returns  to  its  normal  consistence,  thickness,  and  vascularity,  and 
with  this  return  to  the  healthy  state  the  muco-purulent  secretion  abates. 

In  this,  which  is  the  simplest  and  most  common  form  of  bronchitis,  there 
is  no  ulceration,  and  rarely  any  pseudo-membranous  formation  if  the  disease 
be  idiopathic.  Pseudo-membranous  bronchitis  is  not  unusual  as  an  accom- 
paniment of  pseudo-membranous  laryngo-tracheitis. 

Were  bronchitis  limited  to  the  larger  bronchial  tubes,  it  would  indeed  be 
a  simple  affection,  but,  unfortunately,  it  has  a  tendency  to  extend  downward. 
Commencing  in  the  larger,  it  gradually  invades  the  smaller  tubes  in  a  similar 
manner  to  the  extension  of  erysipelas  upon  the  skin.  More  rarely  the  inflam- 
mation commences  simultaneously  in  the  larger  and  smaller  tubes.  The  grav- 
ity of  bronchitis  is  proportionate  to  the  degree  of  its  extension  downward.  It 
may  stop  at  any  point  in  its  progress,  but  if  it  reach  the  smaller  tubes  it  is, 
one  of  the  most  serious  affections  of  early  life. 

The  mucous  membrane  of  the  minute  tubes,  those  next  to  the  air-cells,  is 
delicate,  with  but  little  submucous  connective  tissue,  and  it  frequently,  at 
post-mortem  examinations,  does  not  present  to  the  eye  those  distinct  inflam- 
matory changes  which  are  observed  in  tubes  of  large  diameter.  It  is  some- 
times not  notably  thickened  nor  its  vascularity  much  increased,  even  when 
there  is  reason  to  believe  from  the  symptoms  that  it  was  the  seat  of  active 
phlegmasia.  As  we  pass  from  these  minute  tubes  to  those  of  larger  calibre 
the  inflammatory  lesions  become  more  distinct.  The  inflammation  produces 
minute  and  abundant  points  of  redness  and  the  membrane  is  evidently  thick- 
ened ;  often  it  is  rough  or  granular. 

The  minute  bronchial  tubes  are  very  small,  especially  under  the  age  of 
three  years,  and,  since  in  capillary  bronchitis  a  large  proportion  of  them  are 
inflamed,  the  source  of  the  danger  is  apparent.  It  is  with  difficulty  that 
the  patient  with  capillary  bronchitis  can  by  the  effort  of  coughing  free  the 
tubes  from  the  secretions  which  are  constantly  collecting  in  them.  In 
weakly  children  under  the  age  of  two  years  expectoration  is  most  dif- 
cult,  and  hence  the  great  and  increasing  dyspnoea  from  which  such  patients 
suffer. 

In  severe  and  unfavorable  cases  of  bronchitis,  which  are  chiefly  those  in 
which  the  small  as  well  as  large  tubes  are  inflamed,  the  following  anatomical 
changes  commonly  occur :  The  muco-purulent  secretion,  which  is  tenacious, 
collects  more  rapidly  in  the  smaller  tubes  than  it  is  expectorated  by  the  child, 
whose  strength  begins  to  be  exhausted.  The  accumulation  of  the  secretion 
is  chiefly  in  the  tubes  which  lie  in  the  posterior  and  inferior  portions  of  the 
lung.  As  the  obstruction  from  the  muco-pus  increases  in  these  tubes,  less 
and  less  air  passes  through  them  into  the  alveoli,  with  which  they  communi- 
cate, while  the  quantity  of  air  which  passes  through  the  unobstructed  tubes 
into  the  anterior  and  superior  portions  of  the  lung  is  proportionately  increased. 
The  effect,  as  regards  the  state  of  the  lung,  is  obvious.  In  cases  having  a 
fatal  issue,  and  in  which  we  are  therefore  able  to  inspect  the  lesions,  we  find 
that  the  lower  and  inferior  portions  of  the  organ,  from  which  air  was  to  a 


ANATOMICAL  CHARACTERS.  679 

greater  or  less  extent  excluded,  liavo  a  diuiinished  crepitation  ;  that  they  lie 
a  little  below  the  general  level,  or  that  certain  lobules  do  ;  and  that  they  pre- 
sent a  congested  appearance,  for  while  they  contain  too  little  air,  they  have 
an  excess  of  blood.  We  shall  also  find  that  the  upper  and  anterior  parts  of 
the  organ,  perhaps  the  entire  upper  lobe,  contain  more  than  the  normal  quan- 
tity of  air,  so  as  to  rise  above  the  general  level.  There  is  distension  of  the 
alveoli  in  these  parts,  so  th;it  they  are  probably  visible  to  the  naked  eye, 
and  may  appear  to  be  emphysematous ;  but  this  is  a  state  distinct  from 
emphysema.  It  is  merely  an  inflation  of  the  alveoli  to  nearly  their  full 
capacity. 

Here  and  there  in  the  portion  of  lung  in  which  the  inflation  has  been 
incomplete,  lobules  may  be  observed  which  are  entirely  collapsed,  having  a 
dusky-red  color  and  no  crepitation  ;  while  in  other  parts,  if  the  bronchitis 
have  continued  some  days,  there  are  nodules  of  pneumonia.  Often  when 
the  bronchitis  is  severe  the  inflammation,  commencing  in  the  bronchial 
tubes,  extends  to  the  lungs,  usually  to  lobules,  in  the  lower  lobes,  constitut- 
ing broncho-pneumonia.  The  occurrence  of  pneumonia  is  announced  by 
an  aggravation  of  symptoms,  and  frequently  by  the  expiratory  moan.  The 
incised  surface  of  those  portions  of  the  lung  to  which  the  access  of  air  has 
been  prevented,  whether  they  are  collapsed  fully  or  partially  or  not,  has  a 
reddish  color  from  congestion  and  is  moist  from  serum  and  blood.  On  com- 
pressing the  lung  the  muco-purulent  secretion  appears  upon  the  surface  in 
points,  having  escaped  fi'om  the  divided  ends  of  the  tubes.  (For  other  facts 
relating  to  atelectasis  the  reader  is  referred  to  the  chapter  in  which  this  mal- 
ady is  described.) 

J]xceptionally,  even  when  not  accompanied  by  laryngeal  croup,  fibrinous 
exudation  occurs  in  the  bronchial  tubes,  forming  a  delicate  film  here  and 
there,  and  readily  detached  from  the  surface  underneath,  while  in  rare 
instances  it  occurs  as  a  firm  and  continuous  membrane,  forming  a  mould 
of  the  tubes,  increasing  greatly  the  dyspnoea  constituting  a  true  bronchial 
croup.  If  the  patient  with  severe  bronchitis  survive,  the  inflammation  of 
the  mucous  membrane  soon  begins  to  abate.  The  tubes  which  have  been 
the  seat  of  the  disease  and  the  alveoli  which  have  been  secondarily  involved 
may  return  to  their  normal  state  almost  immediately  ;  but  in  other  instances 
such  anatomical  changes  occur  in  them,  even  when  there  is  no  pneumonia 
nor  atelectasis,  that  full  restoration  to  their  normal  state  is  necessarily  some- 
what slow.  When  the  function  of  a  lobule  ceases,  as  it  does  when  the  tube 
leading  to  it  is  obstructed,  not  only  hyperaemia  occurs,  with  or  without  col- 
lapse, as  already  stated,  but  its  cells  and  nuclei,  and  perhaps  other  parts, 
begin  to  undergo  fatty  degeneration.  These  elements  become  granular, 
somewhat  enlarged  and  opaque,  and  here  and  there  mixed  with  them  are 
other  large  cells  filled  with  oil-globules.  These  are  the  compound  granular 
cells  of  pathologists,  and,  occurring  in  this  situation,  are  produced  by  meta- 
morphoses of  the  epithelial  cells.  They  ave  epithelial  cells  which  have  pro- 
gressed more  rapidly  than  others  in  fatty  degeneration,  having  reached  that 
stage  of  it  which  immediately  precedes  liquefaction.  We  often  with  the 
microscope  observe  not  only  these  corpuscles,  but  their  fragments  as  they  are 
dissolving. 

Minute  abscesses,  usually  directly  under  the  pleura,  have  occasionally 
been  observed  at  the  autopsies  of  those  who  have  recently  had  general  bron- 
chitis, and  pathologists  are  not  agreed  as  to  the  mode  in  which  they  are  pro- 
duced. Some  of  them,  if  not  all,  are  evidently  connected  with  the  minute 
bronchial  tubes,  and  the  quantity  of  pus  contained  in  each  is  not  usually 
more  than  one  or  two  drops.  The  most  reasonable  view  of  their  causation  is 
that  they  are  produced  in  the  terminal  tubes  where  the  mucus  and  pus  col- 


680  BRONCHITIS. 

lect.  The  pus  acts  as  an  irritant  and  causes  inflammation,  and  the  inflamma- 
tion increases  the  quantity  of  pus.  The  walls  of  the  tube  which  is  now  the 
seal  of  an  abcess  are  destroyed  by  ulceration,  and  probably  also  some  of  the 
contiguous  air-cells.  The  little  cavity  is  soon  surrounded  by  a  delicate  mem- 
brane, the  same  in  character,  though  less  thick  and  firm,  as  that  which  con- 
stitutes the  walls  of  larger  abscesses.  The  pus  presents  the  usual  appear- 
ance of  this  liquid,  or  it  may  be  tinged  by  the  presence  of  blood-cells,  or. 
again,  it  may  be  thick  from  partial  absorption  of  the  liquor  puris  so  as  to 
resemble  softened  tubercle. 

The  abscess  is  ordinarily  located  in  the  centre  of  a  collapsed  lobule.  In 
certain  cases  it  approaches  the  surface  of  the  lungs,  so  as  to  produce  circum- 
scribed pleurisy,  with  adhesion  of  the  costal  and  visceral  pleura.  At  the 
autopsy  of  such  a  case,  on  separating  the  adhesions  and  attempting  insufila- 
tion  the  air  passes  through  the  aperture,  so  that  the  lung  on  that  side  can- 
not be  inflated  unless  the  aperture  be  closed.  Occasionally  pneumothorax 
results  from   opening  of  the  abscess  into  the  pleural  cavity. 

In  severe  protracted  bronchitis  dilatation  of  certain  of  the  bronchial  tubes 
sometimes  results.  The  alveoli  in  the  upper  lobes  may  also  be  distended 
beyond  their  physiological  capacity,  so  as  to  produce  emphysema,  but,  as  we 
have  stated  above,  their  maximum  distension  within  physiological  limits 
must  not  be  mistaken  for  emphysema.  Emphysema  in  the  upper  lobes  is 
common  in  feeble  young  children  with  relaxed  and  weakened  tissues,  occur- 
ring even  without  any  severe  disease  of  the  respiratory  organs.  It  may  be 
vesicular  or  interstitial.  If  it  be  interstitial,  the  sacs  of  air  often  attain 
considerable  size,  lying  as  wedges  between  the  alveoli  or  like  little  bladders 
upon  the  surface  of  the  lung.  It  is  not  difficult  to  understand  how  emphy- 
sema occurs  in  severe  bronchitis,  since  the  air  partly  arrested  in  the  tubes 
leading  to  the  lower  lobes  enters  the  upper  lobes  in  increased  volume  and 
force. 

Symptoms. — It  is  evident,  from  the  description  which  has  been  given  of 
the  anatomical  characters  of  bronchitis,  that  its  symptoms  vary  greatly  in 
severity  in  diff"erent  patients.  It  usually  commences  with  more  or  less  cory- 
za.  The  symptoms  are  headache,  flushed  face,  elevation  of  temperature, 
acceleration  and  fulness  of  pulse.  In  the  mildest  cases  these  symptoms  are 
scarcely  appreciable.  The  child  is  observed  to  sneeze  and  have  some  deflux- 
ion  from  the  nostrils,  and  this  is  followed  by  an  occasional  mild,  almost  pain- 
less cough,  which  declines  in  the  course  of  a  few  days.  The  respiration  and 
pulse  are  scarcely  accelerated  and  the  appetite  is  but  slightly  impaired. 
There  may  be  a  little  fretfulness,  but  the  child  is  not  confined  to  his  bed  or 
room  and  usually  amuses  himself  with  his  playthings.  Auscultation  in 
these  mild  cases  reveals  coarse  mucous  rales  in  the  larger  bronchial  tubes, 
while  the  smaller  tubes  are  free  from  mucus.  Sibilant  and  sonorous  rales 
are  also  observed,  especially  in  the  commencement  of  the  bronchitis,  at 
which  time  the  secretion  of  mucus  is  suppressed  or  scanty.  The  cough  in 
the  commencement  is  for  the  same  reason  dry.  It  becomes  looser  by  the 
second  or  third  day,  the  sputum  consisting  of  frothy  mucus,  with  the  admix- 
ture of  pus  and  epithelial  cells.  The  pus  becomes  more  abundant  as  the 
disease  continues.  Expectoration  from  the  mouth  does  not  usually  occur  till 
after  the  age  of  four  or  five  years ;  under  this  age  the  sputum  is  ordina- 
rily swallowed. 

The  mild  form  of  bronchitis  described  above,  that  in  which  only  the 
larger  tubes  are  afi"ected,  is  common  in  infancy  and  childhood,  but  bronchitis 
of  a  non-severe  type  is  also  common,  due  to  extension  of  the  inflammation. 
It  has  already  been  stated  that  there  is  a  tendency  in  bronchial  inflam- 
mation  to   extend   downward,  and   symptoms    are   proportionate   in   gravity 


SYMPTOMS.  681 

to  the  depjrce  of  this  extension.  In  severe  bronchitis  the  pulse  rises  to 
120  or  IHO  per  minute,  and  the  respiration  is  in  a  corresponding  degree 
accelerated.  The  cough  is  frequent  and  painful,  the  pain  being  referred  to 
the  sternum,  and  often  there  is  a  steady  dull  pain  in  this  region.  The  face 
is  flushed  and  indicative  of  suifering,  the  temperature  is  considerably  ele- 
vated, and  the  appetite  is  greatly  impaired  or  lost.  There  is  frequently  an 
exacerbation  of  symptoms  in-  the  latter  part  of  the  day.  Depression  of  the 
inframammary  region  during  inspiration  and  dilation  of  the  alac  nasi  accom- 
pany grave  attacks  of  the  inflammation. 

Auscultation  in  severe  bronchitis  reveals  the  presence  of  rales  in  all 
parts  of  the  chest,  sibilant  and  sonorous  sparingly,  coarse  mucous  and  sub- 
crepitant  more  abundantly. 

General  bronchitis  or  suifocative  catarrh,  the  most  dangerous  form  of  this 
inflammation,  is  less  frequent  than  bronchitis  vphich  is  limited  to  the  larger 
tubes  or  to  the  larger  tubes  and  those  of  medium  size.  It  may  commence 
quite  abruptly,  but  ordinarily  it  results  from  the  milder  form  of  the  disease. 
The  symptoms  at  first  are  such  as  occur  in  the  common  form  of  bronchial 
inflammation,  but,  instead  of  abating  or  remaining  stationary,  they  grad- 
ually increase  in  severity  till  suddenly  marked  dyspnoea  supervenes.  The 
inflammation  has  now  reached  the  minute  tubes,  and  what  promised  to 
be  an  ordinary  attack  of  bronchitis  becomes  one  of  great  severity  and 
danger. 

The  respiration  in  severe  bronchitis  is  short  and  hurried.  Sixty  to  eighty 
inspirations  per  minute  are  not  infrequent,  while  the  pulse  also  is  greatly 
accelerated,  attaining  as  high  a  number  as  140  to  160  or  180  beats  per  minute. 
The  cough  is  frequent,  and  the  sputum,  which  collects  in  abundance,  is 
expectorated  with  difficulty.  If  expectorated  so  as  to  be  examined,  it  is 
found  to  consist  largely  of  frothy  mucus  with  epithelial  cells.  After  a  few 
days,  if  the  patient  live,  it  becomes  more  purulent.  Sometimes,  as  in  bron- 
chitis of  the  adult,  streaks  of  blood  appear  upon  the  mucus.  In  the  first 
days  of  severe  acute  bronchitis  the  temperature  is  considerably  elevated,  the 
face  flushed,  and  the  breathing  oppressed.  The  patient  is  restless,  moving 
from  one  part  of  the  bed  to  another,  seeking  in  vain  for  relief.  The  diges- 
tive function  is  impaired,  as  in  all  severe  inflammations ;  the  tongue  is  moist 
and  covered  with  a  light  fur ;  the  appetite  is  nearly  or  quite  lost.  The 
infant  takes  the  breast  with  difficulty,  frequently  relinquishing  it  on  account 
of  the  dyspnoea  ;  older  children  take  no  solid  food  in  consequence  of  the  ano- 
rexia and  the  dyspnoea,  and  even  drinks  are  swallowed  hastily  and  apparently 
without  relish,  since  deglutition  interferes  with  respiration.  On  auscultation 
in  bronchitis  of  the  minute  tubes  sibilant,  and  after  a  day  or  two  subcrepi- 
tant,  rales  are  observed  in  every  part  of  the  chest.  Percussion  elicits  a 
good  resonance  unless  the  substance  of  the  lung  have  become  involved.  As 
the  disease  approaches  a  fatal  termination  the  pulse  becomes  greatly  acceler- 
ated ;  the  respiration  is  also  in  a  corresponding  degree  frequent  and  panting, 
the  inspiration  being  accompanied  by  increased  inframammary  depression 
and  dilation  of  the  alae  nasi.  The  face  becomes  pallid,  the  prolabia  livid,  and 
the  tips  of  the  fingers  livid  and  cool.  The  mucus  and  pus,  accumulating  in 
the  air-passages,  increase  more  and  more  the  obstruction  to  the  entrance  of 
air,  and  finally  death  occurs  from  apnoea.  The  nursing  infant  usually  ceases 
to  nurse  several  hours  before  death,  and  a  state  of  stupor  commonly  pre- 
cedes the  fatal  event,  due  to  the  accumulation  of  carbonic  acid  in  the  blood. 
In  young  infants,  especially  those  under  the  age  of  six  months,  not  only  in 
bronchitis  of  the  minute  tubes,  but  in  severe  ordinary  bronchitis,  I  have 
often  observed  toward  the  close  of  life  intermission  in  the  respiration.  It 
occurs  after  every  six  or  eight  or  ten  respirations,  and  equals  in  duration  the 


682  BRONCHITIS. 

time  occupied  in  perhaps  half  a  dozen  respiratory  movements.  It  is  there- 
fore an  unfavorable  prognostic  sign,  but  some  in  whom  it  occurs  recover  by 
active  stimulation. 

The  duration  of  acute  bronchitis  varies  according  to  the  extent  of  the 
inflammation.  In  the  mildest  form  the  patient  is  convalescent  after  three  or 
four  days,  and  in  severe  cases  that  terminate  favorably  the  disease  begins 
ordinarily  to  decline  by  the  close  of  the  first  week  or  in  the  second.  The 
progress  of  bronchitis  is  somewhat  more  rapid  in  young  children  than  in 
those  of  a  more  advanced  age.  When  convalescence  is  fully  established  it 
is  not  unusual  for  the  cough  to  continue  three  or  four  weeks,  though  grad- 
ually declining.  It  is  loose  and  painless,  and  is  scarcely  regarded  by  the 
patient. 

Death  sometimes  occurs  as  early  as  the  second  or  third  day  in  severe  gen- 
eral bronchitis.  The  younger  the  infant,  with  the  same  extent  and  intensity 
of  inflammation,  of  course  the  sooner  the  fatal  result.  The  ordinary  dura- 
tion of  fatal  bronchitis  is  from  six  to  eight  days.  If  the  patient  pass  beyond 
the  tenth  day,  decline  of  the  inflammation  may  be  confidently  expected,  with 
recovery,  unless  there  be  a  complication. 

Occasionally  bronchitis  becomes  chronic,  lasting  several  months  before 
it  entirely  ceases.  The  chronic  form  may  result  from  mild  as  well  as  severe 
bronchitis.  The  acute  fever  and  accelerated  respiration  which  characterize 
the  acute  affection  abate,  and  the  general  health  is  nearly  or  quite  restored  : 
but  an  occasional  cough  continues,  and  the  I'espiration  is  often  audible,  from 
the  mucus  which  collects  in  the  tubes  or  from  thickening  of  the  mucous 
membrane.  Sometimes  there  is  moderate  fever,  especially  in  the  latter  part 
of  the  day.  On  auscultation  coarse  mucous,  with  perhaps  sibilant  and  sono- 
rous, rales  are  observed  in  the  chest. 

There  is  great  liability  in  chronic  bronchitis  to  exacerbations.  The  dis- 
ease often  seems  to  be  abating  and  there  is  prospect  of  its  speedy  cure,  when 
all  the  symptoms  are  intensified.  The  exacerbations  are  due  to  the  fact  that 
the  bronchial  surface,  when  it  has  been  a  considerable  time  inflamed,  is  very 
sensitive  to  the  impression  of  cold.  Even  when  the  disease  is  entirely 
relieved  it  is  very  liable  to  return  by  exposure  to  currents  of  air  or  changes 
of  temperature.  Chronic  bronchitis  occurs  most  frequently  in  the  winter, 
spring,  and  autumn,  when  the  weather  is  changeable,  and  is  most  intractable 
in  these  periods  of  the  year.  Many  cases  of  chronic  bronchitis  are  associated 
with  dilation  of  the  bronchial  tubes  or  with  emphysema.  The  general 
health  in  this  form  of  bronchitis,  when  not  dependent  on  a  tubercular  deposit, 
ordinarily  remains  good.  Tubercular  bronchitis,  which  is  the  result  of  a 
grave  disease,  is  treated  of  in  our  remarks  on  Tuberculosis.  It  is  attended 
with  emaciation,  and  is  obstinate  on  account  of  the  nature  of  the  primary 
affection.  It  is  due  to  the  irritating  effect  of  tubercular  matter  lying  against 
the  bronchial  tubes. 

Diagnosis. — Bronchitis  can  ordinarily  be  diagnosticated  by  the  character 
of  the  respiration  and  cough.  The  absence  of  hoarseness,  stridulous  inspira- 
tion, and  croupy  cough  excludes  laryngitis,  and  the  absence  of  the  expiratory 
moan  and  of  the  stitch-like  pain  on  coughing,  which  characterize  pneumonia 
and  pleurisy,  excludes  these  diseases.  Accurate  diagnosis,  however,  can  be 
most  readily  made  by  percussion  and  auscultation.  Examination  of  the  chest 
enables  us  to  state  with  positiveness  not  only  the  nature,  but  the  extent,  of 
the  affection.  If  the  inflammation  be  confined  to  the  larger  bronchial  tubes, 
coarse  rales  are  discovered  in  them,  while  finer  mucous  rales  are  absent.  If 
the  bronchitis  be  in  the  minute  tubes,  subcrepitant  rales  are  discovered  in 
them.  Percussion  gives  clear  resonance  on  both  sides,  except  in  those  instances 
in  which  atelectasis  or  pneumonia  has  supervened. 


PROGNOSIS— TREATMENT.  683 

Prognosis. — Bronchitis  limited  to  tlie  larger  bronchial  tubes  or  to  these 
and  those  of  medium  size  terminates  favorably  in  a  large  majority  of  cases. 
Occasionally,  severe  inflammation,  not  extending  to  the  smaller  tubes,  proves 
fatal  in  young  infants  or  those  of  feeble  constitution.  Bronchitis  extending 
to  the  minute  tubes  is,  on  the  other  hand,  a  disease  of  great  danger.  It  may 
be  fatal  at  any  period  of  childhood,  but  the  younger  and  more  feeble  the 
patient  the  greater  the  liability  to  a  fatal  result.  Under  the  age  of  one  year 
it  is  one  of  the  most  fatal  diseases  of  early  life. 

The  prognosis  in  the  commencement  of  all  cases  of  bronchitis  of  average 
severity  in  the  young  child  should  be  guarded,  on  account  of  the  tendency 
of  the  inflammation  to  extend,  as  has  been  already  stated  in  the  preceding 
pages.  After  five  or  six  days  extension  ceases,  and  if  during  that  time  no 
increase  in  the  severity  of  symptoms  occurs,  the  prognosis  is  favorable. 
Signs  which  indicate  an  unfavorable  result  are  increasing  frequency  of  pulse 
and  respiration,  difficult  and  scanty  expectoration,  restlessness,  a  countenance 
expressive  of  suffering,  and  a  progressively  greater  accumulation  of  mucus 
in  the  bronchial  tubes,  as  determined  by  auscultation.  Pallor  and  coldness 
of  the  face  and  extremities,  lividity  of  the  tips  of  the  fingers,  rapid  and 
feeble  pulse,  drowsiness,  diminution  of  cough,  while  the  mucus  and  pus 
accumulate  in  the  bronchial  tubes,  and,  in  young  children,  intermissions  in 
the  respiration,  indicate  the  near  approach  of  death.  Cases  may,  however, 
recover  by  proper  treatment,  although  the  symptoms  are  most  unfavorable. 

It  is  unnecessary  to  mention  the  favorable  prognostic  signs  of  bronchitis. 
This  disease,  when  fully  established,  continues  a  certain  number  of  days  what- 
ever remedial  measures  are  employed,  and  if  the  symptoms  do  not  increase 
in  severity  during  the  first  five  or  six  days  a  favorable  result  is  highly  prob- 
able. The  prognosis  in  chronic  bronchitis  is  ordinarily  favorable,  so  far  as 
life  is  concerned,  provided  that  no  emaciation  occur.  If  there  be  emaciation 
the  bronchitis  may  be  due  to  tubercles  in  the  bi'onchial  glands  or  lungs,  and 
of  course  the  prognosis  is  less  favorable. 

Treatment. — Bronchitis  may  be  rendered  much  milder,  and  perhaps 
prevented,  by  an  emetic  employed  in  the  fir.st  twelve  or  twenty-four  hours  in 
conjunction  with  a  warm  bath.  The  physician  is  not,  however,  ordinarily 
called  sufficiently  early  to  render  this  treatment  effectual. 

Mild  Bronchitis. — In  mild  bronchitis,  the  inflammation  being  limited  to 
the  larger  tubes  or  to  these  and  those  of  medium  size,  simple,  soothing, 
expectorant,  and  laxative  remedies  are  required.  Mild  counter-irritation  may 
be  produced  by  camphorated  oil  or  a  weak  sinapism,  and  one  of  the  following 
mixtures  may  be  given.  The  late  Dr.  James  Jackson  of  Boston,  in  his  letters 
to  a  young  physician,  writes  of  the  treatment :  "  For  yOung  children  I  employ 
the  following :  Take  of  either  almond  or  olive  oil,  of  syrup  of  squills,  of  any 
agreeable  syrup,  and  of  mucilage  of  gum  acacia  equal  parts,  and  mix  them. 
Of  this  mixtui'e  a  teaspoonful  may  be  given  to  a  child  two  years  of  age ; 
a  little  less  if  younger  and  increased  if  older,  so  as  to  double  the  dose  to  one 
in  the  sixth  year.  This  may  be  given  from  three  to  six  times  in  the  twenty- 
four  hours.  Sometimes  a  little  opiate  must  be  added  at  night  to  appease  the 
urgent  cough.''  Another  good  medicine  is  the  mistura  glycyrrhiza)  com- 
posita.  half  a  teaspoonful  of  which  should  be  given  every  two  hours  to  a 
child  of  three  years  and  one  teaspoonful  to  one  of  six  years.  The  S3'rupus 
ipccacuanhte  compositus  of  the  French  Pharmacopoeia,  the  contre  de  la  tnux, 
consisting  of  ipecacuanha,  senna,  thyme,  poppy,  sulphate  of  magnesia,  orange- 
flower  water,  wine,  water,  and  sugar,  being  soothing  and  slightly  laxative,  is 
also  a  useful  remedy.  These  cases  also  do  well  with  simple  mucilaginous 
drinks  and  confinement  in   a  warm  room. 

Bronchitis  affecting  the  Medium  Size  or  Smallest  Tubes. — The 


684  BRONCHITIS. 

use  of  leeches  has  been,  for  the  most  part,  abandoned  in  the  treatment  of 
bronchitis,  not  only  in  infancy,  but  at  all  ages.  The  application  of  dry  cups 
over  the  sternum  is  recommended  by  some  judicious  physicians  as  a  proper 
remedy  for  bronchitis  in  infancy  as  well  as  childhood,  and  the  use  of  the  wet 
cup  is  even  advocated  for  robust  infants  in  the  commencement  of  the  inflam- 
mation ;  but  the  beneficial  effects  derived  from  this  treatment  can  be  obtained 
by  other  measures  which  preserve  the  strength,  and  are  therefore  preferable. 

Local  treatment  applied  to  the  chest  in  bronchitis  is  important,  since,  if 
properly  made,  it  increases  the  comfort  and  obviously  diminishes  the  intensity 
of  the  inflammation.  Henoch,  whose  amjile  experience  and  sound  judgment 
command  attention,  if  not  acceptance  of  his  views,  says  of  local  treatment : 
"  I  strongly  advise  hydropathic  applications  to  the  chest  from  the  neck  to  the 
umbilicus.  A  napkin  or  diaper  is  dipped  in  water  at  the  temperature  of  the 
room,  well  wrung  out,  and  then  placed  around  the  chest,  without  exercising 
any  compression,  so  that  the  arms  are  free;  this  is  surrounded  by  a  roll  of 
batting  and  then  covered  by  a  layer  of  oil-silk  or  gutta-percha  paper.  When 
the  fever  is  high  these  applications  should  be  renewed  at  least  every  half 
hour ;  later  they  may  be  kept  for  one  or  even  two  hours,  and  this  continued 
for  several  days  and  nights.  I  have  occasionally  continued  it  for  a  week,  the 
cool  water  being  changed  to  a  temperature  of  26°  to  27°  R." 

The  benefit  derived  from  the  cold-water  application  is,  according  to 
Henoch,  threefold :  First,  the  deep  inspiration  which  the  application  of  cold 
causes,  thus  expanding  portions  of  the  lungs  which  are  liable  to  atelectasis ; 
secondly,  "  derivative  irritation  of  the  skin ;"  and,  thirdly,  the  production  of 
moisture  in  the  air  surrounding  the  child,  which  he  inhales.  Deep  inspira- 
tions are,  in  my  opinion,  caused  to  a  greater  extent  by  medicines  which  excite 
cough,  as  ammonia  and  warm  applications  certainly  produce  more  derivation 
to  the  surface  than  cold.  One  benefit  from  the  application  of  cold  Henoch 
does  not  allude  to,  and  that  is  the  reduction  of  temperature.  But  I  prefer 
for  this  purpose  frequent  sponging  of  the  upper  extremities  and  face  with 
cold  water,  and  perhaps  its  constant  application  to  the  head.  I  have  observed 
marked  relief  from  this  use  of  cold  water. 

For  years,  in  my  practice,  the  following  external  treatment  has  been 
employed  with  apparent  benefit  in  nearly  every  case.  For  infants  under  the 
age  of  three  months  who  have  accelerated  respiration  and  painful  cough, 
indicating  the  need  of  external  treatment,  two  poultices  of  ground  flaxseed 
are  prepared,  covered  by  thin  muslin,  and  made  so  moist  that  they  wet  the 
hand  in  holding  them.  They  are  made  as  thin  as  the  pasteboard  cover  of  a 
book,  and  of  such  a  size  that,  applied  in  front  and  behind,  they  cover  the 
entire  chest.  Camphorated  oil  is  smeared  over  their  under  surface  three  or 
four  times  daily,  and  over  their  extei'ior  oil-silk  is  applied.  For  infants  over 
the  age  of  six  months  I  prefer  poultices  of  the  following: 

R.  Pulv.  sinapis,  ,^j  ; 

Pulv.  seminis  lini,  5^vj. 

The  poultice,  to  give  most  relief,  should  be  so  wet  as  to  cause  constant  moist- 
ure of  the  surface,  and  so  irritating  as  to  cause  constant  redness  without 
necessitating  its  removal.  Vesication  .should  never  be  produced.  Flannel 
wrung  out  of  warm  water  made  slightly  irritating  by  mustard  and  covered 
by  oil-silk  also  answers  the  purpose.  External  treatment  should  be  employed 
in  most  instances  so  long  as  the  respiration  is  hurried  and  cough  painful. 
During  the  stage  of  convalescence,  instead  of  the  poultice,  cotton  wadding  or 
batting  around  the  chest  increases  the  comfort  and  prevents  taking  cold. 
Derivation  to    the    surface,   early   made  and  continued,  tends  to  check  the 


TREATMENT.  6<S5 

downward  extension  of  bronchitis.  Often  improvement  in  the  symptoms  is 
observed,  especially  less  dyspnoea  and  restlessness,  immediately  on  the 
employment  of  the  local  measures  recommended  above. 

fnternnl  Trcdtmeiit. — Medicines  are  indicated  which  have  a  tendency  to 
diminish  the  inflammation,  to  prevent  its  downward  extension  to  the  minute 
bronchial  tubes,  and  to  promote  expectoration.  The  bowels  should  be  kept 
open  in  all  cases  of  bronchitis.  For  robust  children  at  or  over  the  age  of 
six  months  the  following  prescription  is  useful  in  the  commencement  of  the 
attack : 

R.  Syr.  ipecac, 

Spts.  aether,  nitr.,  da.  7,\]  ; 

01.  ricini,  ^\\]  ; 

Syr.  bal.  tolut.,  3J.     Misce. 

Dose:  Half  a  teaspoonful  to  one  teaspoonful,  every  second  hour,  for  the  age  of  one  to 
two  years. 

But  the  medicinal  agent  which  experience  has  shown  to  be  the  most  use- 
ful in  the  bronchitis  of  children  is  one  of  the  salts  of  ammonium.  In  the 
treatment  of  infantile  bronchitis  depression  must  be  avoided.  The  cough 
.should  be  strong  and  frequent,  for  the  chief  danger  occurs  from  the  accumu- 
lation of  viscid  mucus  in  the  minute  tubes,  so  as  to  obstruct  the  entrance  of 
air  into  the  alveoli,  leading  to  atelectasis  and  causing  the  dyspnoea  which  is 
so  painful  and  prominent  a  symptom  in  this  disease.  Ammonii  carbonas  or 
chloridum  better  than  any  other  agent  promotes  expectoration  by  exciting 
cough  and  rendering  the  mucus  less  viscid,  and  it  does  not  reduce  the  strength. 
When  anxious  parents  ask  me  to  prescribe  something  to  relieve  the  cough,  I 
reply  that  the  more  frequent  the  cough  the  better  it  is  for  the  infant,  since  it 
affords  the  means  of  freeing  the  tubes  from  the  accumulating  mucus.  For- 
merly I  prescribed  largely  the  carbonate,  but  Dr.  Northrup,  curator  of  the  New 
York  Foundling  Asylum,  has  found  evidences  of  gastritis  in  the  stomachs 
of  infants  who  have  perished  from  various  diseases  for  which  the  carbonate 
was  administered.  It  should  therefore  be  prescribed  in  a  sufl&cient  amount  of 
mucilage  or  syrup  or  milk  to  prevent  its  irritating  action  on  the  stomach.  I 
prefer  to  prescribe  it  in  water,  and  direct  it  to  be  administered  in  milk.  In 
feeble  cases  and  cases  attended  by  dyspnoea  the  carbonate  is  preferable  to  the 
chloride,  since  it  is  more  stimulating,  and  it  promotes  the  cough  by  slightly 
irritating  the  fauces.  The  ammonii  chloridum  may,  in  most  instances,  be 
given  with  benefit  from  the  commencement,  both  in  mild  and  severe  bron- 
chitis, in  infants  under  the  age  of  one  year,  but  in  severe  cases  it  is  appar- 
ently less  efficient  than  the  carbonate.  The  following  is  a  convenient  formula 
for  its  employment : 

R.  Ammonii  chloridi,  .^j ; 

Syr.  bal.  tolut.,  gij.     Misce. 

Fifteen  drops  contain  one  grain,  the  dose  at  the  age  of  three  months. 
Five  drops  should  be  given  at  the  age  of  one  month,  and  thirty  at  the  age  of 
six  months,  in  a  little  water.  This  expectorant  should  be  given  frequently, 
as  every  half  hour  or  every  hour  in  cases  of  severity.  The  urgent  symptoms 
are  relieved  by  free  expectoration,  which  this  medicine  tends  to  produce.  It 
should  be  given  night  and  day,  at  the  short  intervals  mentioned,  until  ameli- 
oration of  symptoms  occurs.  The  benefit  from  its  use  is  most  apparent  under 
the  age  of  eighteen  months,  or  at  the  age  when  capillary  bronchitis  and 
atelectasis  are  most  liable  to  occur. 

Medicines  which  exert  a  gi-eater  controlling  effect  on  the  action  of  the  heart 
than  those  which  we  have  mentioned  are  often  required  during  the  progress 


686  BRONCHITIS. 

of  severe  "  bronchitis."  If  the  patient  give  evidence  of  declining  strength 
while  the  pulse  is  unusually  rapid  and  the  temperature  elevated,  quinine 
given  in  moderate  doses,  as  two  grains  every  fourth  hour  to  a  child  of  two 
years,  has  seemed  to  me  useful  as  a  heart  tonic.  It  may  be  employed  in  the 
following  formula : 

R.  Quinise  sulphatis,  .^^s; 

Syr.  yerbse  santse  comp.,  ^ij.     Misce. 

Give  one  teaspoonful  every  fourth  hour. 

The  tincture  of  digitalis  in  doses  of  one  or  two  drops  every  second  hour 
for  infants  between  the  ages  of  six  months  and  two  years  is  also  useful 
as  a  heart  tonic.  In  a  case  recently  under  treatment  by  Dr.  Jacobi  and 
myself  the  infant,  aged  twenty-three  months,  having  a  temperature  varying 
from  102^°  to  lOSJ^,  respiration  82  to  105,  and  pulse  165  and  higher,  took 
four  drops  of  tincture  of  digitalis,  besides  the  quinine  and  ammonii  chloridum,, 
three  days,  with  apparently  a  good  result  from  the  digitalis.  This  remedy 
was  afterward  continued  in  two-drop  doses,  and  the  patient  recovered. 

For  robust  children,  with  a  strong  and  rapid  pulse,  with  a  temperature 
above  102°,  the  use  of  an  antipyretic  is  indicated.  Formerly,  aconite  or  the 
more  dangerous  remedy,  veratrum  viride,  was  employed  for  this  purpose ; 
but  a  better  antipyretic  for  these  cases  is  antipyrine,  acetanilide,  or  phenace- 
tin.  One  grain  of  antipyrine,  which  is  soluble  in  water,  may  be  administered 
every  third  hour  to  an  infant  of  one  year.  If  the  temperature  fall  to  102°, 
it  should  in  ordinary  cases  be  discontinued,  since  it  is  in  a  measure  depress- 
ing. Its  use  is  seldom  required  longer  than  two  or  three  days.  For  fee-- 
ble  children,  or  those  who  have  atelectasis  or  pneumonia  complicating  the 
bronchitis,  quinine  is  preferable  to  either  of  the  above  antipyretics. 

When  and  how  to  employ  opiates  to  procure  the  needed  rest  in  the  bron- 
chitis of  children  should  be  carefully  considered.  We  have  stated  that  a 
frequent  and  strong  cough  is  required  in  the  infant  in  order  to  prevent  clog- 
ging of  the  minute  tubes  with  muco-pus  and  to  prevent  atelectasis.  Still,, 
some  respite  from  the  cough,  if  it  be  frequent,  is  required  to  prevent  exhaustion. 
I  prefer  for  young  infants  to  give  the  opiate  separately  from  the  expectorant,, 
and  only  occasionally  as  they  may  need  sleep.  The  following  is  a  useful 
formula  for  an  infant  of  six  months  if  it  be  restless  and  without  the  proper 
amount  of  sleep : 

R.  Liq.  opii  composit.  (Squibb),  gtt.  x  ; 

Potass,  bromidi,  3J  ; 

Syr.  rubi  idtei  (raspberry),  ,fj  ; 

Aquse,  ^iss.     Misce. 

Dose :  One  teaspoonful  when  needed. 

Eight  drops  of  paregoric  may  be  given  in  place  of  the  above.  Twice  the 
dose  of  either  of  these  opiates  is  sufficient  at  the  age  of  twelve  months.  For 
older  children  Dover's  powder — an  eligible  form  of  which  is  Squibb's  liquid 
Dover's  powder,  the  tinctura  ipecacuanhge  composita,  one  minim  of  which 
corresponds  to  one  grain  of  the  powder — is  a  useful  remedy  to  procure  sleep. 

During  convalescence  medicines  should  be  administered  less  and  less  fre- 
quently or  in  smaller  doses.  Emetics  in  ordinary  cases  of  bronchitis  are  not 
required,  except  in  the  commencement.  In  severe  bronchitis,  however,  espe- 
cially when  the  smaller  tubes  are  inflamed,  they  sometimes  appear  to  be  use- 
ful. The  cases  which  may  need  their  administration  are  those  in  which  mucus 
and  pus  collect  in  the  tubes  more  rapidly  than  they  are  expectorated,  so  as 


ATELECTASIS.  687 

to  give  rise  to  urgent  dyspnoea.  An  emetic  administered  under  such  cir- 
cumstances may  give  prompt  and  decided  relief.  The  object  to  be  gained  is 
obviously  very  different  from  that  in  the  commencement  of  bronchitis,  and 
such  agents  should  be  employed  as  act  promptly  with  little  depression.  Ipe- 
cacuanha is  probably  the  best  emetic  for  this  purpose. 

Infants  oppressed  by  the  accumulation  of  mucus  and  pus  may  sometimes 
be  relieved  by  tickling  the  fauces  with  the  tinger.  This  provokes  vomiting, 
and  the  viscid  mucus  which  collects  at  the  entrance  of  the  glottis  is  removed 
by  the  finger. 

The  diet  should,  as  a  rule,  be  nutritious  through  the  entire  disease ;  but 
robust  patients  or  those  who  have  ordinary  health,  if  over  the  age  of  two 
years  and  affected  with  primary  bronchitis,  are  sufficiently  nourished  by  light 
diet,  chiefly  farinaceous,  in  the  first  days  of  the  attack,  after  which  animal 
broths  are  proper.  Whatever  food  is  given  in  severe  bronchitis  must  be  in 
the  form  of  drinks,  since  the  appetite  is  lost  and  solid  food  is  not  taken, 
while  the  thirst  is  such  that  liquids  are  less  likely  to  be  refused. 

In  primary  bronchitis,  if  mild  or  of  ordinary  severity,  alcoholic  stimu- 
lants are  not  required.  In  secondary  bronchitis  they  are  often  needed,  and 
also  in  severe  primary  bronchitis  if  there  be  dyspnoea  with  evidences  of 
prostration.  In  the  infant  two  drops  of  brandy  for  each  month  in  the  age, 
given  every  hour  or  second  hour,  enable  the  child  to  expectorate  with  more 
freedom  and  less  exhaustion. 


CHAPTER    VI. 

ATELECTASIS. 

In  certain  new-born  infants  the  lungs  do  not  undergo  inflation  or  only  a 
portion  of  the  lobules  is  inflated — to  wit,  those  in  the  upper  lobes — 'while  the 
remainder  of  the  organ  continues  unchanged  from  the  foetal  state.  This  non- 
inflation  of  the  lung  is  designated  congenital  atelectasis.  It  is  apparently 
not  due,  unless  in  rare  instances,  to  defective  formation  of  the  respiratory 
apparatus,  for  at  the  autopsies  of  cases  which  have  ended  fatally,  as  most 
cases  do  at  an  early  period,  insufflation  is  easy,  there  being  no  occlusion  of 
the  air-passages  nor  unusual  adhesion  of  the  walls  of  the  alveoli  to  prevent 
the  admission  of  air.  Physicians  have  believed  that  in  some  instances  they 
discovered  the  cause  in  an  enlarged  thymus  gland,  which  compressed  the 
lower  part  of  the  trachea,  but  this  cause  has  not  seemed  to  exist  or  was 
exceptional  in  cases  which  I  have  observed ;  for  although  the  thymus  at 
birth  is  large,  having  nearly  the  size  of  an  unexpanded  lung,  it  has  not 
seemed  to  me  to  be  unduly  enlarged  in  most  atelectatic  cases  which  I  have 
examined  after  death. 

The  ordinary  proximate  cause  of  atelectasis  neonatorum  is  feebleness  of 
inspiration,  whether  due  to  general  debility,  as  in  infants  born  prematurely, 
or  weakened  by  placental  hemorrhage  in  the  last  months  of  foetal  life,  or,  as 
is  frequently  the  case,  to  injury  of  the  brain  and  consequent  impairment  of 
the  function  of  the  pneumogastrics  during  birth.  I  have  more  fully  treated 
of  this  form  of  atelectasis  in  the  chapters  which  relate  to  the  maladies  inci- 
dental to  the  birth  of  the  child,  and  to  these  the  reader  is  referred. 

Acquired  atelectasis,  or  collapse  of  lung,  is  less  extensive  than  con- 
genital atelectasis,  being  confined  to  a  portion  of  a  lobe  and  often  to  only  a 


688  ATELECTASIS. 

few  lobules.  It  occurs  chiefly  during  the  period  of  infancy  and  in  feeble 
children.  It  is  a  common  malady  in  foundling  asylums  in  wasted  infants 
who  perish  before  the  close  of  the  first  year.  I  have  frequently  at  the 
autopsies  of  such  infants  observed  it  along  the  thin  inferior  margins  of  the 
lower  lobes  and  in  the  tongue-like  prolongation  of  the  left  upper  lobe.  In 
this  class  of  cases  catarrh  of  the  bronchial  tubes  appears  to  have  little  or  no 
agency  in  causing  the  collapse.  The  cause  is  found  in  the  impaired  functional 
activity  of  the  lungs.  In  the  state  of  debility  the  heart  beats  feebly  and 
the  stream  of  blood  from  it  to  the  lungs  is  small  and  slow,  so  that  the  inspira- 
tion of  a  small  amount  of  air  suffices  for  its  decarbonization.  The  inspira- 
tions also  are  seen  to  be  feeble,  causing  little  expansion  of  the  walls  of  the 
thorax.  Consequently,  the  entire  lung  is  imperfectly  inflated,  as  is  seen  in 
fatal  cases,  but  the  distant  thin  portions  of  the  organ  are  least  expanded. 
These,  receiving  little  or  no  air,  soon  begin  to  contract  from  the  presence  of 
the  elastic  tissue,  and  collapse  or  atelectasis  ensues. 

This  has  been  the  most  common  form  of  atelectasis  in  cases  of  this  malady 
which  I  have  observed  in  foundling  asylums,  and  it  probably  occurred  in  the 
manner  which  I  have  described. 

Another  cause  of  acquired  atelectasis  to  which  all  writers  allude  is  bron- 
chial catarrh,  which,  commencing  in  the  larger  tubes,  extends  downward  into 
those  of  smallest  size.  By  the  swelling  of  the  mucous  membrane  and  the 
accumulation  of  viscid  muco-pus,  which  cannot  be  expectorated,  certain  of 
these  tubules  become  occluded,  so  that  rhe  inspired  air  is  shut  off"  from  the 
alveoli  situated  beyond  them.  Occlusions  are  obviously  most  likely  to  occur 
in  the  bronchitis  of  feeble  infants  whose  cough  has  little  expulsive  force, 
so  that  debility  is  also  a  factor  in  the  production  of  this  form  of  atelectasis. 
The  portion  of  lung  withdrawn  from  the  respiratory  function  soon  collapses, 
the  air  which  it  contained  being  probably  in  part  expired,  but  chiefly  absorbed. 

Atelectasis  is  not,  however,  so  important  or  frequent  a  complication  of 
bronchitis  as  was  formerly  supposed,  for  catarrhal  pneumonitis  due  to  exten- 
sion of  the  inflammation  from  the  bronchioles  into  the  lung  has  been  mistaken 
for  it.  Solid  non-crepitant  nodules  or  portions  of  lung  are  frequently  observed 
at  the  autopsies  of  infants  who  have  perished  of  sevei'e  bronchitis,  and  these 
may  be  atelectatic  or  pneumonic,  but  they  are  more  frequently  the  latter  than 
was  formerly  supposed. 

The  possibility  of  insufflating  these  solid  portions  when  removed  from  the 
body  after  death  was  till  within  a  few  years  regarded  as  decisive  proof  of 
atelectasis.  It  is  now  known  that  this  is  not  a  reliable  test,  since  a  lung 
solidified  by  recent  catarrhal  pneumonitis  can  be  almost  as  readily  inflated  as 
one  which  is  collapsed  ;  but  the  inflated  pneumonic  lung  is  more  solid  and 
resisting  when  pressed  between  the  thumb  and  flngers  than  is  the  collapsed 
lung.  The  decisive  proof  is  afforded  by  the  microscope,  by  which  cell-pro- 
liferation is  discovered  within  the  alveoli  in  catarrhal  pneumonitis,  while  it  is 
lacking  in  simple  collapse.  An  increase  of  the  dyspnoea  not  infrequently 
occurs  in  severe  infantile  bronchitis,  without  either  pneumonia  or  collapse 
from  the  accumulation  in  the  bronchioles  of  the  secretion  which  is  with 
difficulty  expectorated,  but  if  dulness  on  percussion  and  other  physical  signs 
indicate  solidification  of  the  lung  at  some  point,  of  course  pneumonia  or  col- 
lapse has  occurred.  If  a  sufficient  amount  of  lung  be  involved  to  produce 
well-marked  physical  signs,  the  disease  is  in  most  instances  pneumonia  and 
not  collapse,  though  it  may  be  the  latter.  Both  these  pathological  states 
may,  however,  occur  in  the  same  lung  as  complications  of  severe  bronchitis. 
The  severe  paroxysmal  cough  of  pertussis,  especially  when  accompanied  by 
considerable  secretion,  frequently  produces  collapse  of  portions  of  the  lower 
lobes,  while  it  causes  emphysema  in  the  upper  lobes. 


SYMPTOMS— ANATOMICAL  CHARACTERS.  689 

Symptoms. — Atelectasis  resulting  from  bronchitis  gives  rise  to  no  new 
symptoms.  So  far  as  it  has  any  appreciable  effect,  it  aggravates  certain 
symptoms  of  the  primary  disease,  but  as  it  is  ordinarily  limited  to  a  small 
area,  this  effect  is  not  very  marked.  When  a  bronchial  tube  is  so  occluded 
by  muco-pus  that  the  alveoli  with  which  it  communicates  collapse,  there  is 
ordinarily  at  the  same  time  more  or  less  accumulation  of  this  secretion  in 
other  tubes  throughout  the  lungs.  Therefore,  the  entrance  of  air  into  the 
alveoli  with  which  these  tubes  communicate  is  slow  and  difficult,  but  usually 
without  complete  obstruction  and  without  true  atelectasis,  but  with  a  semi- 
collapse  such  as  we  observe  in  fatal  croup.  This  explains  the  dyspnoea  which 
is  present  in  these  cases.  If  the  secretion  be  expectorated  from  these  tubes, 
the  dyspnoea  abates,  even  if  the  plug  which  has  completely  occluded  a  tube 
and  the  consequent  atelectasis  remain. 

Atelectasis  occurring  in  wasted  and  feeble  infants  in  consequence  of  the 
diminished  force  of  the  inspirations  does  not  in  most  instances  give  rise  to 
any  prominent  symptom,  since  it  occurs  chiefly  in  distant  thin  portions  of 
the  lungs.  I  have  observed  an  occasional  short,  nearly  painless,  cough  in 
such  infants  when  the  autopsy  revealed  no  pulmonary  lesion  except  the 
atelectasis. 

Anatomical  Characters. — The  portion  of  lung  which  is  affected  with 
recent  atelectasis  has  a  dark-brown  or  dark-bluish  color.  It  is  depressed 
below  the  general  level  of  the  lung,  is  firm  and  non-crepitant  on  pressure, 
and  its  incised  surface  is  smooth.  Hyper^emia  supervenes,  for  a  portion  of 
lung  in  which  the  circulation  continues,  but  from  which  air  is  excluded,  becomes 
congested.  In  acquired  atelectasis  the  congestion  is  especially  marked,  since 
the  vessels  which  have  been  adapted  by  growth  for  a  larger  area  are  com- 
pressed into  one  of  smaller  extent,  so  that  they  become  tortuous  and  bulging 
within  the  lumina  of  the  alveoli,  while  the  free  flow  of  blood  through  them 
is  retarded  by  the  constriction  of  the  elastic  fibres  of  the  lung.  An  obvious 
and  certain  result  of  the  hyperaemia  is  the  transudation  of  serum  into  the 
alveoli,  producing  oedema.  This  union  of  pulmonary  hyperaemia  with 
oedema,  by  which  air  is  excluded  from  the  alveoli,  constitutes  the  state 
known  to  pathologists  as  splenization,  and  in  proportion  as  it  occurs  the 
lung  depressed  by  the  atelectasis  rises  toward  the  general  level.  It  may 
even  rise  above  it,  and  it  now  has  a  doughy,  elastic  feel.  The  pathology 
of  these  oedematous  atelectatic  spots,  heretofore  obscure,  hag  been  clearly 
explained  by  Pandfleisch. 

If  the  patient  live  and  the  atelectatic  lobules  do  not  soon  return  to  a 
state  of  health,  they  undergo  further  changes.  Rindfleisch  says  :  "  From  the 
series  ""  (of  changes,  provided  inflammation  do  not  occur)  "  we  especially  ren- 
der prominent  two  conditions — inveterate  oedema  and  slafi/  induration.  But 
inflammation  does  commonly  occur  after  a  time  in  a  collapsed  lung."  Those 
who  are  familiar  with  the  post-mortem  examination  of  infants  will  fully 
agree  with  Rindfleisch  when  he  says :  "  Splenization,  quite  generally  taken, 
appears  to  pi-esent  extraordinarily  favorable  preliminary  conditions  for  the 
occurrence  of  inflammatory  changes.  It  may  directly  represent  the  initial 
hyperaemia  of  acute  inflammation,  and  be  followed  by  lobular  and  lobar,  but 
constantly  catarrhal,  infiltrates."'  It  is  well  known  by  pathologists  that  pro- 
tracted congestion,  active  or  passive,  of  whatever  organ  or  tissue,  is  ver}- 
liable  to  pass  from  a  state  of  simple  stasis  of  blood  to  one  of  cell-prolifera- 
tion, and  the  atelectatic  lung,  as  I  have  myself  observed  at  autopsies,  affords 
a  common  example  of  this.  I  have  several  times  made  or  have  procured 
microscopic  examinations  of  the  atelectatic  portions  of  lungs  of  infants 
who  had  died  for  the  most  part  in  a  wasted  and  enfeebled  state,  and  have 
found  in  them  clear  evidence  of  the  presence  of  a  catarrhal  pneumonia. 
44 


690  PNEUMONIA. 

The  interesting  fact  therefore  must  be  recognized  that  atelectasis  fre- 
quently passes  to  a  state  of  inflammation,  so  as  to  present  the  characters 
of  ordinary  hypostatic  pneumonia,  and  no  doubt  undergo  the  same  subse- 
quent changes. 

Atelectasis  when  recent  and  simple  or  uncomplicated  may  soon  disappear 
by  the  expectoration  of  the  obstructing  secretion,  if  such  be  present,  or  if 
there  be  no  obstruction  by  increased  force  of  inspiration.  If  it  do  not  soon 
disappear  it  undergoes  one  of  the  ulterior  changes  alluded  to  above,  and 
henceforth  the  symptoms  and  history  are  those  of  the  new  malady  which  has 
supervened. 

Treatment. — The  treatment  of  acquired  atelectasis  is  simple.  If  it  be 
recent  and  there  be  evidence  that  it  is  due  to  the  accumulation  of  the  secre- 
tion in  the  bronchial  tubes,  an  emetic  which  acts  promptly  and  with  the 
least  possible  depression  may  be  very  useful.  It  is  especially  indicated  if 
there  be  little  or  no  pneumonia,  the  strength  not  greatly  reduced,  and  there 
be  dyspnoea  with  insufficient  decarbonization  of  blood  in  consequence  of  the 
abundance  of  the  secretion  in  the  smaller  tubes.  An  emetic  which  acts 
promptly  and  with  little  prostration  may  aid  greatly  in  establishing  the  res- 
piratory function  in  collapsed  lobules  by  expelling  the  obstruction  and  pro- 
ducing a  freer  and  deeper  inspiration.  One  of  the  best  if  not  the  best 
emetic  for  this  purpose  is  sulphate  of  copper,  given  in  a  dose  of  one  or  two 
grains  to  a  child  of  one  year.  With  or  without  the  use  of  the  emetic,  our 
main  reliance  must  be  on  sustaining  and  stimulating  measures,  by  which  the 
cough,  the  cry,  and  the  inspii'ations  acquire  more  volume  and  force.  Most 
cases  require  alcoholic  stimulants  and  the  ammonium  carbonate.  Rube- 
facient applications  to  the  chest  are  also  commonly  employed,  and  are 
probably   useful. 


CHAPTEK    VII. 

PNEUMONIA. 
Catarrhal  Pneumonia. 

This  is  the  common  form  of  pneumonia  under  the  age  of  three  years. 
In  most  cases  it  results  from  bronchitis  by  extension  of  the  inflammation. 
Hence  it  is  designated  by  the  terms  broncho-pneumonia  and  lobular  pneu- 
monia. 

Etiology. — Catarrhal  pneumonia,  as  we  have  stated  above,  commonly 
results  from  simple  bronchitis.  The  inflammation,  affecting  first  the  larger 
bronchial  tubes,  extends  to  the  bronchioles,  and  from  them  to  the  air-cells 
in  certain  lobules.  Its  causes  under  such  circumstances  are  evidently  the 
same  as  those  of  the  bronchitis  which  precedes  and  accompanies  it.  It  often 
occurs  as  a  complication  of  certain  infectious  maladies,  among  which  we  may 
mention  pertussis,  measles,  diphtheritic  croup,  influenza,  and,  more  rarely, 
scarlatina,  variola,  typhoid  fever,  and  erysipelas.  Ill-nourished,  rachitic,  and 
anaemic  children  with  little  power  of  I'esistance  are  most  liable  to  it.  It  is 
in  the  cities  especially  common  among  the  children  of  the  tenement-houses, 
who  live  in  small,  overcrowded,  overheated,  and  dirty  apartments,  and  are 
frequently  taken  from  these  apartments  to  the  lower  temperature  of  the 
streets  or  are    exposed    at  open    windows.       Different    opinions    have    been 


CATARRHAL  PNEUMONIA.  G91 

expressed  as  to  the  mode  in  wliicli  piieiiuioiiia  supervenes  upon  capillary 
bronchitis.  The  theory  of  direct  propa<^ation  of  inflanniiation  from  the 
minute  bronchial  tubes  to  the  air-cells  is  plausil>le,  but  Buhl  holds  that  the 
alveoli  become  inflamed  by  the  entrance  into  them  from  the  bronchioles, 
during  inspiration,  of  inflammatory  products,  wliicli  act  as  an  irritant.  A 
form  of  subacute  catarrhal  pneumonia  sometimes  results  from  hypostasis 
or  passive  congestion.  It  is  not  uncommon  in  infant  asylums  in  infants 
enfeebled  by  chronic  disease,  who  have  weak  action  of  the  heart  and  languid 
circulation.  Lying  in  their  cribs  day  after  day,  with  little  movement  of  the 
body,  they  are  very  liable  to  passive  congestion  of  depending  portions  of 
their  lungs,  and  this  by  and  by  eventuates  in  a  pneumonia  presenting  some 
peculiarities,  but  of  the  catarrhal  form.  It  is  sometimes  designated  hypo- 
static pneumonia.  It  is  so  fre(juent  in  foundling  asylums,  where  feeble 
infants  are  received  and  treated,  that  certain  physicians,  whose  observations 
have  been  largely  in  such  institutions,  have  almost  ignored  any  other  form 
of  pneumonia  in  infants.  Billard,  a  close  and  accurate  observer,  wrote 
nearly  half  a  century  ago  :  "  Pneumonia  of  infancy  presents  peculiar  cha- 
racters, in  which  it  differs  from  the  same  affection  in  adults.  Instead  of 
being  an  idiopathic  affection  arising  from  irritation  developed  in  the  pulmo- 
nary tissue  under  the  influence  of  atmospheric  causes,  which  often  excite  the 
disease,  the  pneumonia  of  young  infants  is  evidently  the  result  of  a  stagna- 
tion of  blood  in    their  lungs.       Under  these    circumstances   this  blood  may 

be  regai'ded  as  a  kind  of  foreign    body It  would   therefore  appear 

that  inflammation  of  the  lungs,  which  produces  hepatization,  arises  in  infants, 
in  general,  from  some  mechanical  or  physical  cause."  Valleix  also  states 
that  he  found  the  lesions  of  pneumonia  in  a  majority  of  the  infants  who  died 
in  the  Hopital  des  Enfants  Trouves.  The  statements  of  Valleix  are  applica- 
ble also  to  the  Infants'  Hospital,  the  Foundling  Asylum,  and  the  Nursery  and 
Child's  Hospital  of  this  city,  as  regards  those  cases  in  which  death  results 
from  chronic  disease.  We  shall  see  hereafter  that  hypostatic  pneumonia  is 
also  a  common  complication  of  chronic  infantile  entero-colitis,  the  summer 
complaint  of  the  cities. 

Catarrhal  pneumonia  of  infants  sometimes  results  from  atelectasis  or  col- 
lapse. It  is  not  unusual  to  find,  at  the  autopsies  of  infants  who  have  died 
in  a  state  of  emaciation  and  feebleness,  portions  of  the  lungs  remote  from 
the  bronchi  collapsed,  as,  for  example,  the  thin  edges  of  the  inferior  lobes  and 
the  tongue-like  process  of  the  upper  lobe,  the  process  which  lies  over  the 
heart.  The  immediate  cause  of  the  collapse  has  been  a  bronchitis,  or  it  has 
resulted  directly  from  the  general  weakness  of  the  infant  and  its  feeble 
respirations.  Now,  a  collapsed  lung  soon  becomes  the  seat  of  passive  con- 
gestion. The  functional  activity  of  an  organ  favors  circulation  through  it, 
and  if  the  function  be  abolished  the  flow  of  blood  in  the  part  is  retarded  and 
stasis  more  or  less  complete  results.  The  hyperjemic  state  of  collapsed 
pulmonary  lobules  presents  the  same  anatomical  condition  for  the  super- 
vention of  pneumonia  as  occurs  in  cases  of  hypostatic  congestion.  Conse- 
quently, cell-proliferation  soon  begins  in  the  collapsed  alveoli,  the  volume 
of  the  affected  lung  increases  and  it  becomes  firmer  and  more  resisting  to 
the  touch,  and  the  microscope  reveals  the  characters  of  a  subacute  but  gen- 
uine catarrhal  pneumonitis.  I  have  made  or  have  procured  microscopic 
examinations  of  a  considerable  number  of  such  specimens,  and  have  found 
the  alveoli  more  or  less  filled  with  cells  of  the  epithelial  character.  (See 
article  Atelectasis).  Pneumonia  resulting  from  hypostatic  congestion  and 
that  occurring  from  atelectasis  are  not  only  subacute,  but  usually  protracted. 

Anatomical  Characters. — If  we  have  an  opportunity  to  make  a  post- 
mortem inspection  of  the  inflamed  lung  when  broncho-pneumonia  has  con- 


692 


PNEUMONIA. 


tinued  a  few  days  we  will  find  the  pleura  covering  it  either  normal  or  covered 
in  spots  with  a  thin  film  of  fibrin.  The  bronchial  tubes  contain  muco-pus, 
and  their  walls  are  thickened  and  congested.  The  inflamed  lobules  are  few 
or  many,  and  they  are  more  numerous  in  the  lower  lobes  and  in  its  posterior 
portion  than  elsewhere.  Their  incised  surface  is  not  granular,  as  in  croupous 
pneumonia,  but  smooth,  and  its  color  in  recent  cases  is  a  pale  red  or  deep  red. 
In  protracted  cases  the  color  may  be  grayish,  but  the  change  from  red  to  gray 
hepatization  does  not  occur  as  early  as  in  lobar  or  croupous  pneumonia,  so 
that  weeks  after  the  commencement  of  inflammation  in  the  lobule  its  color 
may  be  red.  White  points  or  lines  in  the  lobule  indicate  the  location  of  the 
bronchioles.  The  inflamed  lobule  is  in  some  cases  very  distinct  from  the 
surrounding  healthy  parenchyma,  but  in  other  instances  it  gradually  blends 
with  it. 

In  some  cases  the  air-vesicles  contain  chiefly  pus,  in  others  chiefly  epithe- 
lial cells  or  epithelial  cells  and  pus,  and  in  others  still  epithelium,  pus,  and 
fibrin.  Mixed  with  these  inflammatory  products  we  detect  also  red  blood- 
corpuscles.  The  capillaries  in  the  walls  of  the  vesicles  are  large  and  sinuous. 
The  amount  of  inflammatory  products  in  the  alveoli  varies  greatly  in  difi'erent 
cases.  The  alveoli  may  be  only  partially  filled,  or  they  may  be  so  packed 
that  it  is  difficult  to  detect  the  alveolar  walls.  The  adjacent  non-hepatized 
lobules  do  not  exhibit  any  marked  change,  except  that  their  epithelial  cells 
may  be  somewhat  swollen  and  more  distinct  than  in  health.  The  bronchial 
tubes  not  only  contain  more  or  less  muco-pus  and  epithelial  cells,  but  their 
walls  are  frequently  thickened  and  infiltrated  with  pus-cells  and  connective- 
tissue  cells.  This  infiltration  causes  the  bronchioles  to  appear  as  white  lines 
or  dots  in  the  inflamed  area. 

In  protracted  cases  the  red  color  changes  to  gray,  this  change  commencing 
in  the  interior  of  the  lobules  and  extending  outward.     In  gray  hepatization 

Fig.  42. 


Fig.  42  represents  an  inflamed  air-vesicle  from  the  lung  of  a  child  who  died  of  catarrhal 
pneumonia  supervening  on  pertussis. 

the  epithelial  and  pus-cells  have  undergone  granulo-fatty  degeneration.  If 
resolution  do  not  occur  and  the  disease  reach  a  still  more  advanced  stage,  the 
granulo-fatty  degeneration  becomes  more  complete,  and  the  lobules  enter  the 
stage  of  cheesy  degeneration,  becoming  yellowish-white  and  hard  and  homo- 
geneous, the  elements  which  make  up  the  lobules  being  no  longer  discernible. 
The  ulterior  change  in  the  gravest  cases  is  softening  and  the  formation  of 


CROUPOUS  PNEUMONIA.  693 

cavities,  or  interstitial  pneumonia  may  supervene,  vvitli  an  increase  of  the 
connective  tissue.  Cheesy  degeneration  and  interstitial  pneumonia  are  much 
more  tVe((uent  in  lobular  pneumonia,  the  disease  which  we  are  describing, 
than  in  lobar  or  croupous  pneumonia,  and  when   the  stage  of  cheesy  degen- 

FiG.  43. 


Fig.  4:1  represents  lobular  pneumonia  of  a  more  .severe  grade,  some  librin  being  ]iresent  in  the 
centre  of  the  air-vesicle.    Both  plates  are  copied  from  Delafleld's  Pathological  Anatomy. 

eration  is  reached  the  conditions  are  present  in  which  tuberculosis  is  likely  to 
supervene. 

In  a  large  proportion  of  instances,  when  broncho-pneumonia  has  not  con- 
tinued longer  than  two  or  three  weeks,  the  inflamed  lobules  can  be  inflated 
after  death.  We  would  infer  that  this  would  be  possible  in  cases  in  which 
the  alveoli  are  only  partially  filled  with  the  cellular  eleiuents.  It  was  for- 
merly supposed  that  if  an  infant  died,  having  had  the  dyspnoea  and  other 
syiuptoms  characteristic  of  severe  bronchitis  or  broncho-pneumonia,  and  por- 
tions of  the  lungs  were  found  firm  and  without  air,  if  they  could  be  inflated 
the  pathological  state  was  atelectasis ;  if  they  could  not  be  inflated,  it  was 
pneumonia.  Bttt  I  have  many  times  been  able  to  inflate  lobules  that  were 
undoubtedly  inflamed,  though  when  inflated  they  were  still  semi-solid  on 
palpation,  so  that  the  fact  of  insufflation  or  non-insufflation  is  not  a  test  of 
the  presence  of  atelectasis  or  pneumonia.  Still,  as  we  have  elsewhere  stated, 
a  lung  primarily  collapsed  is  very  liable  to  take  on  a  low  grade  of  pneumonia. 

Croupous  Pneumonia, 

also  designated  fibrinous  pneumonia  and  lobar  pneumonia,  is  the  common 
form  of  pneumonia  in  the  adult,  and  it  is  not  infrequent  in  children  over  the 
age  of  five  years.  It  rarely  occurs  under  the  age  of  three  years,  but  cases 
have  been  reported.  It  involves  an  entire  lobe  or  a  large  part  of  a  lobe. 
Besides  the  parenchyma,  the  smaller  bronchial  tubes  also  participate   in  the 


694  PNEUMONIA. 

inflammation.  Croupous  pneumonia  is  usually  a  primary  disease,  but  it  is 
occasionally  secondary,  as,  for  example,  when  it  occurs  in  certain  debilitating 
diseases,  as  nephritis,  or  in  infectious  diseases,  as  occasionally  in  measles  and 
pertussis. 

Etiology. — Formerly  croupous  pneumonia  was  commonly  attributed  to 
catching  cold,  but  the  microscopic  examinations  and  experiments  of  Klebs, 
Friedlander,  and  Frankel  have  shown  that  this  disease  is  microbic,  and  the 
two  latter  gentlemen,  it  is  believed,  have  detected  the  microbe  which  causes 
the  inflammation  in  ordinary  cases,  and  they  have  given  it  the  name  pneumo- 
coccus.  It  has  a  breadth  of  about  one-third  its  length,  and  it  occurs  in 
groups  of  two  or  more  surrounded  by  a  gelatinous  envelope.  According  to' 
the  observations  of  Salvioli,  Eberth,  and  Nauwerk,  it  appears  that  the 
pneumococci  may  also  enter  the  general  circulation,  and,  being  conveyed  to 
distant  organs,  may  excite  inflammation  in  them  ;  as,  for  example,  nephritis, 
meningitis,  and  pericarditis.  In  ordinary  cases  of  croupous  pneumonia  it  is 
probable  that  the  pneumococcus  has  entered  the  lungs  by  inspiration  of 
infected  air,  and  certain  observers  believe  that  it  sometimes  enters  the 
blood  and  produces  disease  elsewhere,  while  the  lungs  escape.  Ci'oupous 
pneumonia  is  more  common  in  certain  years  and  certain  seasons  than  in 
others.  Its  frequency  in  the  spring  months  has  been  mentioned  by  physi- 
cians in  different  countries.  It  was  common  among  children,  according  to  my 
observations,  in  April.  1890,  in  New  York  City,  after  a  mild  and  very  rainy 
winter,  the  disease  commencing  suddenly  with  considerable  elevation  of  tem- 
perature, and  the  physical  signs  of  pneumonia  being  sufficient  for  diagnosis 
on  the  second,  third,  or  fourth  day.  Epidemics  of  croupous  pneumonia  some- 
times occur  in  certain  localities,  lasting  weeks  or  months,  and  there  are 
also  certain  infected  houses  in  which  new  cases  of  this  inflammation  occur 
during  many  months.  In  the  Amberg  prison  in  1880,  161  cases  of  pneu- 
monia were  treated,  and  in  the  ceiling  of  the  dormitory  in  which  most  of  the 
cases  occurred  Keller  detected  pneumococci,  cultivated  them,  and  success- 
fully inoculated  animals  with  them.  Bad  ventilation,  overcrowding,  and 
uncleanliness  favor  the  occurrence  of  pneumonia,  and  epidemics  have  ceased 
when  troops  were  removed  from  crowded  and  infected  barracks  to  those  that 
were  more  spacious  and  cleaner. 

It  is  the  opinion  of  some  good  observers  that  other  microbes  besides  the 
pneumococcus  may  cause  croupous  pneumonia — that  when  this  form  of  pneu- 
monia occurs  in  the  common  infectious  diseases,  as  scarlet  fever,  pertussis, 
and  measles,  the  specific  microbes  of  these  diseases  enter  the  alveoli  and 
excite  the  inflammation.  Prof.  Prudden,  who  has  given  much  attention  to 
the  pathology  of  pneumonia,  expresses  the  opinion  that  while  the  pneumo- 
coccus ordinarily  causes  croupous  pneumonia,  it  may  result  from  other 
microbes,  especially  when  it  occurs  as  a  complication  of  the  common  microbic 
or  infectious  diseases.  It  is  a  question  also  whether  it  does  not  sometimes 
occur  without  the  agency  of  microbes — especially  from  taking  cold,  in  accord- 
ance with  the  popular  belief — and  in  those  rare  cases  in  which  it  results 
from  severe  injuries  it  seems  probable  that  the  microbe  is  not  the  causal 
agent. 

Anatomical  Characters. — Croupous  or  lobar  pneumonia  aff"ects  an 
entire  lobe  or  even  an  entire  lung.  Its  first  stage  is  that  of  congestion,  which 
is  characterized  by  distension  of  the  arterioles  and  an  increased  afflux  of  blood 
to  the  part.-  In  the  second  stage,  or  that  of  red  hepatization,  the  lung  becomes 
more  solid  and  resisting  on  palpation,  and  at  the  same  time  it  breaks  down 
easily  on  pressure.  Its  color  is  a  deep  red,  and  its  section  presents  the 
appearance  of  granules  closely  aggregated.  .  Each  granule  is  the  contents  of 
an  air-cell.     The  bronchial  tubes  connecting  with  the  inflamed  lobule  contain 


CR  0  UPO  US  PNE  UMONIA . 


695 


inuco-pus,  fibrin,  and  epithelium,  uiid  the  pleura  covering  the  inflamed  lobe  is 
coated  with  fibrin. 

The  substance  which  fills  the  air-vesicles  and  gives  the  torn  or  incised 
surface  of  the  inflamed  lobe  its  granular  appearance  consists  of  epithelial 
cells,  pus-cells,  red  blood-globules,  and  fibrin.  The  blood-vessels  are  dis- 
tended with  non-coagulated  blood.  The  fibrin  usually  occurs  in  a  network. 
The  epithelial  cells  are  abundant,  ^  and  they  are  frequently  enlarged  and 
granular.  The  pus-cells  are  abundant  ;  the  red  corpuscles  are  few,  or 
they  may  be  so  abundant  that  they  till  some  of  the  air-vesicles.  When  the 
second  stage,  or  that  of  red  hepatization,  is  completed,  the  air-vesicles  are 
entirely  tilled  with  the  inflammatory  products,  so  that  in  the  cadaver  they 
cannot  be  inflated.     The  third  stage,  or  that  of  gray  hepatization,  gradually 

Fig.  44. 


Fig.  ii.  copied  from  Dt-Iafield'-s  Palhulogical  Anatomy,  represents  an  air-vesicle  from  the  lung  of  a 
patient  who  died  forty-eight  hours  after  the  commencement  of  croupous  pneumonia.  The 
vesicle  is  only  partially  filled  with  inflammatory  products,  on  account  of  the  brief  duration 
of  tlae  inflammation. 


supervenes  after  a  few  days  upon  the  stage  of  red  hepatization,  a  gray  mottling 
first  occurring  ;  subsequently  the  gray  color  becomes  complete.  In  this  stage 
the  same  elements  remain,  but  the  congestion  diminishes,  the  red  corpuscles 
lose  their  color,  and  the  inflammatory  products  gradually  undergo  granular 
degeneration.  When  they  are  filled  with  granules  the  red  color  is  entirely 
replaced  by  the  gray.  Dr.  Delafield  states  that  the  inflamed  lung  was  found 
in  this  state  in  one-fourth  of  the  cases  examined  by  him.  Death  occurred  in 
these  cases  between  the  fourth  and  twenty-fifth  days.  The  stage  of  resolu- 
tion succeeds  in  favorable  cases,  in  which  the  inflammatory  products  soften, 
liquefy,  and  are  absorbed  or  expectorated.  The  hepatized  lung,  instead  of 
resolving,  may  undergo  a  change  identical  with  or  closely  resembling  cheesy 
degeneration.  It  becomes  dry  and  firm  and  of  a  white  cheesy  color.  Epi- 
thelium, pus,  and  fibrin  can  be  detected  in  some  of  the  alveoli,  while  in  others 
they  are  replaced  by  a  granular  mass.  Again,  in  severe  eases  portions  of  the 
lung  may  undergo  necrosis  in  consequence  of  arrest  of  circulation.     Delafield 


696  PNEUMONIA. 

has  observed  in  these  cases  the  presence  of  a  large  amount  of  fibrin,  and  but 
little  pus  and  epithelium.  At  a  later  stage  the  cavities  formed  contained  pus. 
This  is  a  serious  state,  which  is  likely  to  eventuate  in  cheesy  degeneration  of 
the  bronchial  glands  and  tuberculosis. 

Septic  or  Embolismal  Pneumonia. 

In  rare  instances  in  infancy  and  childhood  pneumonia  results,  as  it  more 
frequently  does  in  the  adult,  from  an  embolus  detached  from  a  clot  which  had 
formed  in  some  remote  vein,  in  consequence  of  arrest  of  circulation  in  it,  by 
inflammation  of  the  contiguous  tissues.  This  is  described  by  writers  as  a  dis- 
tinct form  of  pneumonia,  designated  embolic  or  embolismal.  A  specimen 
showing  this  mode  of  causation  was  exhibited  by  me  at  the  New  York  Patho- 
logical Society  in  February,  1868.  An  infant,  born  January  22,  1868.  of 
strumous  parents  had  been  fretful,  but  without  appreciable  ailment  till  Feb- 
ruary 3d,  when  inflammation  of  the  connective  tissue  occurred  on  the  anterior 

aspect  of  the  left  leg,  a  little  below  the  knee. 
Fig.  45.  This   extended    downward,   suppurated,   and 

,  .,        ,:tcJ;;  the   pus  was   evacuated   February   5th.     In 

1^,  -  \l^fe{-  ^^^  mean  time  three  other  similar  inflamma- 

4  M.k  -|^5  tions   occurred — two   on  the  right  foot  and 

*\'^P'fl\"'ftt<  ;>,,5.,  leg,  and  the  other  over  the  parietes  of  the 


%k',^%'^''*'' Xi^f  ik^ ''i^  W  chest   in    the    right   inframammary    region. 

■S&i  ^^-^^d^Ai  '"    Iv^-^S^-JT.  Suppuration  occurred  in  all  of  these. 

On  February  8th  this  infant  was  suddenly 


seized  with  extreme  dyspnoea,  and  died  in  a 
few  hours.     Numerous  minute  puriform  col- 
lections (formerly  called  metastatic  abscesses  j 
were  discovered  in  each  lung,  most  of  them 
scarcely  larger  than  a  pin's  head.     One  of 
them,  on  the  right  side  in  the  middle  lobe,  connecting  with  a  bronchial  tube, 
had  ruptured  into  the  pleural  cavity,  causing  pneumothorax,  collapse,  and 
incipient  pleuritis. 

The  annexed  figure  exhibits  the  microscopic  appearance  of  this  softened 
fibrin,  which  to  the  naked  eye  so  closely  resembled  pus. 

On  account  of  the  speedy  death  the  emboli  had  produced  in  the  lobules 
where  they  had  lodged  little  more  than  congestion  or  the  first  stage  of  pneu- 
monia around  them.  Had  the  infant  lived  longer,  doubtless  the  microbes 
and  ptomaines  would  have  caused  a  greater  amount  and  more  advanced  stage 
of  pneumonia. 

Cheesy  Pneumonia. 

Cheesy  degeneration  of  the  inflammatory  product  occasionally  occurs  in 
the  croupous  form  of  inflammation,  but  it  is  more  common  in  the  catarrhal. 
I  have  most  frequently  observed  it  in  New  York  during  epidemics  of  measles, 
when  this  form  of  pneumonia  supervened  upon  the  catarrhal  bronchitis  of 
that  disease.  Cheesy  pneumonia  is  in  its  nature  chronic  and  attended  with 
great  reduction  of  the  vital  powers. 

Cheesy  degeneration  of  the  exudate  consists  essentially  in  the  absorption 
of  the  liquid  portion  and  fatty  degeneration  of  the  solid.  The  obstruction 
of  the  circulation  in  the  capillaries  and  the  accumulation  of  cells  in  the 
alveoli  and  bronchioles  which  cannot  be  expectorated  are  conditions  which 
favor  cheesy  metamorphosis.  The  appearance  and  consistence  of  the  lung 
when  it  has  undergone  this  change  are  well  expressed  by  the  term  which  is 


CHEESY  PNEUMONIA.  697 

employed  to  designate  it.  The  cheesy  mass  consists  of  fatty,  shrivelled,  and 
fragmentary  cells,  and  amorphous  matter  in  which  can  be  traced  the  fibres 
of  connective  tissue  and  larger  vessels  of  the  parenchyma,  the  other  histo- 
logical elements  having  disappeared. 

The  caseous  mass  after  a  time  softens,  attracting  moisture  from  the  sur- 
rounding tissues.  The  molecular  detritus  and  the  shrivelled  cells  are  now 
suspended  in  a  liquid,  and,  like  any  dead  matter,  they  are  irritant  to  the  sur- 
rounding lung-substance.  The  bronchial  tube  which  supplies  the  affected 
lobule,  and  which  in  many  instances  was  the  starting-point  of  the  disease, 
again  becomes  pervious,  either  by  softening  of  the  plug  or  by  ulceration  at 
a  higher  point  upon  its  walls,  and  air  is  admitted,  which  promotes  the  putre- 
factive process  and  chemical  changes  of  the  caseous  substance. 

The  presence  of  softening  caseous  matter  in  the  lungs  very  frequently 
leads  to  the  development  of  tubercles  (see  art.  Tuberculosis),  and  accordingly 
before  the  case  ends  clusters  of  tubercles  may  appear  in  the  connective  tissue 
and  walls  of  the  vessels  of  the  lungs  and  in  other  organs. 

In  the  subsequent  progress  of  cheesy  pneumonia,  if  the  patient  live 
sufficiently  long,  more  or  less  expectoration  of  the  offending  substance  occurs, 
producing  a  cavity.  Around  the  cavity  a  vascular  pyogenic  membrane  forms, 
upon  which  granulations  arise.  These  granulations,  which  produce  pus  abun- 
dantly, and  from  which  small  extravasations  of  blood  are  fre(iuent,  are  grad- 
ually transformed  into  connective  tissue.  If  the  dead  portion  be  expectorated 
and  there  be  a  single  small  cavity,  the  child  may  recover,  the  empty  space 
being  finally  filled  up  by  the  extension  of  the  granulations  and  the  production 
of  a  cicatrix,  which  contracts,  producing  a  puckered  appearance.  Ordinarily, 
however,  there  are  several  centres  of  caseous  degeneration,  and  several  cav- 
ities resulting,  which  continue  to  enlarge  by  the  progressive  softening  of 
the  cheesy  matter.  Often,  also,  the  cavities  intercommunicate.  The  bron- 
chial glands  undergo  hyperplasia,  and  certain  of  them  are  liable  also  to 
become  cheesy.  As  the  disease  advances  the  suppuration  and  expectoration 
increase.  The  fatal  result  occurs  sooner  in  children  than  in  adults,  and  there- 
fore the  destructive  and  inflammatory  lesions  observed  at  autop.sies  are  ordi- 
narily not  so  far  advanced  in  the  former  as  in  the  latter.  Other  unfavorable 
changes  may  occur  in  the  hepatized  lung,  but  cheesy  degeneration  is  the  most 
common  and  noteworthy. 

To  the  possibility  of  inflating  a  lung  which  presents  to  the  naked  eye  the 
appearance  of  pneumonia  we  have  alluded  in  a  foregoing  page.  The  facts 
as  regards  the  possibility  of  insufflation  are  these  :  In  croupous  pneumonia, 
when  it  has  passed  beyond  the  first  stage,  insufflation  is  impossible  in  the 
lung  of  the  child  as  well  as  adult  with  the  utmost  force  of  the  breath.  We 
produce  emphysema  in  healthy  portions  of  the  lungs,  while  the  inflamed  area 
is  not  encroached  upon. 

On  the  other  hand,  in  catarrhal  pneumonia,  which  we  have  seen  is  the 
common  form  of  pulmonary  inflammation  in  children  under  the  age  of  three 
years,  and  in  which  less  distension  of  the  air-cells  by  inflammatory  products 
occurs,  the  lung  can  be  inflated,  except  in  protracted  cases,  but  when  fully 
inflated  the  solidified  lobules  can  still  be  felt  between  the  thumb  and  fingers. 
In  protracted  catarrhal  pneumonia,  as  well  as  in  protracted  collapse — which, 
indeed,  may  and  often  does  become  a  pneumonia — full  inflation  is  impossible. 
Central  portions  still  remain  impervious  to  air.  While,  therefore,  the  possi- 
bility or  impossibility  of  inflating  a  lung  removed  from  an  adult,  and  which 
presents  to  the  naked  eye  the  appearance  of  pneumonic  solidification,  is  a 
valuable  sign  as  indicating  whether  or  not  the  disease  be  pneumonia,  this 
test  is  uncertain  and  unreliable  when  applied  to  the  pulmonary  lesions  of 
children   under  the  age  of  three  years. 


698  PNEUMONIA. 

Symptoms. — Croupous  pneumonia  commonly  begins  abruptly  or  it  is  pre- 
ceded for  a  brief  period  by  symptoms  of  a  cold.  In  the  adult  the  abrupt 
commencement  is  ordinarily  with  a  chill.  In  the  child  there  is  often  a  sensa- 
tion of  chilliness,  but  a  distinct  chill  is  not  common.  Convulsions  sometimes 
occur  in  place  of  a  chill.  Catarrhal  pneumonia,  being  ordinarily  consecutive 
to  bronchitis,  begins  in  a  more  gradual  way,  its  symptoms  being  preceded  by 
and  associated  with  those  of  the  primary  aifection. 

The  symptoms  of  acute  pneumonia,  whether  catarrhal  or  croupous,  are 
the  following :  Anorexia,  thirst,  restlessness,  elevation  of  temperature,  accel- 
eration of  pulse  according  to  the  intensity  of  the  inflammation  and  the  fee- 
bleness of  the  patient,  flushed  face,  a  countenance  expressive  of  suff"ering, 
accelerated  respiration,  with  an  expiratory  moan.  These  symptoms  are  con- 
stant in  the  acute  inflammation  unless  of  the  mildest  form.  Those  which 
are  important  I  shall   explain  more  fully. 

The  expiratory  moan  is  described  by  writers  as  a  pathognomonic  symp- 
tom of  pneumonia  or  of  pleurisy.  It  is  due  to  the  pain  experienced  from 
the  movement  of  the  inflamed  part.  As  a  rule,  the  expiratory  moan  indi- 
cates either  pneumonia  or  simple  pleuritis ;  but  there  are  exceptions.  It 
may  occur,  for  example,  from  indigestible  substances  in  the  stomach  and 
intestines,  giving  rise  to  acute  dyspepsia,  or  from  certain  forms  of  abdominal 
inflammation  which  render  movements  of  the  diaphragm  painful,  as  dia- 
phragmatic peritonitis. 

The  cough  in  the  first  days  of  pneumonia  is  usually  dry  or  hacking  and 
painful.  It  afterward,  if  the  case  be  favorable,  becomes  looser  and  is  pain- 
less. We  very  seldom  observe  in  the  child  the  bloody  sputum  which  cha- 
racterizes pneumonia  in  the  adult,  since  in  catarrhal  inflammation  there  is 
much  less  exudation  of  blood-corpuscles.  The  sputum,  which  in  this  form 
of  the  disease  is  the  product  of  secretion  and  cell-proliferation,  is  at  first  thin 
and  frothy,  but  afterward  thicker  and  less  tenacious  from  the  increased  num- 
ber of  cells.  There  is  often,  in  the  first  period  of  the  inflammation,  pretty 
severe  and  constant  headache,  the  patient  complaining  of  the  head,  if  old 
enough  to  speak,  before  he  does  of  the  chest.  In  a  severe  attack  the  child 
at  this  period  lies  with  the  eyes  shut,  apparently  in  a  half-conscious  state, 
fretful  if  spoken  to  or  aroused,  so  that  the  physician  may  be  led  to  suspect 
the  presence  of  cerebral  disease.  If  there  be  vomiting  accompanied  with 
sudden  twitching  of  the  muscles  and  convulsions — symptoms  which  some- 
times occur — the  liability  to  error  in  diagnosis  is  greatly  increased.  Cerebral 
symptoms  are  more  prominent  in  the  commencement  of  pneumonia  than  sub- 
sequently. As  the  disease  advances  they  subside,  and  symptoms  referable  to 
the  chest  become  more  conspicuous. 

The  breathing  is,  as  I  have  said,  accelerated.  Thirty  or  forty  respirations 
per  minute  are  common,  and  in  severe  cases  the  number  reaches  sixty  or  even 
eighty.  In  infants  there  is  greater  frequency  of  respiration  than  in  children. 
In  those  at  the  breast,  if  the  dyspnoea  be  urgent,  nutrition  is  sometimes  seri- 
ously interfered  with,  since  in  these  severe  cases  respiration  is  performed 
more  through  the  mouth  than  nostrils,  so  that  if  the  infant  seize  the  nipple 
it  is  forced  to  relinquish  it  in  order  to  breathe,  dilation  of  the  alse  nasi 
and  depression  of  the  inframammary  region  accompanying  inspiration.  The 
dyspnoea  in  catarrhal  pneumonia  is  often  due  in  great  part  to  accompanying 
bronchitis. 

The  temperature  in  mild  cases  of  pneumonia  is  elevated  to  about  101°  to 
10.3°  ;  in  severe  cases  it  may  reach  105°  or  even  107°,  the  former  being  the 
highest  observed  by  Mr.  Squire.  In  97  observations  made  by  M.  Roger  the 
average  temperature  was  104°  during  the  active  period  of  the  inflammation. 
The  face  is  therefore  flushed  and  the  heat  of  surface  pungent,  except  in 


CHEESY  PNEUMONIA..  699 

weakly  children,  in  whom,  even  in  severe  and  active  inflammation,  the  face 
is  sometimes  pallid  and  the  extremities  of  natural  or  less  than  natural 
temperature. 

The  tongue  is  moist  and  covered  with  a  light  fur;  the  thirst  is  such  that 
nutriment  may  be  given  in  the  form  of  drinks  when  the  loss  of  appetite  pre- 
vents the  use  of  solid  food.  The  bowels  are  usually  constipated.  The  secre- 
tions in  the  first  and  second  stages  are  diminished.  The  urine  is  more  deeply 
colored  than  in  health,  and  in  vigorous  patients  it  deposits  urates  on  cooling. 
The  chlorides  are  also  deficient  or  absent  from  the  urine  so  long  as  the  inflam- 
mation is  extending. 

In  favorable  ca.ses  in  from  seven  to  ten  days  the  heat  and  thirst  decline  ; 
the  pulse  and  respiration  gradually  become  less  frequent ;  the  cough  looser ; 
the  features  have  a  more  placid  or  contented  expression ;  the  appetite 
returns :  and  the  patient  is  again  amused  by  playthings.  The  improvement 
is  progressive,  but  gradual.  A  slight  cough  is  occasionally  observed  two  or 
three  weeks  after  convalescence  is  fully  established. 

Death  in  the  acute  stage  .of  the  inflammation  commonly  occurs  from 
asthenia.  The  pulse  gradually  becomes  more  frequent  and  feeble,  the  respi- 
ration more  oppressed,  and  finally,  near  the  close  of  life,  the  face  and  extrem- 
ities become  cool.  Occasionally  death  results  from  apnoea,  due  in  great  part 
to  coexisting  bronchitis.  In  exceptional  instances  it  occurs  from  convul- 
sions, followed  by  coma,  especially  in  the  first  week.  In  those  protracted 
cases  in  which  the  inflammatory  products  have  undergone  cheesy  degenera- 
tion death  occurs  from  asthenia. 

Such  are  the  .symptoms  and  progress  of  ordinary  acute  pneumonia  in 
children.  When  the  inflammation  is  subacute,  as  in  those  forms  of  the  dis- 
ease which  result  from  collapse  or  hypostasis,  the  symptoms  are  less  pro- 
nounced. The  respiration  in  such  cases  is  but  moderately  accelerated,  is 
attended  by  little  pain,  and  therefore  the  expiratory  moan  is  often  absent. 
An  occasional  short,  dry  cough  occurs,  with  so  little  increase  of  temperature 
and  quickening  of  the  pulse  that  the  pneumonia  is  often  overlooked  by  the 
phy.sician,  the  symptoms  being  referred  to  bronchitis.  Pleuritis  seldom  occurs 
in  connection  with  this  form  of  pneumonia,  except  when  a  small  abscess  or 
gangrene  results  in  an  affected  lobule  directly  under  the  pleura.  A  few 
such  cases  I  have  observed. 

Tubercular  pneumonia  extends  over  much  or  little  of  the  lung  accord- 
ing to  the  amount  of  the  tubercules.  The  symptoms  are  like  those  of 
severe  primary  pneumonia,  superadded  to  such  as  pertain  to  tuberculosis. 
This  inflammation,  when  once  established  in  the  consumptive  child,  com- 
monl}"  continues  till  the  close  of  life.  I  have  sometimes  had  these  cases 
under  observation  several  consecutive  weeks,  even  months,  and  during  the 
whole  time  there  was  not  only  acceleration  of  pulse  and  respiration,  but  the 
expiratory  moan.  As  regards  pneumonia  occurring  in  whooping  cough,  it  is 
an  interesting  fact  that  it  sometimes  modifies  the  symptoms  of  the  primary 
disease,  so  that  during  the  active  pei'iod  of  the  inflammation  the  paroxysmal 
cough  diminishes,  and  a  short,  hacking  cough  and  expiratory  moan  occur  in  its 
place.  As  the  inflammation  abates  the  spasmodic  cough  returns.  Pneumo- 
nia occurring  in  measles  is  more  obstinate,  protracted,  and  dangerous  than 
the  primary  form.  It  usually  commences  about  the  period  of  the  decline  of 
the  eruption,  and  in  favorable  cases  continues  two  or  three  weeks.  It  is 
then  a  sequel  rather  than  complication. 

Physical  Signs. — The  physical  signs  of  pneumonia  in  infancy  and 
childhood  are  the  same  as  in  the  adult,  but  in  a  large  proportion  of  cases 
they  are  less  distinct.  In  a  majority  of  patients  -under  the  age  of  three 
years  the  crepitant  rale  is  not  observed.     This  is  due  to  the  small  size  of  the 


700  PNEUMONIA. 

alveoli  at  this  age.  I  have  now  and  then  detected  it  in  quite  young  children, 
in  whom  it  is  a  finer  rale  than  in  the  adult.  If  observed  it  is  positive  proof 
of  the  existence  of  pneumonia.  The  physical  signs,  therefore,  in  the  first 
stage  of  the  inflammation  are  often  obscure  in  consequence  of  the  absence 
of  the  pathognomonic  rale.  The  vesicular  murmur  is  somewhat  intensified 
through  the  chest,  and  there  is  at  this  stage  slight  dulness  on  percussion 
over  the  seat  of  the  inflammation  due  to  engorgement  of  the  vessels,  but  it 
is  difficult  to  appreciate  this. 

In  the  second  stage,  which  supervenes  more  or  less  rapidly,  the  physical 
signs  are  more  distinct.  Bronchial  respiration  is  in  most  cases  detected 
higher  in  pitch  than  the  vesicular  murmur,  with  the  sound  of  expiration 
higher  than  that  of  inspiration.  The  voice  of  the  patient  is  transmitted  to 
the  ear  applied  over  the  seat  of  the  disease,  and  often  a  peculiar  vibratory 
sensation  is  communicated  to  the  hand  applied  over  the  part,  so  that  it  is 
possible  to  locate  the  disease  by  palpation  alone.  In  the  second  stage,  and 
sometimes  in  the  first,  coarse  mucous  rales  in  various  parts  of  the  chest  are 
often  observed  occurring  from  coexisting  bronchitis. 

Percussion  in  the  second  stage  elicits  a  dull  sound  as  compared  with  that 
produced  on  the  opposite  side  of  the  chest.  The  dulness  corresponds  in 
extent  with  the  solidification  and  with  the  bronchial  respiration. 

As  the  inflammation  abates  the  dulness  on  percussion  gradually  dimin- 
ishes, and  the  bronchial  respiration  is  succeeded  by  the  subcrepitant  rale. 
Often  for  a  considerable  period  after  convalescence  is  established  moist  rales 
are  observed  in  the  chest,  and  sometimes  the  dulness  on  percussion  does  not 
entirely  disappear  until  the  health  is  fully  restored. 

In  catarrhal  pneumonia  these  signs  are  commonly  less  distinct  than  in 
the  croupous  form  of  inflammation.  This  is  due  in  part  to  the  limited 
extent  of  the  inflammation,  in  part,  in  many  cases,  to  its  subacute  character, 
and  in  part  to  the  fact  that  it  is  in  many  patients  double,  so  that  we  lose  the 
aid  of  comparison.  When  it  results  from  hypostatic  congestion  it  is  nearly 
always  bilateral. 

Diagnosis. — It  will  aid  in  diagnosis  to  recollect  that  under  the  age  of 
three  years  pneumonia  is  ordinarily  catarrhal,  and  that  it  is  preceded  by  and 
associated  with  bronchitis.  Coincident  with  it,  and  often  preceding  its  devel- 
opment for  a  few  days,  are  the  usual  symptoms  of  nasal  and  bronchial  catarrh. 
Defluxion  from  the  nostrils  and  other  symptoms  due  to  "  taking  cold  "  help 
us  to  diagnosticate  catarrhal  pneumonia  from  the  essential  fevers,  with 
the  exception  of  measles.  Croupous  pneumonia  begins  more  abruptly,  but 
in  this  form  of  inflammation  the  greater  extent  of  pulmonary  solidification 
soon  gives  us  clear  and  unmistakable  physical  signs.  The  various  forms  of 
so-called  remittent  fever  bear  considerable  resemblance  as  regards  symptoms 
to  certain  cases  of  pneumonic  inflammation,  but  in  the  latter  there  are  more 
acceleration  of  respiration  and  greater  suffering,  especially  when  the  child 
is  disturbed,  than  in  the  former.  The  physical  signs,  however,  afford  decisive 
proof  of  the  nature  of  the  malady — to  wit,  dulness  on  percussion,  bronchial 
respiration  of  a  higher  pitch  and  harsher  than  the  normal  vesicular  respi- 
ratoi'y  sound,   bronchophony,  vocal  fremitus,  etc. 

Difficulty  sometimes  attends  the  diagnosis  of  broncho-pneumonia  from 
simple  bronchitis.  The  presence  of  the  expiratory  moan,  if  it  be  pretty 
constant  and  marked,  affords  evidence  that  the  inflammation  has  extended  to 
the  lungs,  but  the  physical  signs  constitute  the  reliable  means  of  exact  diag- 
nosis. They  should  be  carefully  noted,  in  order  to  determine  if  there  be 
some  point  of  solidification. 

Solidification  gives  rise  to  dulness  on  percussion,  bronchial  respiration, 
and  bronchophony.     These  three  signs  coexisting  aff"ord  sufficient  proof  of 


CHEESY  PNEUMONIA.  701 

pneumonia,  unless  there  be  tubercular  consolidation  or  possibly  collapse  super- 
veiiinii;  on  suffocative  broiicliitis.  The  history  of  the  case  aids  in  determining 
whether  there  be  either  of  these  diseases.  ^Moreover,  collapse  occurs  later 
after  the  attack  commences  tlian  hepatization,  and  does  not  produce  so  dis- 
tinct bronchophony  or  bronchial  respiration  as  is  observed  in  ordinary  cases 
of  pneumonia. 

Pleuritis  with  effusion  may  present  physical  signs  which  bear  considerable 
resemblance  to  those  in  pneumonia ;  but  in  pneumonia,  except  when  asso- 
ciated Avitli  tubercular  disease,  the  dulness  on  percussion  is  not  so  great  as 
that  from  pleuritic  effusion.  In  pleuritic  effusion  in  a  young  child  the  respi- 
ratory murmur  can  often  be  heard  with  the  ear  applied  over  the  liquid,  but  it 
is  indistinct  and  transmitted  through  the  liquid  from  a  distance.  The  prac- 
tised ear  is  able  to  discover  the  difference  between  it  and  the  bronchial  respi- 
ration of  pneumonia.  Vocal  fremitus,  which  is  absent  in  pleuritic  effusions, 
is  another  reliable  sign  of  pneumonia  in  children  over  the  age  of  three  or  four 
years.  In  younger  children  it  is  indistinct.  Occasionally  the  physical  signs 
indicate  the  coexistence  of  the  pulmonary  and  pleural  inflammations. 

In  catarrhal  pneumonia  it  is  often  difficult  to  determine  certainly  the 
nature  of  the  disease,  since  the  physical  signs,  if  there  be  but  little  extent  of 
inflammation,  are  absent  or  indistinct.  I  have  often,  in  post-mortem  exami- 
nations, found  so  small  a  part  of  the  lung  hepatized  that  it  could  not  possibly 
have  produced  any  appreciable  dulness  on  percussion,  bronchial  respiration, 
or  bronchophony.  Such  cases  often  pass  for  simple  bronchitis,  and  practi- 
cally this  matters  little,  since  the  treatment  required  by  the  two  is  not  dis- 
similar. 

Prognosis. — Primary  pneumonia,  affecting  only  one  lung,  if  properly 
treated  in  most  instances  terminates  favorably  in  children  and  even  infants. 
If  double,  it  is,  as  in  the  adult,  much  more  serious,  and  is  in  certain  cases 
fatal.  Secondary  pneumonia,  pneumonia  occurring  in  measles,  whooping 
cough,  tuberculosis,  or  resulting  from  hypostatic  congestion  in  the  course 
of  some  exhausting  disease,  is,  on  the  other  hand,  more  frequently  fatal.  As 
death  usually  occurs  from  asthenia,  the  younger  the  child  and  more  feeble 
the  constitution  the  greater  the  danger. 

Unfavorable  symptoms  are  an  increase  of  dyspnoea,  a  pulse  becoming  more 
and  more  frequent  and  feeble,  pallor  of  countenance,  inability  of  the  patient 
to  support  the  head,  total  loss  of  appetite,  refusal  to  notice  or  be  amused  by 
playthings,  absence  of  tears  when  crying — a  symptom  which  French  writers 
have  pointed  out — and  the  appearance  of  pemphigus  on  the  face  or  elsewhere. 

Indications  on  which  a  favorable  prognosis  may  be  based  are  moderate 
acceleration  of  pulse  and  elevation  of  temperature,  pneumonia  primary  and 
limited  to  one  side,  ability  to  support  the  head  or  sit  erect,  being  amused  by 
playthings,  etc. 

Treatment. — The  treatment  of  the  two  forms  of  pneumonia — namely, 
catarrhal  and  croupous,  the  former  occurring  chiefly  under  the  age  of  three 
years  and  being  secondary,  the  latter  occurring  in  most  patients  over  that 
age — requires  to  be  considered  separately,  as  much  as  do  their  symptoms  and 
anatomical  characters. 

Cafarrhal  j^i'^^^^nonia,  when  developed  from  and  upon  a  bronchitis,  as  it 
so  often  is,  requires  for  the  most  part  the  continuance  of  the  remedies  which 
are  appropriate  for  the  primary  disease.  (See  art.  Bronchitis.)  But  from  the 
fact  that  it  is  secondary  and  in  children  of  tender  age,  and  since  the  danger 
as  regards  the  pneumonia  is  due  to  asthenia,  more  actively  sustaining  meas- 
ures are  demanded  than  are  required  for  uncomi)licated  bronchitis.  When 
the  pneumonia  has  continued  a  few  days,  and  often  in  its  commencement, 
carbonate  of  ammonium  and  alcoholic  stimulants  are  needed,  and  the  diet 


702  PNEUMONIA. 

from  the  first  should  be  nutritious.  In  that  form  of  catarrhal  pneumonia 
which  is  due  to  passive  congestion  or  hypostasis,  in  the  causation  of  which 
debility  is  an  important  factor,  tonic  and  stimulating  measures  are  still  more 
imperatively  required.     Frequent  change  of  position  is  useful  in  such  cases. 

In  croupous  pneumonia,  if  seen  at  the  commencement  or  within  a  few  hours 
of  the  commencement,  an  emetic  of  ipecacuanha  may  be  given,  as  recom- 
mended by  Trousseau.  This  acts  promptly  as  a  cardiac  sedative,  diminishing 
somewhat  the  afflux  of  blood  to  the  lungs  and  moderating  the  inflammation. 
It  should  not  be  employed  except  at  the  period  mentioned. 

The  abstraction  of  blood  by  leeches  or  otherwise  has  justly  fallen  into 
disrepute  in  the  treatment  of  the  inflammations  of  children,  since  it  is  too 
depressing.  We  have  in  aconite,  antipyrine,  antifebrin,  phenacetin,  efiicient 
substitutes  for  bloodletting,  which  by  their  sedative  efi"ect  on  the  heart  dimin- 
ish the  exaggerated  afflux  of  blood  to  the  inflamed  lung,  and  thus  enable  us 
to  meet  the  indication  of  treatment  in  the  first  stage  of  the  inflammation.  It 
is  important  in  all  severe  cases  to  preserve  the  blood  and  the  strength,  for  the 
danger  in  the  end  is  chiefly  from  asthenia,  and  therefore  the  use  of  one  of 
the  cardiac  sedatives  mentioned  above  is  preferable  to  the  abstraction  of 
blood. 

The  following  prescription  will  be  found  useful  in  the  commencement  of 
pneumonia,  when  the  child  is  restless  and  has  the  expiratory  moan.  It  is 
especially  useful  if,  in  addition  to  the  general  restlessness,  occasional  twitch- 
ings  of  the  limbs  occur,  which  is  a  forewarning  of  eclampsia : 


R. 

Tine,  opii  deodorat., 

gtt.  xvj ; 

Antipyrine, 

gr.  xvj  ; 

Potas.  bromidi, 

i5J  5 

Syr.  simplic, 

Iss; 

Aquse  anisi, 

giss. 

Shake  bottle.     Give  one  teaspoonful  every  two  to  three  hours  to  a  child  of  two  to  three 
vears.     If  nervous,  symptoms  are  not  prominent,  the  bromide  may  be  omitted. 

If  bronchial  respiration,  bronchophony,  and  dulness  on  percussion  are 
present,  indicating  the  second  stage  of  pneumonia,  it  is  better  to  discontinue 
the  use  of  the  antipyrine  or  other  cardiac  sedative,  unless  the  temperature 
reach  or  exceed  104°.  If  it  do,  one  grain  of  antipyrine  may  still  be  admin- 
istered every  third  hour  to  a  child  of  two  years,  and  two  grains  to  one  of 
three  or  four  years. 

The  remarks  made  in  reference  to  the  use  of  quinia  and  digitalis  for  bron- 
chitis apply  with  still  more  force  to  their  use  in  both  the  catarrhal  and 
croupous  forms  of  pneumonia.  In  secondary  pneumonia  and  in  primary 
occurring  in  feeble  children  these  agents  are  in  many  instances  preferable  tO' 
any  other  medicine  for  the  purpose  of  reducing  the  temperature  and  pulse, 
since  they  produce  this  result  without  depression.  They  may  be  administered. 
in  such  cases  from  the  first  day. 

In  some  observations  recently  made  (1880-81)  in  the  New  York 
Foundling  Asylum  it  seemed  to  us  probable  that  quinine,  given  in  one  or 
two  large  doses  at  the  commencement  of  acute  primary  pneumonia,  as  five 
grains  to  a  child  of  three  years,  exerts  some  controlling  eff"ect  on  the  infiam- 
mation,  perhaps  even  rendering  it  abortive,  and  that  its  subsequent  use  in 
smaller  doses  may  yet  supersede  in  great  part  that  of  the  cardiac  sedatives 
mentioned  above. 

When  the  infiammation  begins  to  abate  there  is  usually  progressive  im- 
provement. Many  now  recover  with  simple  mucilaginous  drinks  or  mild 
expectorants  useful  for  the  accompanying  bronchitis,  as  chloride  of  ammo- 
nium in  the  syrup  of  tolu.    Others  require  more  sustaining  measures,  and  for 


CHEESY  PNEUMONIA.  703 

such  carbonate  of  ammonium  is  preferable,  with,  perhaps,  quinia.  In  severe 
pneumonia  it  is  of  the  utmost  importunce  to  sustain  the  vital  powers,  even 
from  the  commencement  of  the  inflammation.  There  can  be  no  doubt  that 
the  great  error  in  the  therapeutic  management  of  children  with  this  malady 
has  been  the  employment  of  medicines  which  reduce  the  strength  when 
gentler  measures  or  those  of  a  sustaining  nature  were  needed.  Alcoliolic 
stimulants  are  required  sooner  or  later  in  most  cases  at  an  early  period  in 
feeble  children  and  in  secondai-y  forms  of  the  inflammation.  Infants  may 
take  three  or  four  drops  of  Bourbon  whiskey  or  brandy  for  each  month  of 
their  age  every  two  or  three  hours.  The  diet  should  be  nutritious,  consisting 
of  milk,  animal  broths,  and  the  like,  unless  during  the  first  three  or  four  days 
in  robust  children. 

The  bowels  should  be  kept  open  as  an  important  part  of  the  treatment  of 
croupous  pneumonia  in  its  first  stages.  A  small  dose  of  castor  oil,  Rochelle 
salts,  or  citrate  of  magnesia  should  be  given  if  there  be  any  tendency  to  con- 
stipation, and  repeated  from  time  to  time  if  required.  A  saline  aperient  by 
its  derivative  and  refrigerant  effect  in  some  ca.ses  obviates  the  necessity  of 
employing  cardiac  sedatives.  A  laxative  enema  is  preferable  for  a  feeble 
child  and  in  most  cases  of  secondary  pneumonia. 

Local  treatment  is  required  in  all  cases ;  counter-irritation  should  be  pro- 
duced as  soon  as  possible  over  the  chest  by  mustard  or  some  stimulating  lini- 
ment, and,  except  at  the  time  of  this  application,  the  chest  should  be  con- 
stantly covered  with  an  emollient  poultice  or  with  a  cloth  wrung  out  of 
warm  water  and  covered  with  oil-silk.  I  prefer,  however,  the  constant 
application,  under  the  oil-silk,  of  the  following  poultice,  made  large,  but  as 
thin  as  the  pasteboard  cover  of  a  book,   and  therefore  light : 

B.  Pulv.  sinapis,  ^ss  ; 

Pulv.  semin.  lini,  H'^iij-     Misce. 

Vesication,  in  my  opinion,  very  rarely  expedites  the  cure  or  benefits  the 
patient.  The  ordinary  fly-blister  should  never  be  employed  ;  and  if  it  be 
thought  best  to  vesicate,  cantharidal  collodion  should  be  prescribed  for  this  pur- 
pose. A  safe,  almost  painless,  and  at  the  same  time  efficient,  mode  of  apply- 
ing this  is  in  spots  as  large  as  a  ten-cent  piece,  half  a  dozen,  more  or  fewer 
according  to  the  extent  of  the  inflammation,  the  skin  of  course  I'emaining 
sound  between  them.  This  mode  of  application  obviates  the  danger  of  pro- 
ducing a  troublesome  sore  which  sometimes  occurs  in  children  from  the 
ordinary  mode  of  vesication.  I  have,  however,  entirely  discarded  vesication 
in  all  forms  of  pneumonia. 

In  cheesy  pneumonia^  which  is  always  accompanied  by  anaemia  and  great 
reduction  of  the  vital  powers,  carbonate  of  ammonium  with  citrate  of  iron 
and  ammonium  equal  parts,  or  cod-liver  oil  administered  three  times  daily 
with  two  drops  or  more  of  syrup  of  iodide  of  iron,  will  be  found  useful, 
as  is  also  quinine  with  iron.  Patients  require  the  most  nutritious  diet  and 
alcoholic  stimulants.  In  the  local  treatment  of  this  form  of  inflammation 
vesication,  even  so  mild  as  that  by  cantharidal  collodion,  should  be  avoided. 
Recently  in  protracted  cases  of  pneumonia  attended  by  wasting,  for  the  pur- 
pose of  destroying  the  tubercle  bacillus  if  it  have  obtained  a  lodgment  in  the 
lungs,  there  has  been  recommended  the  inhalation  from  a  sponge  several  times 
daily  of  the  vapor  of  the  following  mixture  : 

B.  Creasoti  (Merson's),  .^ij  ; 

Terebene,  5iij.     Misce. 

Add  25  drops  to  a  sponge,  and  place  it  near  the  nose  of  the  patient,  especially  in  sleep. 


704  PLEURISY. 


CHAPTER    VIII. 

PLEUKISY. 

The  term  pleurisy  or  pleuritis  is  employed  in  this  chapter  to  designate 
inflammation  of  the  pleura  when  not  produced  by  extension  of  the  inflamma- 
tory process  from  the  lung  or  by  the  irritation  of  tubercles  upon  or  under  the 
pleura.  Catarrhal  pneumonia,  common  in  infancy ;  croupous  pneumonia, 
common  in  childhood  ;  pulmonary  tuberculosis,  not  rare  in  both  periods  in 
wasted  and  cachectic  children, — are  ordinarily  accompanied  by  pleurisy,  aris- 
ing consecutively  to  the  lung  disease,  and  limited  nearly  to  the  portion  of  the 
pleura  which  covers  the  aff"ected  lobes  or  lobules.  But  since  in  these  cases 
the  pleuritis  is  subordinate  to  and  dependent  on  the  graver  diseases,  and  is 
comparatively  unimportant,  it  does  not  require  separate  consideration.  It  is 
properly  treated  of  in  our  books  in  connection  with  and  as  a  part  of  those 
diseases.  All  other  cases  of  pleuritic  inflammation,  although  presenting  wide 
diff"erences  in  form  and  clinical  history,  are  embraced  under  the  general  term 
pleiirisy. 

Frequency. — Pleurisy  was  formerly  supposed  to  be  rare  in  young  chil- 
dren. Even  M.  Barrier  of  Lyons,  the  author  of  a  creditable  treatise  on  dis- 
eases of  children,  wrote  as  late  as  1860:  "  Ainsi  done,  en  generalisant  les 
faits  de  Vallieus  et  les  notres,  nous  pouvons  dire :  que  la  pleurisie,  depuis  la 
naissance  jusqu'a  I'age  de  six  ans  environs,  ne  constitue  presque  jamais  une 
afi"ection  simple,  unique,  et  independante  de  la  pneumonie."  But  greater 
precision  in  the  examination  of  cases,  more  accurate  means  of  diagnosis,  more 
knowledge  of  the  nature  of  diseases,  and  more  frequent  autopsies  have 
enabled  the  profession  to  correct  this  as  well  as  many  other  errors,  and  it 
is  now  known  that  primary  pleurisy  is  not  infrequent  in  young  children, 
even  in  infants.  In  asylums  and  hospitals  for  children,  in  which  institutions 
the  nature  of  diseases  is  more  accurately  ascertained  than  in  private  prac- 
tice— for  autopsies  are  made  in  the  fatal  cases — the  frequency  of  pleurisy  in 
its  various  forms — latent,  semi-fibrinous,  and  purulent^ — is  surprising  to  those 
whose  knowledge  of  the  disease  has  been  acquired  only  through  private  prac- 
tice. Thus,  in  the  New  York  Foundling  Asylum  in  the  seven  months  from 
April  1  to  November  1,  1879,  while  there  were  35  eases  of  bronchitis,  21  of 
pneumonia,  and  3  of  tuberculosis,  there  were  11  clearly-ascertained  cases  of 
pleurisy.  There  can  be  no  doubt  that  many  cases  of  this  malady  in  young 
children  are  mistaken  by  good  practitioners  for  other  diseases,  especially  for 
pneumonia,  or,  if  the  pleurisy  be  to  a  certain  extent  latent,  for  remittent  or 
malarial  fever  or  fever  due  to  intestinal  irritation.  I  have  records  of  several 
cases  occurring  in  family  and  hospital  or  asylum  practice  in  which  children 
perished  with  a  wrong  diagnosis  or  without  diagnosis,  when  the  post-mortem 
examination  revealed  pleurisy,  sometimes  of  long  standing.  Thus  in  one 
case  of  fatal  empyema,  commencing  at  the  age  of  six  months  and  continuing 
several  months,  chronic  pneumonia  had  been  diagnosticated  by  physicians 
known  to  be  thorough  in  their  examination  and  usually  accurate.  In  another 
case,  which  proved  fatal  at  about  the  age  of  one  year,  the  child,  who  lived  in 
a  malarial  locality,  had  been  for  weeks  under  treatment  for  supposed  malarial 
disease  ;  but  in  this  case  diagnosis  was  easy,  for  at  my  first  visit,  which  was 
when  the  child  was  dying,  there  was  decided  dulness  on  percussion  over 
the  right  side  of  the  chest.     In  this  case  the  right  lung  was  adherent  to 


CA  USES. 


705 


the  ribs  anteriorly  and  laterally,  while  posteriorly  it  was  separated  by 
pus,  which  crowded  forward  the  organ  so  that  its  posterior  surface  was 
concave. 

In  wards  of  institutions  and  in  the  crowded  quarters  of  the  poor  pleurisy 
appears  to  be  more  frequent  than  in  families  in  comfortable  circumstances. 
Its  frequency  varies  also  in  different  years  according  to  the  presence  and 
prevalence  of  its  causes.  Thus  during  epidemics  of  scarlet  fever  it  is  more 
common  than  at  other  times. 

Daring  several  weeks  immediately  preceding  May,  1874,  when  there  was 
no  unusual  prevalence  of  the  causes  or  conditions  which  give  rise  to  pleurisy, 
I  noted  carefully  the  character  of  the  sickness  in  404  consecutive  cases  under 
the  age  of  twelve  years  in  private  practice,  and  of  these,  2  had  primary 
pleurisy,  or  i  per  cent.  This  is  probably  about  the  usual  proportion  of 
pleurisies  in  children  in  family  practice,  except  when  scarlet  fever  is 
prevalent. 

1  have  preserved  the  records  of  5(5  cases  of  pleurisy  in  children  under 
the  age  of  twelve  years,  most  of  them  occurring  in  the  institutions  which  I 
am  attending  or  have  attended  as  physician,  and  the  remainder  in  private 
practice.  The  statistics  of  these  cases,  embraced  in  the  following  table,  are 
interesting,  as  showing  the  frequency  of  pleurLsy,  and  pleurisy  of  the  suppura- 
tive form,  in  young  children.  The  large  number  of  empyemas  seen  in  the  table 
does  not,  however,  indicate  the  true  proportion  of  suppurative  to  sero-fibrinous 
pleurisies,  since  protracted  and  stubborn  cases,  which  are  largely  empyemas, 
are  more  frequently  brought  to  institutions  for  treatment  than  are  those  of  a 
milder  and  more  manageable  type.  Thus,  in  the  class  of  children's  diseases 
in  the  Bureau  for  the  Relief  of  the  Out-door  Poor,  a  large  percentage  of  the 
cases  are  empyemas  which  have  resisted  treatment  elsewhere.  Besides,  pleu- 
risy with  little  exudation  is  sometimes  latent  or  so  mild  that  it  is  overlooked 
or  not  diagnosticated  even  by  physicians  who  are  thorough  and  careful  in 
their  examinations,  and  I  do  not  doubt  that  such  cases  have  occurred  in  the 
institutions  and  in  my  private  practice  during  the  time  in  which  my  statistics 
were  collected : 


Af/e  (49 

Cases). 

Under  Two 

From  Two  to  Six 

From  Six  to 

From  One  Year 

From  Three 

Months. 

Months. 

Twelve  Months. 

to  Three  Years. 

Years  to  Six 

Years. 

Over  Six  Tiears. 

3;  all  empy- 

15; 9  at  least 

2  ;  both  em- 

13;  8  right, 

10;  7  right, 

6  ;  5  right,  1 

emas  ;        1 

empyemas — i 

pyemas — 1 

5  left. 

3  left. 

left;  1  em- 

double. 

on  right  side, 

riglit,     the 

Exudation  in 

Exudation  in 

pyema. 

4  on  left  side, 

other  left. 

some  sero- 

some sero- 

4 double. 

fibrinous; 
in  others 

fibrinous; 
in  others 

purulent. 

purulent. 

Causes. — Primary  pleurisy  in  the  child  has  hei'etofore  been  attributed 
to  that  common  cause  of  inflammations,  "  taking  cold."  It  is  often  most 
common  in  times  of  changeable  temperature.  Cachexia  is  an  acknowledged 
predisposing  cause,  so  that  children  whose  blood  is  impoverished,  whether 
from  previous  disease  or  from  antihygienic  influences,  are  more  liable  to  this 
inflammation  than  those  who  pos.sess  a  sound  and  vigorous  constitution. 
From  the  operation  of  this  cause  a  larger  proportion  of  cases  occur  among 
the  children  of  the  city  poor  than  among  those  who  are  well  nourished  and 
who  live  in  comfortable  circumstances,  since  the  cachectic  and  ill-cared-for 
are  not  only  more  exposed,  but  are  less  able  to  resist  noxious  agencies. 
45 


706  PLEURISY. 

Pleurisy  is  not  rare  in  new-born  infants,  and  its  cause  when  thus  occur- 
ring is  not  always  apparent.  It  may  sometimes  be  heedless  exposure  to  cold 
or  to  currents  of  air  by  the  nurse,  but  the  common  cause  at  this  age  is 
believed  to  be  the  absorption  of  septic  matter. 

Billard,  whose  observations  were  made  among  foundlings  in  the  Hospice 
des  Enfants  Trouves,  says  :  "  Pleurisy  is  more  common  among  young  infants 
than  is  generally  supposed ;  it  often  appears  without  the  lungs  participating 
in  the  inflammation.  I  have  seen  several  infants  die  immediately  after  birth 
from  this  affection."  He  relates  two  cases  of  double  idiopathic  pleuritis  end- 
ing fatally  at  the  ages  of  two  and  ten  days  (^Diseases  of  Infants,  page  419). 
Mignot,  whose  observations  were  made  in  the  same  institution,  also  records 
16  pleurisies,  5  of  which  were  idiopathic,  in  119  dissections  of  new-born 
infants  (^Maladies  pendant  le  Premier  Age). 

Cases  like  the  following  are  not  infrequent: 

In  1867,  I  made  the  post-mortem  examination  of  a  foundling  who  died  in 
the  New  York  Infant  Asylum  at  the  age  of  about  one  month.  On  each  side 
of  the  thorax,  the  pleura,  costal  and  pulmonary,  was  uniformly  injected,  and 
a  small  amount  of  pus,  not  more  than  one  drachm,  was  found  in  one  pleural 
cavity,  and  a  still  less  quantity  of  pus  in  the  other,  with  little  or  no  sero- 
fibrinous exudation.  There  was  also  pus  at  the  root  of  each  lung,  lying  not 
entirely  upon  the  free  surface  of  the  pleura,  but  partly  underneath  it. 

The  fact  of  a  double  pleurisy  without  disease  of  the  lungs,  which  might 
produce  it,  indicated  a  constitutional  cause.  Its  system  had  probably  become 
infected  by  the  absorption  of  septic  matter  from  the  umbilical  vessels. 

One  of  the  eruptive  fevers,  scarlatina,  not  infrequently  produces  pleurisy, 
occurring  as  a  complication  or  sequel.  This  result  seems  to  be  sometimes- 
due  to  septic  matter  in  the  blood  resulting  from  the  action  of  the  scar- 
latinous virus.  In  other  instances  it  is  possibly  the  result  of  retained  urea 
consequent  on  scarlatinous  nephritis,  for  pleurisy  is  a  common  complication 
of  Bright's  disease,  due,  it  is  supposed,  to  the  irritating  property  of  urea,, 
which  is  excreted  upon  the  pleural  surface.  Pleurisy  in  young  children  i& 
sometimes  also  caused  by  the  discharge  into  the  pleural  cavity  of  some  mor- 
bid product,  as  pus,  softened  tubercle,  or  decomposed  lung-tissue,  which  from 
its  highly  irritating  effect  causes  intense  and  general  inflammation  of  the 
pleura.     I  have  observed  several  such  cases. 

Thus,  in  November,  1866,  an  infant  of  three  and  a  half  months  died  of 
pleurisy  occurring  upon  the  left  side.  The  left  lung  was  firmly  bound  down 
by  adhesions,  so  as  to  be  reduced  to  about  one-sixth  its  normal  size.  On 
attempting  inflation  of  this  organ  when  it  was  removed  from  the  body,  air 
escaped  from  a  small  opening  in  the  middle  of  the  upper  lobe,  and  around 
this  opening  the  lung-substance  was  of  a  dark  reddish  color,  softened  and 
disintegrated.  It  seemed  probable  from  the  appearance  that  there  had  been 
hypostatic  congestion,  or  perhaps  pneumonia,  in  the  posterior  part  of  the 
lung,  and  that  the  loss  of  vitality  and  softening  had  occurred  from  the  slug- 
gish or  suspended  circulation  in  the  part,  and  that  the  fatal  pleurisy  had 
resulted  from  a  little  of  this  decomposed  tissue  entering  the  pleural  cavity. 

A  case  having  apparently  a  similar  origin  occurred  in  the  New  York 
Foundling  Asylum  in  October,  1879  : 

An  infant  aged  five  months  and  a  half  became  suddenly  and  severely  sick 
with  pleurisy  on  the  right  side,  and  died  in  five  days.  On  opening  the  pleural 
cavity,  air  escaped.  The  record  of  the  examination  states :  "  In  about  the 
middle  of  the  posterior  surface  of  the  lower  lobe  was  an  opening  which 
admitted  the  tip  of  the  little  finger  to  the  depth  of  one-fourth  to  one-third 
inch.  The  lung-tissue  seemed  to  be  disorganized  and  of  pultaceous  consist- 
ence around  the  cavity.     Through  this  cavity,  which  communicated  with  a. 


CA  USES.  707 

bronchial  tube,  the  air  had  escaped,  which  was  noticed  on  opening  tlie 
chest." 

Occasionally  we  meet  cases,  especially  in  foundling  asylums,  in  which 
the  cause  is  different  from  the  foregoing,  hut  in  some  respects  similar.  An 
indolent  pneumonia  occurs  over  a  circumscribed  area  in  the  posterior  part 
of  the  lung,  either  from  hypostasis  or  exposure  to  cold.  Minute  abscesses 
form  in  the  inflamed  parenchyma,  not  larger  tlian  pins'  heads  or  small  shot. 
J'erhaps  they  are  located  in  bronchioles,  and  are  produced  by  the  accumula- 
tion of  muco-pus,  which  collects  in  these  tubes,  and  is  not  expectorated  on 
account  of  the  low  vitality  and  feeble  functional  activity  of  the  tissues  con- 
cerned. These  abscesses  approaching  the  pleural  surface  produce  a  circum- 
scribed pleurisy  of  small  extent ;  and  finally  one,  probably  in  some  sudden 
movement  of  the  lungs,  as  in  crying  or  coughing,  breaks  into  the  pleural 
cavity,  causing  general  purulent  inflammation.  The  following  was  such  a 
case : 

In  May,  1859,  a  male  infant  aged  two  months  was  admitted  into  the 
Nursery  and  Child's  Hospital.  He  was  delicate,  and  had  what  was  diag- 
nosticated a  mild  bronchial  catarrh  ;  but  by  wet-nursing  his  general  condition 
gradually  improved.  In  July,  however,  he  had  repeated  attacks  of  diarrhoea, 
and  progressively  lost  flesh  and  strength.  On  August  3d  his  respiration 
became  suddenly  accelerated  and  painful,  and  death  occurred  from  dyspnoea 
and  exhaustion.  No  cough  or  other  symptom  referable  to  the  respiratory 
apparatus  had  been  observed  previously  to  the  day  of  death. 

At  the  autopsy  the  intestines  were  found  to  present  the  usual  lesions  of 
intestinal  catarrh  of  the  summer  season.  The  right  lung  was  compressed  by 
a  sero-fibrinous  exudation,  though,  from  the  small  size  of  the  pleural  cavity, 
the  quantity  of  exuded  liquid  was  not  more  than  two  ounces.  Nearly  the 
entire  right  pleura,  visceral  and  parietal,  was  covered  with  fibrin  of  a  creamy 
appearance,  and  there  were  loose  flocculi  in  depending  portions  of  the  cavity. 
This  lung  could  be  inflated,  except  a  little  of  the  lower  lobe,  which  was  hepa- 
tized.  The  left  lung  also  occupied  a  very  small  space,  being  partially  col- 
lapsed. It  could  be  readily  inflated,  when  it  appeared  normal,  except  a  small 
portion  in  the  posterior  aspect  of  the  lower  lobe,  which  was  partially  covered 
with  lymph,  and  was  found  to  contain  two  abscesses,  one  closed  and  the  other 
opening  externally  on  the  surface  of  the  lung  and  connecting  internally  with 
the  bronchial  tube.  On  attempting  inflation  air  passed  directly  through  this 
opening.  The  closed  abscess  contained  from  one-third  to  one-half  a  drachm 
of  pus  and  disintegrated  lung-tissue,  as  shown  by  the  microscope. 

Another  case,  showing  a  similar  cause  of  pleurisy,  occurred  in  a  female 
infant  of  about  four  months,  in  the  same  institution,  in  November,  1869 : 

She  was  admitted  in  October,  somewhat  reduced  from  diarrhoea,  but  her 
health  improved  partially,  though  she  remained  feeble,  and  the  records  state 
that  she  was  much  troubled  with  meteorism  and  occasional  pain.  On  Novem- 
ber 2d  she  was  suddenly  seized  with  great  dyspnoea,  and  died  in  about  fifteen 
minutes.  No  cough  had  been  noticed  or  other  symptom  referable  to  the 
chest,  but  there  can  be  little  doubt  that  the  occasional  symptoms  of  pain 
referred  to  in  the  notes  were  due  to  the  pleurisy.  The  body  was  much 
emaciated,  and  depending  portions  showed  hypostatic  congestion  :  right  lung 
adherent  to  diaphragm  and  to  a  considerable  part  of  the  costal  pleura  by 
fibrinous  exudation  ;  this  lung  was  somewhat  compressed  and  non-crepitant ; 
its  upper  lobe  floated  in  water,  while  its  middle  and  lower  lobes  sank  and 
could  be  only  partially  inflated ;  this  portion  of  the  lung  contained  a  few 
small  superficial  abscesses,  each  holding  scarcely  more  than  one  drop  of  pus  ; 
two  of  these  were  empty,  and  air  passed  through  them  on  attempting  infla- 
tion.    They  probably,  one  or  botli,  opened  into  the  pleural  cavity  during  life. 


708  PLEURISY. 

but  possibly  they  were  opened  in  separating  the  adhesions  which  united  the 
two  pleural  surfaces  at  this  point ;  the  pleural  cavity  contained  from  two  to 
three  ounces  of  liquid,  consisting  mainly  of  pus  and  fibrinous  shreds. 

A  similar  case  occurred  in  the  New  York  Foundling  Asylum,  in  October, 
1879: 

The  patient,  aged  four  months,  began  to  be  sick  October  11th,  having 
the  characteristic  symptoms,  and  died  October  15th.  The  right  pleural 
cavity  contained  about  giij  of  sero-purulent  liquid,  pressing  the  lung  forward 
and  toward  the  median  line.  In  the  posterior  surface  of  the  right  lower  lobe, 
near  its  base  and  immediately  under  the  pleura,  were  three  or  four  small 
abscesses,  each  not  larger  than  a  small  drop  of  pus,  and  two  or  perhaps  three 
of  these  had  ruptured,  so  that  air  escaped  from  them  on  attempting  inflation, 
while  one  was  closed,  the  pus  in  it  being  visible  under  the  pleura. 

This  cause  of  pleurisy — namely,  the  bursting  of  a  minute  abscess  in  the 
lung — and  that  in  which  a  portion  of  the  lung  loses  its  vitality,  disintegrates, 
and  enters  the  pleural  cavity,  are  probably  not  frequent,  except  in  the  first 
months  of  infancy  in  wasted  and  ill-conditioned  infants  in  families  of  the  city 
poor  and  in  the  asylums. 

A  peripharyngeal  abscess,  descending  along  the  oesophagus,  has  been 
known  to  cause  fatal  pleuritis  by  bursting  into  the  pleural  cavity,  and  pus 
from  carious  vertebrge  has  produced  the  same  result.  In  January,  1864,  I 
presented  to  the  New  York  Pathological  Society  the  lungs  of  an  infant  whose 
history  was  as  follows  : 

E, ,  aged  nine  months,  of  strumous  parentage,  and  whose  only  sister 

had  suff"ered  severely  from  strumous  ophthalmia  and  periostitis,  was  taken 
sick  about  December  19,  1863,  with  febrile  symptoms,  attended  by  restless- 
ness, but  apparently  without  any  serious  indisposition.  On  the  22d  the 
mother  called  my  attention  to  a  prominence  just  below  the  right  clavicle, 
which  proved  to  be  an  abscess,  and  a  poultice  was  applied  over  it.  On  the 
24th  the  prominence  suddenly  subsided,  and  immediately  the  symptoms  were 
greatly  aggravated.  The  pulse  rose  to  160  per  minute,  the  respiration  from 
60  to  80,  and  expiration  was  accompanied  by  a  moan,  indicating  acute  pleu- 
ritic inflammation.  Within  forty-eight  hours  after  the  disappearance  of  the 
swelling  and  the  exacerbation  of  symptoms  dulness  on  percussion  over  the 
right  side  of  the  chest  was  observed,  and  this  increased  till  it  was  complete 
from  the  clavicle  to  the  base  of  the  thorax.  The  acceleration  of  pulse  and 
respiration  continued,  the  patient  grew  more  and  more  feeble,  and  death 
occurred  December  31st. 

On  dissecting  away  the  integument  from  the  right  side  of  the  chest  an 
abscess  was  opened  containing  nearly  one  ounce  of  pus,  located  at  the  point 
where  the  tumor  had  been  observed.  At  the  base  of  this  abscess,  between 
two  of  the  ribs,  was  a  small  round  opening,  not  much  larger  than  a  knitting- 
needle,  leading  directly  into  the  cavity  of  the  chest,  so  that  on  depressing 
the  ribs  liquid  flowed  from  the  pleural  cavity.  On  removing  the  sternum 
the  liquid  was  found  to  be  sero-fibrinous,  with  considerable  pus  in  depending 
portions  of  the  pleural  cavity. 

I  have  met  one  other,  apparently  almost  identical,  case,  occurring  in  an 
infant  of  seven  months. 

Pleurisy  in  the  adult  is  sometimes  the  result  of  violence.  The  most 
notable  and  unequivocal  cases  having  this  origin  are  those  in  which  the  ribs 
are  fractured.  It  rarely  happens  that  we  can  attribute  the  pleurisy  of  chil- 
dren to  this  cause.  I  can  recollect  only  one  case  in  which  the  inflammation 
seemed  to  be  due  to  violence  : 

In  September,  1867,  an  infant  of  twenty -two  months  in  the  almshouse 
on    Blackwell's   Island,  having  had   a  cough  half  a   year  and  being   some- 


CA  USES.  709 

what  reduced,  fell  from  bed,  striking  against  the  left  side  of  the  thorax. 
Severe  pleuritic  symptoms  supervened,  and  the  child  died  of  empyema  in 
three  and  a  half  weeks.  More  than  a  pint  of  pus  was  found  in  the  left 
pleural  cavity,  pressing  the  heart  beyond  the  median  line  and  the  diaphragm 
downward,  so  that  it  was  convex  toward  the  abdomen.  The  bronchial  glands 
were  hyperplastic  and  slightly  cheesy,  and  a  caseous  nodule  lay  in  the  anterior 
surface  of  the  right  lung,  which  seemed  otherwise  healthy.  The  left  lung, 
bound  down  by  adhesions,  could  be  partially  inflated.  Whether  or  not  it  con- 
tained small  tubercles  is  not  stated  in  the  records. 

The  occurrence  of  the  injury  just  before  the  commencement  of  the  pleu- 
risy may  indeed  have  been  a  coincidence,  but  the  mother  constantly  believed 
that  the  fall  caused  the  inflammation,  and  there  was  no  other  assignable 
cause. 

It  is  probable,  from  the  history  of  this  case  and  the  lesions,  that  the 
cheesy  degenerations  antedated  the  fall,  and  that  the  pleura  was  in  an  abnor- 
mal state  and  prone  to  inflammation  when  the  injury  was  received. 

The  etiology  of  pleurisy  in  children  difi'ers,  therefore,  from  that  in  adults. 
Certain  causes  are  the  same ;  but  others,  as  scarlet  fever  and  irritating 
products  generated  in  the  walls  of  the  chest  and  bursting  into  the  pleural 
cavity,  are  not  rare  in  infancy  and  childhood,  while  they  seldom  occur  in 
adults. 

Histories  of  cases  like  the  above  strengthen  the  belief  that  pleurisy  in 
children  frequently,  and  perhaps  usually,  has  a  microbic  origin.  This  belief 
also  receives  support  from  the  researches  of  Dr.  Henry  Koplik  of  New  York. 
An  interesting  and  instructive  paper  detailing  his  investigations  was  read 
before  the  American  Paediatric  Society,  June  -1,  1890.  He  has  kindly  fur- 
nished me  the  following  resume  of  this  paper: 

"  My  methods  of  investigation  were  strictly  in  accord  with  those  of  the 
Koch  school,  and  the  results  attained  in  the  above  cases  correspond  closely 
to  those  of  the  above  authors  in  the  adult  subject.  The  twelve  cases  could 
be  divided  from  a  bacteriological  standpoint  into  four  groups.  The  first  group 
includes  those  cases  in  which  the  examination  of  the  pus  of  the  empyema 
yielded  either  the  streptococcus  pyogenes  or  the  staphylococcus  pyogenes 
aureus.  The  etiology  of  this  set  of  cases  is  still  obscure.  The  exact  source 
of  these  micro-organisms  is  still  a  matter  of  speculation.  Whether  we  agree 
with  Weichselbaum,  and  assume  that  the  empyemas  may  follow  a  pneu- 
moniae?), or  that  these  organisms,  being  present  in  the  subpleural  tissues, 
may  be  enabled  to  become  potent  through  such  a  predisposing  agent  as  cold 
or  a  slight  traumatism,  the  etiology  for  the  present  is  veiled  in  doubt.  The 
micro-organisms  found  are  not  characteristic.  The  second  group  of  cases 
includes  the  empyemas  of  pneumonic  character.  They  are  those  in  which 
the  diplococcus  pneumoniae  (Frankel  and  Weichselbaum)  is  found  in  the 
purulent  exudate.  In  seven  cases  of  the  above  series  this  micro-organism 
alone  was  found  in  the  pus  withdrawn  from  the  chest.  It  was  in  uncontami- 
nated  form,  and  when  cultivated  in  pure  culture  and  inoculated  upon  animals 
results  were  attained  identical  with  those  of  Frankel  and  Weichselbaum. 
The  isolated  presence  of  such  a  virulent  micro-organism  in  a  pure  state  in 
the  pus  of  an  empyema  must  lead  to  the  inevitable  conclusion  that  a  pneu- 
monia in  the  lung  had  preceded  or  complicated  the  empyema.  In  two  cases 
of  the  above  seven  the  pleural  exudate,  though  at  first  quite  serous  in  cha- 
racter, contained  the  diplococcus  pneumoniae.  These  cases  subsequently 
developed  into  well-marked  empyemas.  The  pus  in  the  empyemas  also  con- 
tained only  the  diplococcus  of  Frankel  and  Weichselbaum. 

"  The  third  group  includes  those  cases  in  which  the  processes  are  of  a 
tubercular  nature.     There  is  only  one  case  of  this  group  to  report — a  boy 


710  PLEURISY. 

get.  eight  years.  The  tubercle  bacilli  were  found  in  the  pus  by  cover-glass 
stain  only.  Experiments  upon  animals  have  thus  far  proved  negative.  The 
pus  in  this  case  was  contaminated  with  streptococcus  pyogenes.  The  patient 
is  still  living  at  the  time  of  writing,  but  the  lung  has  not  expanded  on  the 
affected  side.  There  are  no  physical  signs  in  this  case  of  lung  tuberculosis 
in  the  lung  of  the  healthy  or  affected  side  of  the  chest. 

"  The  fourth  group  of  empyemas  includes  those  cases  in  which  a  focus  of 
suppuration  outside  of  the  chest  can  with  probability  be  fixed  upon  as  a 
source  of  infection  and  as  the  direct  cause  of  the  empyema.  In  the  above 
twelve  cases  only  one,  an  infant  set.  four  months,  could  be  classed  in  this 
group.  For  two  weeks  preceding  the  chest  trouble  the  patient  had  suffered 
from  a  deep  burrowing  abscess  of  one  foot.  The  study  of  the  pus  from  the 
chest  yielded  a  pure  culture  of  streptococcus  pyogenes.  A  pure  culture  of 
this  injected  into  animals  proved  very  virulent  and  fatal.  The  little  patient 
died  quickly,  even  in  spite  of  operation  for  the  relief  of  the  empyema." 

Anatomical  Characters. — In  the  commencement  of  pleurisy  the  sub- 
pleural  blood-vessels,  lying  in  the  connective  tissue,  and  the  capillaries  of 
the  pleura  are  engorged  with  blood,  producing  vascular  points  and  arbor- 
escence,  seen  through  a  magnifying-glass  of  low  power.  Frequently  in  chil- 
dren, as  in  adults,  minute  extravasations  of  blood,  resulting  from  extreme 
congestion,  occur  under  the  endothelial  layer,  scarcely  perceived  by  the 
naked  eye,  but  readily  seen  under  the  glass.  Immediately  exudation  of 
liquid  holding  numerous  cells  begins  in  the  connective  tissue  which  sur- 
rounds the  capillaries;  the  pleura  becomes  dry  and  lustreless,  while  the  pro- 
duction and  exfoliation  of  its  endothelial  cells  are  greatly  increased.  These 
no  longer  present  their  normal  appearance,  but  are  swollen  and  granular  in 
consequence  of  the  inflammation. 

Immediately  after  these  parenchymatous  changes  occur,  serum,  fibrin- 
ogenic  substance,  and  leucocytes  begin  to  exude  upon  the  free  surface  of  the 
pleura.  The  term  fibrinogenic  substance,  instead  of  fibrin,  is  employed, 
because  it  is  now  believed  that  fibrin  itself  is  not  exuded,  but  a  substance 
which  becomes  fibrin  through  the  presence  and  action  of  certain  agents  with 
which  it  comes  in  contact,  among  which  may  be  mentioned  air,  red  blood-cor- 
puscles, and  even  serum,  from  which  fibrin  has  been  precipitated  (Virchow, 
Cornil,   Ranvier,  and  others). 

In  the  exuded  liquid,  even  if  it  have  the  appearance  to  the  naked  eye  of 
ordinary  serum,  the  microscope  always  reveals  the  presence  of  pus-cells  or 
leucocytes  and  red  blood-cells,  however  small  their  quantity  may  be.  The 
minute  rootlets  of  the  lymphatic  system,  which  are  interspaces  or  lacunae  in 
the  subpleural  connective  tissue,  and  which  here  and  there  open  by  stomata 
upon  the  pleural  surface,  are  clogged  by  inflammatory  products  and  their 
walls  swollen  at  an  early  stage  (E.  Wagner  and  others).  In  these  lymphatic 
channels  both  pus-cells  and  coagulated  fibrin  are  seen  by  the  microscope. 
That  pneumonia,  whether  catarrhal  or  croupous,  seldom  occurs  in  super- 
ficial parts  of  the  lungs  without  causing  inflammation  of  that  portion  of  the 
pleura  which  covers  the  affected  lobules  is  universally  known  :  but  the 
reverse  is  also  true,  that  pleurisy  seldom  occurs  without  causing  inflamma- 
tion of  the  alveoli  which  are  adjacent  to  the  inflamed  membrane.  The  pneu- 
monia thus  caused  is  so  superficial  that  it  is  very  liable  to  be  overlooked  at 
the  post-mortem  examination  in  the  presence  of  the  graver  lesions  of  the 
pleura ;  but  a  knowledge  of  its  occurrence  is  important  in  diagnosis,  for, 
though  it  may  have  no  greater  depth  than  a  line,  it  is  sufiicient  to  produce 
crepitant  rales  like  those  in  ordinary  pneumonia.  Therefore,  if  we  hear 
these  rales,  we  may  mistake  the  disease  for  pulmonary  inflammation  and 
overlook  the  pleurisy — an  error  not  unusual  in  the  treatment  of  children. 


ANATOMICAL   CHARACTERS.  711 

Trousseau,  wlio  surpassed  most  of  his  contemporaries  as  a  clinical  observer, 
wrote  :  "  This  sound,  wiiich  is  mot  with  in  the  fijreat  majority  of  cases  of 
pleurisy,  is  in  fact  a  crepitant  rale,  and  I  have  called  it  a  crepitant  rale  of 
pleurisy.  My  interpretation  is  very  simple.  Just  as  we  never  have  erysip- 
elas without  engorgement  of  the  cellular  tissue,  there  cannot  be  erysipelas 
of  the  pleura  or  pleurisy  without  an  irritative  engorgement  of  the  subpleural 
cellular  tissue  or  of  the  perijiheric  iiulmonary  parenchyma.  This  fluxion 
naturally  carries  with  it  into  the  pulmonary  vesicles  a  serous  exudation. 
....  We  also  meet  with  a  fine  subcrepitant  rale,  which  is  very  often  heard 
quite  at  the  beginning  of  pleurisy,  and  which  likewise  nearly  always  con- 
tinues for  some  weeks."  More  recent  observers  and  writers  fully  agree  with 
the  statement  of  Trousseau,  except  that  what  he  designates  irritative  engorge- 
ment the  microscope  shows  to  be  a  true  inflammation  of  the  pulmonary 
alveoli. 

There  are  four  constituents  of  every  pleuritic  exudation — to  wit,  serum, 
fibrin,  red  blood-corpuscles,  and  leucocytes  or  pus-cells ;  which  last  are  iden- 
tical in  appearance  with  the  white  blood-corpuscles  and  the  lymph-corpuscles, 
and  the  origin  of  which  has  been  investigated  by  many  microscopists.  It  is 
convenient  to  classify  cases  of  pleuritis  according  to  the  quantity  and  rela- 
tive proportion  of  these  constituents,  as  follows:  1st.  The  plastic,  sometimes 
designated  dry  or  adhesive  ;  2d.  The  sero-fibiinous  ;  od.  The  purulent ;  4th. 
The  hemorrhagic. 

1.  Plastic  Pleurisy. — In  cases  which  pertain  to  this  group  the  inflam- 
mation is  chiefly  parenchymatous,  either  no  exudation  occurring  upon  the 
free  surface  of  the  pleura,  or  if  any,  whether  fibrin,  pus,  or  serum,  it  is  so 
slight  that  it  possesses  no  clinical  importance.  The  essential  anatomical 
changes  in  this  form  of  pleurisy,  as  regards  the  pleural  surface,  are  rapid 
proliferation,  retrogressive  change  or  decay  and  exfoliation  of  the  endothe- 
lial cells,  and  the  sprouting  out  of  granulations  which  develop  into  connec- 
tive tissue.  In  plastic  pleurisy  thei'c  is  no  compression  of  the  lungs,  and 
the  pleural  surfaces  are  separated  from  each  other  only  by  the  granulations, 
which  soon  unite  with  those  of  the  opposite  surface.  This  form  of  pleui'isy 
is  not  infrequently  latent  in  children,  for  at  the  autopsies  of  those  who  have 
died  of  various  diseases  we  often  observe  bands  of  connective  tissue  uniting 
the  opposite  pleural  surfaces,  when  the  parents  or  nurses  cannot  recall  to 
mind  any  sickness  or  symptoms  such  as  pleurisy  commonly  causes.  It  is 
certain  also  that  plastic  pleurisy  is  often  overlooked  when  not  latent,  the 
fever  and  other  symptoms  being  attributed  to  causes  quite  distinct  from 
the  true  one.  The  symptoms  and  physical  signs  are  obviously  less  pro- 
nounced in  this   than  in  other  forms   of  pleurisy. 

2.  Sero-flbrinous  Pleurisy. — This  is  the  most  frequent  of  all.  It  is  the 
pleurisy  which  is  usually  thought  to  result  from  catching  cold.  The  serum 
exudes  from  the  capillaries  of  the  inflamed  pleura  in  very  variable  quantity  in 
different  cases,  and  the  pleural  surface  is  soon  covered  with  a  fibrinous  layer. 
This  may  be  a  mere  film  or  it  may  attain  the  thickness  of  half  an  inch  or 
more.  It  is  usually  at  first  slightly  attached,  but  afterward,  from  being 
blended  with  the  granulations,  it  may  be  firmly  adherent.  In  some  cases  it 
is  quite  compact,  while  in  others  it  has  a  loose  areolar  texture,  containing  in 
its  interstices  serum  and  pus-cells.  The  fibrin  is  for  the  most  part  deposited 
on  the  pleura,  but  shreds  and  flakes  of  it  also  float  in  the  serum.  In  the 
serum,  as  well  as  entangled  in  the  fibrin,  we  find  not  only  red  blood-cells  and 
leucocytes,  but  endothelial  cells  thrown  off"  from  the  pleura,  which,  as  well 
as  those  still  adherent,  are  almost  always  in  process  of  degeneration  and 
decay. 

If  a  perpendicular  section  be  made  through  the  pleura,  in  this  as  well  as 


712  PLEURISY. 

in  the  other  forms  of  pleurisy  many  newly-formed  cells,  the  lymph-corpuscles, 
are  observed  in  the  meshes  of  the  subpleural  connective  tissue,  and,  as  we 
examine  the  section  nearer  to  the  surface  of  the  pleura,  these  cells  are  seen 
to  be  aggregated  in  masses  and  held  together  by  a  structureless,  homogeneous 
matrix.  The  lymph-corpuscles  appear  to  be  the  active  agents  in  the  forma- 
tion of  granulations.  They  are  observed  in  various  stages  of  transformation 
from  the  round  to  the  spindle-shaped.  The  prolongations  of  the  spindle- 
shaped  cells  unite  with  each  other,  so  as  to  form  the  connective  tissues, 
capillaries,  and  other  elements  of  the  granulating  surface.  That  the 
endothelial  cells  take  no  part  in  the  production  of  the  new  tissue  is  inferred 
from  the  fact  that  most  of  them  present  the  appearance  of  retrogressive 
change  and  decay.  The  granulations,  as  they  sprout  out  from  the  pleura, 
become  intimately  blended  with  the  fibrinous  exudation,  and  when  the  effused 
liquid  is  absorbed  they  unite  with  those  of  the  opposite  pleural  surface, 
forming  an  organic  union,  by  blood-vessels  and  nerves,  between  the  lung  and 
parietes,  the  lung  and  pericardium,  or  different  lobes  of  the  same  lung,  as  the 
case  may  be.  They  pass  in  two  or  three  weeks  from  embryonic  to  perfect 
tissue,  vessels  and  nerves  grow  in  them,  and  they  possess  henceforth  all  the 
properties  of  living  tissues ;  they  are  able  to  absorb ;  they  are  liable  to 
inflammation  and  hemorrhage,  and  may,  in  fine,  participate  in  all  the  altera- 
tions of  the  organism  of  which  they  are  a  part  (Jaccoud). 

3.  Purulent  Pleurisy. — Although,  as  stated  above,  pus-cells  are  always 
present  in  the  pleuritic  exudation,  we  designate  the  disease  purulent  or 
empyema  when  the  cells  are  so  numerous  as  to  render  the  liquid  turbid. 
If  there  be  cloudiness  appreciable  to  the  naked  eye  and  due  to  the  pus-cells, 
the  case  is  regarded  as  one  of  this  form  of  pleurisy.  Purulent  pleurisy  is 
at  first,  in  a  large  proportion  of  cases,  sero-fibrinous,  becoming  purulent  after 
some  days  or  weeks — a  fact  readily  ascertained  by  the  use  of  the  hypodermic 
syringe  at  difi'erent  periods.  In  other  instances  the  pleurisy  is  purulent  from 
the  first.  Pleurisy  is  in  family  and  in  hospital  practice  more  frequently 
purulent  in  children  than  in  adults,  and  in  ill-conditioned  children  than  in 
those  who  are  robust.  It  is  therefore  apt  to  be  purulent  in  one  who  has  had 
an  exhausting  disease,  as  scarlet  fever,  and  in  the  cachectic  children  who 
reside  in  or  are  brought  to  institutions  for  treatment.  Thus,  in  the  New  York 
Foundling  Asylum  in  1879  an  infant  aged  two  months  and  three  days  became 
feverish,  and  had  the  expiratory  moan  and  hurried  respiration  characteristic 
of  pleurisy.  On  the  fourth  day  Dr.  Reynolds,  who  was  in  attendance, 
inserted  the  hypodermic  syringe  and  filled  it  with  thin  pus.  This  was, 
apparently,  a  case  of  primary  idiopathic  empyema.  Pleurisy  is  purulent 
when  it  is  produced  by  the  entrance  of  some  irritating  substance  into  the 
pleural  cavity,  as  pus  or  decomposed  lung-tissue. 

The  production  of  pus  in  the  pleural  cavity  is  often  surprisingly  rapid, 
for,  when  many  ounces  have  been  removed  by  the  aspirator,  nearly  the 
original  quantity  is  sometimes  restored  within  two  or  three  days.  As 
Frantzel  says,  it  does  not  seem  possible  that  so  many  pus-cells,  which  must 
surpass  in  numbers  the  aggregate  of  the  white  blood-corpuscles,  could  wan- 
der from  the  blood-vessel  in  so  short  a  time,  so  that  we  must  look  for  some 
other  source  of  the  immense  production  of  leucocytes,  in  addition  to  that  dis- 
covered by  Cohnheim.  A  large  part  of  the  pus-cells  is,  in  all  probability, 
produced  by  rapid  segmentation  of  the  lymph-corpuscles.  In  two  cases  of 
purulent  pleurisy,  occurring  in  infancy,  I  found  pus  underlying  the  pleura 
near  the  hilus,  without  apparently  any  loss  of  integrity  in  the  pleura,  in  such 
quantity  that  it  was  immediately  recognized  by  the  naked  eye.  Pus  under 
the  pleura,  as  well  as  in  the  pleural  cavity,  was  apparently  due  to  unusual 
violence  in  the  inflammation  and  rapid  production  of  leucocytes. 


ANATOMICAL   CHARACTERS.  713 

4.  Hemorrhagic  Pleurisy. — 'I'his  is  not  coiniuuii.  I  recall  but  one  case, 
a  child,  ill  whom  the  phuirisy  occurred  as  a  se(|ucl  of  scarlet  fever.  The 
fluid  several  times  removed  by  the  aspirator  had  a  deep  reddish-brown  color. 
I  was  apprehensive  that  the  point  of  the  aspirator,  by  wouiidinj;'  the  ^granula- 
tions, had  caused  the  henujrrhage  which  stained  the  pus  removed  at  each  sub- 
sequent operation.  But,  with  the  care  exercised  and  the  great  amount  of 
blood-stained  exudation,  it  seems  almost  certain  that  this  was  not  the  true 
explanation,  and  that  it  was  a  genuine  case  of  hemorrhagic  pleurisy. 

Hemorrhagic  exudation  in  the  pleurisy  of  children  is  .sometimes  due  to 
purpura  htemorrhagica,  being  like  the  other  hemorrhages  a  symptom  of  the 
general  disease.  In  other  cases  it  signalizes  the  commencement  of  a  new 
inflammation  in  the  vascular  granulations  of  a  previous  pleurisy.  Occurring 
under  such  circumstances,  it  is  due  to  the  increased  fluxion  in  the  numerous 
delicate  capillaries  of  the  granulations.  Pleurisy  due  to  cancerous  or  tuber- 
cular formations  in  or  upon  the  pleura  is  sometimes  hemorrhagic.  Jaccoud 
says:  "A  sero-fibrinous  or  purulent  exudation  may  be  red  by  the  transuda- 
tion of  haematin,  without  true  hemorrhage  ;  ....  the  red  exudations  which 
have  been  observed  in  scorbutus  and  marsh  cachexia  are  really  due  to  these 
psemlo-hemorrhages."  In  those  cases  in  which  there  is  true  hemorrhage,  it 
is  still  uncertain  whether  rupture  of  the  capillaries  or  a  transudation  ordinarily 
occurs,  or  whether  the  blood-cells  may  not  escape  in  both  modes. 

A  liquid  pleuritic  exudation,  whether  sero-fibrinous  or  purulent,  obviously 
produces  an  important  mechanical  effect  from  its  location.  In  young  chil- 
dren, especially  those  enfeebled  by  sickness,  the  expansive  power  of  the  lung 
is  slight,  so  that  it  readily  yields  to  pressure  applied  to  its  surface,  and  be- 
comes more  and  more  compressed  as  the  liquid  accumulates.  Except  when 
retained  by  adhesions,  the  lung  is  pressed  toward  the  mediastinum,  and  at 
the  same  time  carried  forward  and  upward.  Patients  with  pleurisy  usually 
lie  on  the  back  and  affected  side,  so  that  gravitation  determines  to  a  consider- 
able extent  in  what  part  of  the  pleural  cavity  the  liquid  will  collect.  In  the 
considerable  number  of  post-mortem  examinations  which  I  have  witnessed  of 
children  who  perished  from  pleurisy,  chiefly  empyema,  the  lung  was  usually 
attached  anteriorly  to  the  thorax  from  the  mediastinum  outward,  as  far  as 
the  costo-chondral  articulations,  or  farther,  except  in  the  lower  part  of  the 
cavity,  where  there  were  no  adhesions  or  adhesions  only  near  the  medias- 
tinum. There  were  also  attachments  along  the  mediastinum,  and  attachments 
more  or  less  firm  on  all  sides,  anteriorly,  laterally,  and  posteriorly,  in  the 
upper  part  of  the  pleural  cavity,  toward  which  the  lung  was  compressed. 
Many  variations  occur,  depending  on  the  amount  of  liquid  and  the  extent  of 
the  adhesions;  but,  judging  from  autopsies  which  I  have  seen,  I  would  say 
that  in  the  average  in  cases  so  severe  that  the  question  of  operative  inter- 
ference arises,  if  we  draw  a  line  from  the  axilla  downward  and  forward  to  the 
epigastrium,  the  lung  is  adherent  to  the  thorax  over  the  space  anterior  and 
internal  to  this  line,  while  external  and  posterior  to  it  the  liquid  separates 
the  lung  from  the  ribs.  This  fact  is  important,  as  indicating  the  proper  point 
for  puncturing  the  chest — namely,  below  the  lower  angle  of  the  scapula 
and  between  the  eighth  and  ninth  ribs.  One  reason  why  the  earlier  per- 
formers of  thoracentesis  were  so  unsuccessful  was  that  they  selected  the 
anterior  wall  of  the  chest  as  the  point  of  operation.  Now-a-days,  however, 
no  one  would  be  justified  in  performing  thoracentesis  unless  he  first  employed 
the  hypodermic  syringe  and  removed  fluid  at  the  point  which  he  selects  for  the 
puncture.  The  statistics  of  Mohr  relating  to  lung  displacement  in  empyema, 
chiefly  statistics  of  adult  cases,  are  somewhat  different  from  my  general 
recollection  of  cases  occurring  in  infancy  and  childhood,  as  stated  above.  In 
23  cases  he  found  the  lung  free  from   adhesions  and  compressed  against  the 


714  PLEURISY. 

vertebral  column  and  the  mediastinum  ;  in  13  cases  the  organ  was  compressed 
from  below  upward ;  in  1  from  above  downward  ;  in  4  from  within  outward  ; 
in  4  from  behind  forward ;  and  in  4  from  before  backward.  These  variations 
depend  on  the  adhesions  which  the  lung  happens  to  contract.  Perhaps  a 
point  a  little  external  to  the  perpendicular,  passing  through  the  angle  of  the 
scapula,  is  preferable  for  puncture,  as  I  have  known  the  lung  to  be  adherent 
to  the  posterior  wall  of  the  chest  near  the  mediastinum  when  the  portion 
farther  removed,  say  two  inches  from  the  median  line,  was  separated  by 
interposed  liquid. 

Sometimes  the  liquid  is  collected  in  multilocular  cavities  formed  by  the 
connective  tissue,  and  these  frequently  intercommunicate.  Exceptionally  in 
children,  as  in  the  adult  cases  observed  by  Mohr,  when  there  has  been  a 
large  and  rapid  liquid  exudation  or  when  the  disease  has  been  violent  and  of 
short  duration  adhesions  do  not  occur. 

On  account  of  the  great  difference  in  the  size  of  the  pleural  cavity  at 
different  ages  during  infancy  and  childhood,  the  amount  of  liquid  which 
produces  that  degree  of  compression  of  the  lung  which  materially  impairs 
its  function  varies  greatly.  At  the  age  of  four  months  three  ounces  produce 
complete  collapse  of  lung,  so  that  it  resembles  a  fleshy  mass  (carnification). 
The  largest  amount  of  liquid  relatively  to  the  size  of  the  chest  in  any  of  the 
cases  which  I  have  observed  was  about  one  and  a  half  pints  in  the  left  pleu- 
i-al  cavity  in  an  infant  that  died  at  the  age  of  twenty-two  months  in  Septem- 
ber, 1867.  The  heart  lay  chiefly  to  the  right  of  the  median  line,  and  the 
diaphragm  was  convex  toward  the  abdominal  cavity.  The  case  occurred  in 
the  almshouse  on  Blackwell's  Island,  and  might  in  all  probability  have  been 
relieved  had  attention  been  directed  to  it  sufficiently  early. 

Liquid  in  the  left  pleural  cavity,  when  considei'able,  presses  the  heart 
toward  the  mediastinum,  so  that  the  apex  beat,  instead  of  being  a  little 
internal  to  the  linea  mammalis,  approaches  the  sternum.  As  the  heart  is 
carried  to  the  right,  the  beat  is  felt  under  the  lower  end  of  the  sternum, 
and  with  still  greater  increase  in  the  effusion  the  jDulsation  is  detected  by 
the  finger  to  the  right  of  the  sternum.  If  the  exudation  be  on  the  right 
side,  the  displacement  of  the  heart  toward  the  left  is,  for  obvious  reasons, 
less  than  the  displacement  toward  the  right  in  pleurisy  of  the  left  side. 
Much  external  pressure  upon  the  heart  embarrasses  its  movements  and  pre- 
vents proper  filling  of  its  cavities,  while  the  action  of  the  organ  is  accel- 
erated so  as  to  compensate.     Therefore,  the  pulse  is  quick  and  feeble. 

In  one  instance  in  my  practice  the  lower  extremities  and  the  portion  of 
the  trunk  below  the  thorax  became  oedematous  from  compression  of  the 
ascending  vena  cava,  and  writers  allude  to  cases  in  which  other  vessels  and 
ducts,  as  the  thoracic,  were  compressed  so  as  seriously  to  embarrass  their 
functions.  The  patient  with  the  oedema  was  a  boy  of  about  four  years, 
with  empyema  of  the  left  side. 

In  large  effusion  the  mediastinum  is  pressed  against  the  healthy  lung  so 
as  to  diminish  its  transverse  diameter,  and  Traube  has  shown  that  the  effect 
of  this  is  to  increase  the  length  of  the  lung  or  its  vertical  measurement. 
Consequently,  as  the  lung  on  the  healthy  side  extends  lower  than  in  the 
normal  state,  the  convexity  of  the  diaphragm  on  this  side  is  diminished,  as 
well  as  on  the  affected  side,  where  it  is  depressed  by  the  effusion. 

The  pleura  in  protracted  cases  of  empyema  becomes  much  infiltrated, 
and  from  the  growth  of  connective  tissue  which  blends  with  it  is  thickened, 
sometimes  to  the  extent  of  one  or  two  lines.  A  few  months  since,  in 
removing  the  lungs  from  the  body  of  a  young  infant  that  perished  of  empy- 
ema in  the  New  York  Foundling  Asylum,  a  portion  of  the  costal  pleura, 
two  or  three  inches  in  diameter,  being  adherent  to  the  lungs,  was  detached 


ANATOMICAL   CHARACTERS.  715 

from  the  ribs.  It  had  a  thickncHs  oi"  i'ully  two  lines  and  its  free  surface  was 
rougli. 

Occasionally  the  intiainniation  extends  from  the  pleura  to  the  pericar- 
dium, producing  general  pericarditis.  1  recall  to  mind  4  cases  with  this 
complication  in  which  the  diagnosis  was  verified  by  post-mortem  examina- 
tions. All  had  empyema,  3  on  the  left,  and  1  on  the  right  side.  Pericar- 
ditis, always  a  grave  disease,  is  almost  necessarily  fatal  when  thus  occurring 
as  a  complication  of  empyema.  More  rarely  the  inflammation  extends  from 
the  pleura  to  the  peritoneum.  One  such  case  occurred  in  my  practice,  the 
child  dying  of  empyema  on  the  right  side,  and  at  the  autopsy  we  found  the 
lesions  of  a  localized  diaphragmatic  peritonitis  of  the  right  side,  with  a 
fibrinous  exudation  of  small  extent  on  the  convex  surface  of  the  liver 
directly  opposite  to  that  on  the  diaphragm.  We  are  indebted  to  Von  Reck- 
linghausen for  knowledge  of  the  mode  in  which  inflammation  is  propagated 
from  the  pleura  to  the  peritoneum,  and  the  same  explanation  probably 
applies  to  its  propagation  to  the  pericardium.  In  the  serous  covering  of  the 
diaphragm,  pleural  and  peritoneal,  minute  stomata  have  been  discovered 
which  pertain  to  the  lymphatic  system.  They  open  upon  the  surface  of  the 
diaphragm,  and  underneath  in  the  substance  of  the  diaphragm  connect  with 
lacunae  or  interspaces  from  which  the  minute  lymphatic  vessels  originate. 
These  stomata  and  lymphatic  spaces,  pervious  in  their  normal  state,  are  usually 
clogged,  as  has  been  stated  above,  by  inflammatory  products  when  the  serous 
membrane  is  inflamed.  Occasionally  the  inflammation  traverses  these  lym- 
phatic channels  from  one  surface  to  the  other,  from  the  pleura  to  the  peri- 
toneum, thus  causing  by  extension  a  circumscribed  peritonitis. 

The  changes  which  the  inflammatory  products  undergo  are  the  following: 
"With  the  abatement  of  the  inflammation  the  liquid  portion  begins  to  be 
absorbed,  though  absorption  is  much  more  tardy  than  in  non-inflammatory 
eff"usions,  since  the  absorbents  are  to  a  great  extent  covered  and  clogged  by 
fibrin  and  pus.  The  serum  is  first  absorbed,  and  the  flocculi  of  fibrin  sink 
into  depending  portions  of  the  cavity  or  become  attached  to  the  fibrinous 
layers  or  the  granulations  upon  the  pleural  surface.  The  pus-cells  and  the 
fibrin,  whether  in  flocculi  or  layers,  begin  to  undergo  retrogressive  change. 
They  become  granular  from  fatty  degeneration,  liquefy,  and  are  absorbed. 
Sometimes  portions  of  these  degenerated  products  which  are  not  absorbed 
form  inert  caseous  masses  in  recesses  of  the  cavity  or  between  the  bands  of 
connective  tissue,  where  they  remain  unchanged  for  years.  With  few  excep- 
tions, those  who  recover  from  an  attack  of  pleurisy  experience  no  subsequent 
ill-effect,  though  the  bands  and  patches  of  connective  tissue  are  permanent. 

Pus  always  possesses  irritating  properties.  Decomposed  and  putrid  pus 
(ichor)  is  very  irritating.  Empyemic  pus,  therefore,  like  pus  in  other  situa- 
tions, now  and  then  produces  ulceration  or  necrosis  of  the  pleural  surface  by 
which  it  is  confined,  and  in  consequence  of  its  destructive  action  it  sometimes 
establishes  an  outlet  by  which  it  escapes,  with  relief  of  the  patient  and  cure 
of  the  disease.  The  chest-wall  is  thinnest  anteriorly  in  the  inframammary 
region,  and  at  this  point  the  pus,  when  it  makes  its  way  through  the  thoracic 
wall,  usually  points  and  discharges.  The  fistulous  opening  thus  produced 
continues  many  months,  until  the  pleural  cavity  is  gradually  obliterated  by 
the  adhesions  and  the  patient  recovers. 

By  a  similar  destructive  process  in  the  pulmonary  pleura  pus  occasionally 
escapes  into  the  bronchioles  and  is  expectorated.  This  mode  of  cure  appears 
to  be  common  in  children,  for  my  attention  has  not  infrequently  been  called 
to  the  fact  that  children,  during  the  progressive  but  slow  convalescence  from 
empyema,  expectorated  large  quantities  of  muco-pus,  although  in  some  of 
the  cases  pus  had  been  removed  by  the  aspirator  or  trocar.     Frantzel  makes 


716  PLEURISY. 

the  remark — which  is  fully  sustained  by  clinical  experience  in  this  country — 
that  although  an  opening  is  made  in  the  lung  by  the  necrotic  or  ulcerative 
process,  so  that  pus  escapes  into  the  bronchioles,  air  does  not  pass  from  them 
into  the  pleural  cavity.  Pyopneumothorax  is  very  rare  in  the  empyema  of 
children,  except  as  air  is  admitted  in  the  operation  of  thoracentesis. 

As  the  liquid  is  absorbed  the  compressed  lung  ordinarily  expands  in  pro- 
portion to  the  absorption,  so  that  more  and  more  air  enters  its  alveoli.  But 
frequently,  in  cases  of  long  duration,  the  absorption  proceeds  faster  than  the 
expansion,  so  that  the  ribs  on  the  affected  side  sink  below  their  normal  level. 
As  a  consequence,  the  intercostal  spaces  are  narrowed,  the  shoulder  is  depressed, 
and  the  dorsal  portion  of  the  spinal  column  bends  to  accommodate  the  ribs, 
so  as  to  be  concave  toward  the  affected  side.  It  is  very  rarely  that  the 
deformity  thus  produced  is  permanent.  Though  the  newly-formed  bands  and 
patches  of  connective  tissue  may  so  bind  the  lung  that  its  return  to  the  nor- 
mal state  is  tardy,  yet  with  few  exceptions  the  alveoli  one  after  another  open 
to  admit  air,  and  when  full  inflation  is  attained  the  symmetry  of  the  chest  is 
restored.  But  there  are  rare  cases  in  which  the  newly-formed  connective 
tissue  is  firm  and  unyielding  almost  as  cartilage,  and  lime  salts  are  some- 
times deposited  in  it,  forming  a  calcareous  plaque  which  invests  the  lung  like 
a  cuirass.  An  unexpanded  lung  with  such  a  covering  obviously  can  never 
afterward  be  fully  inflated.  I  can  recall  to  mind,  however,  only  one  case  of 
permanent  complete  collapse  or  carnification  of  lung  resulting  from  pleurisy. 
The  inflammation,  which  was  treated  by  the  late  Dr.  Cammann,  occurred  in 
childhood,  and  several  years  afterward,  when  the  patient  reached  womanhood, 
although  the  general  health  was  good,  there  were  physical  signs  of  an 
unaerated  lung  and  the  consequent  deformity  (depressed  shoulder  and  ribs 
and  bent  spinal  column).  Pleurisy  with  its  granulations  and  retrogressive 
products  affords  one  of  the  conditions  in  which  tubercles  are  developed,  so 
that  we  sometimes  find  at  the  post-mortem  examination  of  cases  which  have 
been  protracted,  "  miliary  tubercles  in  the  pleura,  while  chronic  phthisis  and 
general  tuberculosis  are  absent"  (Delafield). 

From  the  intimate  relation  of  the  heart  to  the  lungs  this  organ  obviously 
suffers  severely  in  every  large  pleuritic  exudation.  Total  compression  of  a 
lung  arrests  one-half  of  the  circulation  through  the  pulmonary  artery,  except 
as  the  increased  flow  in  the  opposite  lung  serves  for  compensation.  Hence  in 
cases  of  large  effusion  which  end  fatally  we  commonly  find  the  pulmonary 
artery  and  the  right  cavities  of  the  heart  distended  with  blood  and  clots, 
while  the  left  cavities,  having  received  a  diminished  quantity  of  blood,  are 
probably  empty. 

Symptoms. — As  has  been  stated  above,  pleurisy  in  children  is  sometimes 
latent  or  attended  by  symptoms  so  mild  as  to  attract  little  attention  even 
when  there  has  been  general  inflammation  of  the  pleural  surface  with  much 
effusion.  Both  primary  and  secondary  pleurisy  may  present  this  form, 
latency  being  more  frequent  the  younger  the  patient.  In  feeble,  cachectic 
children,  with  blood  thin  and  impoverished,  pleuritic  symptoms,  as  pain, 
dyspnoea,  and  fever,  are  less  pronounced  than  in  the  robust,  and  hence 
latency  is  more  common  in  the  tenement-house  population  of  the  cities  and 
in  institutions  than  in  the  better  walks  of  life.  The  following  is  a  not  infre- 
quent example  of  latency  :  A  feeble  infant,  aged  five  months  and  twenty- 
eight  days,  died  suddenly  in  the  Nursery  and  Child's  Hospital  in  December, 
1870.  The  attention  of  the  resident  physician  had  not  been  called  to  it,  as 
it  was  not  supposed  to  be  sick,  except  that  it  was  ill-nourished  and  its  general 
condition  bad.  The  nurse  who  had  charge  of  the  ward  stated  that  it  pre- 
sented no  symptom  of  acute  disease,  unless  a  slight  cough  during  the  three 
or  four  days  preceding  its  death.     Percussion  over  the  right  side  of  the  chest 


SYMPTOMS.  717 

of  tlic  corpse  gave  a  flat  resonance,  and  at  the  autopsy  the  right  lung  was 
found  compressed,  nearly  or  quite  destitute  of  air,  and  covered  by  a  loose 
filirinous  layer  three-fourths  of  an  inch  thick  in  places,  and  a  moderate  serous 
exudation. 

Ordinarily,  acute  idiopathic  })lcurisy  in  children  begins  quite  abruptly, 
and  with  symptoms  which  attract  attention  from  the  first.  Probably  in  most 
instances  it  is  preceded  by  rigors  or  a  chilly  sensation,  but  this  usually  escapes 
notice,  if  it  be  present,  in  patients  under  the  age  of  five  or  six  years.  Fever, 
fretfulness,  and  a  physiognomy  indicative  of  pain  are  the  common  initial 
symptoms.  If  the  patient  be  an  infant,  the  fretfulness  closely  resembles 
that  produced  by  colic,  for  which  I  have  on  several  occasions  known  it  to 
be  mistaken  by  the  attending  physician. 

The  symptoms  of  pleurisy  are  twofold — namely,  the  constitutional,  or 
such  as  are  common  to  all  inflammations,  and  the  local,  or  those  referable 
to  the  chest.  Various  observers  have  noted  the  position  in  which  patients 
lie  in  bed  as  indicating  the  seat  of  the  inflammation.  It  has  been  stated  that 
adults,  in  the  commencement  of  pleurisy,  ordinarily  obtain  most  relief  with 
a  decubitus  on  the  sound  side,  but  when  eft'usion  has  occurred  they  lie  on  the 
aff"ected  side,  unless  tliere  be  marked  dyspnoea,  which  is  most  relieved  by  a 
semi-erect  position,  which  allows  greater  descent  of  the  diaphragm.  I  have 
not  noticed  that  children  with  pleurisy  prefer  any  fixed  or  uniform  position, 
except  there  be  marked  dyspnoea,  which  may  prompt  them  to  elevate  the  shoul- 
ders. The  patient  in  the  acute  stage  is  commonly  quiet  when  he  lies  in  the 
po.sition  which  he  selects,  and  if  disturbed  from  it  becomes  more  fretful,  his 
cough  more  fre((uent,  and  his  suff'ering  apparently  increased. 

In  ordinary  cases  the  temperature  rises  on  the  first  da}'  to  102°  or  103°. 
If  it  be  more  elevated  than  this  there  is  usually  a  complication.  The  tem- 
perature begins  to  abate  when  the  exudation  has  occurred.  In  suppurative 
pleurisy  the  fever  is  more  protracted,  often  continuing  for  weeks  or  months, 
presenting,  after  the  acute  stage  has  passed,  the  characters  of  hectic  fever, 
with  morning  abatement  and  evening  recrudescence.  In  weakly  and  anaemic 
children,  even  when  the  pleurisy  is  pretty  severe  and  most  of  the  usual  symp- 
toms are  present,  the  temperature  may  be  but  slightly  elevated.  Thus  in  one 
of  the  institutions  with  which  I  am  connected,  in  a  young  infant  whose  fret- 
fulness was  during  the  first  twenty-four  hours  ascribed  to  colic  the  axillary 
temperature  during  the  first  three  days  never  rose  above  100°. 

The  pulse  in  the  acute  stage  is  usually  between  100  and  130  per  minute, 
but  in  young  children  who  are  restless  it  is  often  more  frequent  than  this 
during  the  first  week.  It  is  accelerated  as  long  as  the  temperature  is  elevated, 
but  in  sero-fibrinous  pleuritis  after  exudation  has  occurred  its  frequency 
diminishes  unless  the  heart  be  compressed.  Compi'ession  and  imperfect  or 
partial  filling  of  the  cavities  of  the  heart  produce  a  feeble  and  rapid  pulse. 
In  empyema  the  pulse  is  accelerated  as  long  as  pus  is  confined  in  the  pleural 
cavity,  unless  its  quantity  be  small. 

Headache,  usually  frontal,  is  frequent  during  the  febrile  stage.  Convul- 
sions, which  occasionally  occur  in  the  beginning  of  pneumonia,  are  rare. 
Pain  in  the  chest  on  the  afi"ected  side  is  common,  and  is  therefore  a  valuable 
diagnostic  symptom,  but  it  is  often  so  slight  as  to  be  overlooked  in  infants 
and  feeble  children.  It  is  increased  by  movements  of  the  chest-walls,  as  in 
full  inspiration,  by  coughing,  and  when  pressure  is  made  by  the  fingers  in 
the  examination.  Its  common  seat  is  between  the  fifth  and  eighth  ribs,  exter- 
nal to  the  linea  mammalis,  but  there  are  many  cases  in  which  the  pain  is 
referred  to  some  other  part,  as  the  infraclavicular,  mammary,  inframammary, 
or  even  the  scapular  or  infrascapular,  region,  liarely,  it  is  referred  to  the  epi- 
gastric or  umbilical  region,  or  even,  it  is  said,  to  some  point  upon  the  sound 


718  PLEURISY. 

side  of  the  thorax.  This  location  of  the  pain  at  a  point  distant  from  the  seat 
of  the  inflammation  is  atti'ibutable  to  the  anastomosis  of  the  intercostal  nerves 
with  those  of  the  opposite  side  of  the  chest  or  with  those  which  ramify  in 
the  abdominal  walls. 

The  pain  of  pleurisy,  as  it  ordinarily  occurs,  has  received  different  expla- 
nations. It  has  been  attributed  to  tension  of  the  pleura,  to  friction  of  the 
pleural  surfaces  on  each  other,  and  to  extension  of  the  inflammation  to  the 
neurilemma  of  the  minute  nervous  branches  of  the  pleura.  All  these  causes 
apparently  act  in  producing  it,  but  the  persistent  pain  in  the  first  days  of 
pleurisy,  though  increased  by  motion,  is  probably  due  in  great  part  to  that 
last  mentioned.  Pleuritic  pain  is  sharp  or  stitch-like.  It  begins  to  abate  in 
a  few  days,  and  in  a  large  proportion  of  cases  ceases  by  the  fifth  or  sixth 
day,  or  is  no  longer  noticed  except  in  coughing  or  during  sudden  movement 
of  the  chest. 

The  respiration  is  accelerated,  as  in  all  febrile  diseases,  but  it  is  more  rapid 
than  in  inflammatory  ailments  which  do  not  involve  the  thoracic  organs,  on 
account  of  the  pain  experienced  on  full  inspiration.  The  patient  instinctively 
avoids  full  inflation  of  the  lungs,  and  the  breathing  is  consequently  rapid,  to 
compensate  for  incompleteness  of  the  inspiratory  act. 

In  ordinary  attacks  of  pleurisy  painful  and  hurried  respiration  is  of  short 
duration.  It  becomes  easier  and  more  natural  toward  the  close  of  the  first 
week.  In  subacute  and  chronic  cases  the  rhythm  and  frequency  of  respi- 
ration differ  but  little  from  the  normal. 

A  cough,  whatever  the  form  of  pleurisy,  is  one  of  the  earliest  symptoms. 
It  is  short,  frequent,  and  dry,  and  in  the  most  favorable  cases  begins  to  dimin- 
ish in  the  second  week.  A  loose  cough  is  due  to  accompanying  bronchitis  or 
broncho-pneumonia,  or,  at  a  late  stage  of  the  disease,  to  escape  of  pus  from 
the  pleural  cavity  into  the  bronchial  tubes. 

Little  need  be  said  in  regard  to  symptoms  referable  to  the  digestive  appa- 
ratus. Vomiting  is  common  on  the  first  and  second  days.  Thirst,  loss  of 
appetite,  and  consequent  loss  of  flesh  and  strength,  are  uniformly  present. 
In  empyema,  which  from  its  nature  is  protracted,  nutrition  is  always  greatly 
impaired.  The  sui'face  presents  an  anaemic  appearance,  the  flesh  is  soft  and 
flabby,  and  the  emaciation  is  progressive  till  the  pus  is  evacuated. 

Physical  Signs. — In  children  above  the  age  of  three  or  four  years,  the 
physical  signs  diff'er  but  little  from  those  in  adult  cases,  but  under  this  age 
there  are  certain  differences  which  the  practitioner  should  know.  We  may, 
in  the  commencement  of  the  attack,  notice  diminution  in  the  movement  of 
the  chest-walls  on  the  affected  side,  since  the  patient  instinctively  endeavors 
to  repress  respiration  on  that  side  in  order  to  lessen  the  pain.  In  severe 
cases  the  epigastrium  and  hypochondria  are  sometimes  depressed  during 
inspiration  (the  so-called  abdominal  respiration),  but  this  sign  is  less  common 
and  less  marked  than  in  severe  bronchitis,  and  when  present  it  may  be  largely 
due  to  accompanying  bronchitis.  After  eff"usion  has  occurred  and  the  pain 
has  abated  or  is  slight,  the  respiration  is  less  accelerated  than  at  first,  and  it 
may  be  nearl)'  or  quite  normal. 

Inequality  of  the  two  sides  produced  by  the  liquid  is  more  common  in 
children  of  an  advanced  age  than  in  those  under  the  age  of  three  or  four 
years.  In  infants,  even  when  there  is  a  large  liquid  exudation,  the  bulging 
is  often  so  slight  that  it  is  scarcely  appreciable  either  by  sight  or  measure- 
ment, and  in  not  a  few  there  is  no  apparent  difference  in  the  circumference 
of  the  healthy  and  aff"ected  sides.  I  have  made  measurements  in  infantile 
pleurisy  during  the  stage  of  effusion,  and  been  unable  to  convince  myself 
that  there  was  any  difference,  although  other  signs  indicated  the  presence  of 
an  effusion  which  filled  at  least  one-half  the  pleural  cavity.     I  explain  this 


PHYSICAL  SIGNS.  719 

fact  in  this  way  :  The  luii<;-.s  of  an  infant,  especially  of  one  reduced  by  sick- 
ness, arc  very  liable  to  a  state  of  seuii-coUapse  or  partial  inflation  in  their 
whole  extent  and  of  complete  collapse  of  their  thin  borders,  as  of  the  tongue- 
like  process  of  the  left  upper  lobe,  which  lies  over  the  pericardium,  and  of 
the  margins  of  the  lower  lobes,  which  lie  in  the  angle  made  by  the  thorax 
or  diaphragm.  This  occurs  in  the  weakly  infant  even  when  there  is  no 
obstruction  to  the  entrance  of  air,  and  the  liability  to  it  is  greatly  increased 
by  external  pressure  applied  to  the  lung,  as  from  a  pleuritic  effusion,  so  that 
the  lung  recedes,  becomes  compressed,  and  unaerated  before  the  ribs  yield  to 
the  pressure.  If  the  exudation  cease  as  soon  as  the  lung  is  collapsed,  there 
is  little  or  no  outward  displacement  of  the  ribs  and  the  intercostal  spaces  are 
not  elevated.  It  is  obviously  very  important  to  know  this  difference  between 
infantile  and  adult  cases,  as  it  has  a  bearing  upon  the  diagnosis  between 
pleurisy  with  effusion  and  pneumonia. 

Pdlpution. — In  adults  and  in  children  with  strong  voices,  if  the  lung 
deprived  of  air,  either  by  compression  or  an  exudation  within  its  alveoli,  lie 
against  the  chest-wall,  speaking  or  moaning  produces  a  vibratory  sensation 
which  is  communicated  to  the  han'd  placed  upon  the  chest.  The  fremitus  is 
feeble  or  not  appreciable  when  the  voice  is  feeble.  Therefore,  in  infants 
whose  vocal  cords  are  small,  and  particularly  in  infants  reduced  by  sickness, 
this  sign  is  ordinarily  absent  or  so  slight  that  it  is  detected  with  difficulty, 
while  in  older  and  robust  children  it  is  distinctly  perceived.  If  the  condition 
be  otherwise  favorable  for  the  production  of  fremitus,  but  the  lung  be  pressed 
away  from  the  ribs  by  an  intervening  liquid,  no  vibration  is  felt  when  the 
patient  speaks  or  cries.  But  if.  in  the  same  case,  the  fingers  be  removed  to 
the  suprascapular,  axillary,  infraclavicular,  or  mammary  region,  where  the 
compressed  lung  comes  in  contact  with  the  walls  of  the  chest,  fremitus  may 
be  perceived.  Palpation  also  enables  us  to  ascertain  the  point  of  apex-beat 
of  the  heart,  variation  of  which  from  the  normal  size  being  one  of  the  most 
conclusive  proofs  of  a  pleuritic  effusion. 

Percnssio)i. — In  the  first  hours  of  pleurisy  there  is  either  no  perceptible 
change  in  the  percussion  sound,  or  the  resonance  is  slightly  diminished  from 
the  fact  that  inspiration  on  the  affected  side  is  resisted  by  the  patient  and  the 
lung  is  only  partially  inflated.  When  exudation  occurs,  if  there  be  a  thin 
layer  of  liquid  over  the  lung  the  percussion  sound  is  tympanitic.  It  has, 
therefore,  this  quality  at  an  early  stage  in  the  inframammary,  mammary,  and 
perhaps  infrascapular  regions  when  the  amount  of  liquid  is  small,  and  at  a 
later  stage,  when  the  quantity  of  liquid  is  greater,  the  percussion  sound  over 
the  lower  part  of  the  chest  is  dull,  while  that  over  the  central  or  upper  part 
is  tympanitic.  Entire  filling  of  the  pleural  cavity  with  liquid,  and  total 
exclusion  of  air  from  the  lung,  give  rise  to  a  dull  or  flat  percussion  sound 
over  every  part  from  the  apex  to  the  base.  It  may  be  stated  as  a  rule  in  the 
pleurisy  of  children  that  at  a  certain  stage  of  the  effusion  percussion  pro- 
duces a  sound  which  is  either  decidedly  tympanitic  or  which  partakes  of  the 
tympanitic  character.  Skoda  attributed  the  occurrence  of  tympanism  to  the 
fact  that  a  lung  still  aerated  vibrates  better  if  surrounded  by  a  thin  layer  of 
liquid,  and  consequently  gives  better  resonance  than  when  it  lies  against  the 
chest-walls. 

When  the  exudation  is  so  great  that  the  lung  is  totally  compressed  and 
removed  to  a  distance  from  the  chest-walls,  the  finger  in  percussing  experi- 
ences a  sensation  of  solidity  or  resistance  and  there  is  no  longer  any  vibra- 
tion of  the  ribs.  Consequently,  the  percussion  sound  is  dull  or  flat,  as  over 
any  .solid  body,  differing  from  that  in  pneumonia,  in  which  there  is  still  some 
vibration  of  the  chest-walls  and  the  dulness  is  not  absolute.  In  pleurisy, 
therefore,  there  is,  according  to  the  amount  of  exudation,  either  nearlj-  the 


720  PLEURISY. 

normal  percussion  sound,  as  at  tlie  beginning  of  the  attack  and  in  any  stage 
of  plastic  pleurisy  (pleuresie  seclie),  or  a  zone  of  dull  sound  below  and 
another  of  tympanitic  sound  above,  or  a  zone  of  normal  resonance  above 
and  one  of  dull  resonance  at  the  base,  with  an  intervening  one  of  tympan- 
ism ;  or,  finally,  there  is  absolute  dulness  from  the  clavicle  to  the  base  of  the 
chest. 

It  very  rarely  happens  in  the  child  that  the  level  of  the  fluid  changes  by 
changing  the  position,  on  account  of  the  adhesions,  so  that  this  sign,  described 
in  the  books  as  one  of  great  importance  in  diagnosis,  affords  very  little  assist- 
ance to  diagnosis  in  children. 

Auscultation. — In  the  beginning  of  pleurisy  auscultation  affords  but  slight 
information,  except  that  the  practised  ear  may  detect  a  little  diminution  in 
the  fulness  of  the  respiratory  act  in  the  lung  whose  pleura  is  inflamed,  and 
perhaps  a  slightly  exaggerated  I'espiration  in  the  other  lung.  But  after 
twelve  or  fifteen  hours,  when  exudation  begins  to  occur  upon  the  pleural 
surface,  we  may  hear  the  dry  friction  sound,  which  can  be  imitated  by  push- 
ing the  finger  strongly  across  the  dry  palm  of  the  hand.  It  is  only  heard  in 
occasional  cases,  since  the  physician  may  not  make  his  visit  at  the  proper 
time  for  hearing  it  or  he  does  not  apply  the  ear  over  the  proper  place. 
Frantzel  says :  "  We  shall  scarcely  ever  fail  to  find  the  friction  sound  in 
recent  pleuritis  if  we  look  for  it  early  and  diligently  in  some  circumscribed 
spot."  I  do  not  think  that  this  remark,  however  true  it  may  be  of  adult 
cases,  is  entirely  correct  as  regards  children,  for  it  is  only  in  exceptional 
instances  that  it  can  be  heard  in  them.  It  occurs  both  during  inspiration 
and  expiration,  and  it  does  not  disappear  after  coughing.  Being  produced 
upon  the  surface  of  the  lung,  it  seems  near  the  ear  of  the  auscultator.  Per- 
haps it  is  not  observed  during  several  consecutive  respirations,  and  then  a 
deeper  inspiration  causes  the  pleural  surfaces  to  glide  upon  each  other,  and 
it  is  detected.  The  friction  sound  as  sometimes  heard  is  well  described  by 
the  term  "  scraping,"  and  in  other  cases  by  the  term  "  creaking,"  as  was 
noticed  by  Hippocrates,  who  compared  it  to  the   creaking  of  leather. 

In  some  patients  it  is  heard  for  a  brief  period,  and  does  not  recur,  and  it 
may  be  detected  only  during  strong  and  deep  respiration  or  in  coughing.  It 
disappears  entirely  when  the  accumulation  of  liquid  prevents  contact  of  the 
surfaces.  After  absorption  of  the  liquid  the  friction  sound  may  reappear, 
and  in  certain  patients  it  is  heard  only  at  this  time — to  wit,  in  the  third 
stage. 

An  interesting  and  common  sound  heard  on  inspiration  is  the  so-called 
crepitant  ride  uf  jilemisy.,  produced  in  the  superficial  alveoli.  The  remarks 
made  by  Trousseau  upon  it  have  been  already  given.  As  stated  above,  the 
inflammation  extends  from  the  pleura  to  the  pulmonary  vesicles  which  lie 
directly  underneath,  and  as  soon  as  exudation  occurs  within  them  the  ana- 
tomical conditions  are  present  in  which  the  crepitant  rale  is  produced,  as  in 
the  ordinary  form  of  pneumonia.  This  rale  may  obviously  be  heard  before 
any  effusion  takes  place  upon  the  free  surface  of  the  pleura,  and  it  continues 
until  the  alveoli  are  so  compressed  by  the  plueritic  exudation  that  they  no 
longer  admit  air. 

The  exudation  in  the  pleural  cavity  changes  the  character  of  the  respira- 
tory sound.  A  thin  layer  of  liquid  over  the  lung  causes  diminution  in  the 
force  of  the  vesicular  murmur,  and  soon  an  expiratory  as  well  as  an  inspira- 
tory sound  begins  to  be  heard.  This  modified  vesicular  murmur  is  weak, 
and  more  distant  from  the  ear  than  the  respiratory  sound  of  health.  When 
the  exudation  is  sufiicient  to  close  the  alveoli,  while  the  air  still  traverses  the 
medium-sized  bronchial  tubes,  we  notice  a  tubular  or  bronchial  hriiit.  If  the 
small  and  medium-sized  tubes  are  compressed  while  the  air  enters  the  large 


PHYSICAL  SIGNS.  721 

tubes,  the  respiratory  bruit  may  be  amphoric.  Total  absence  of  respiratory 
sound  results  from  complete  collapse  of  the  alveoli  and  consequent  exclusion 
of  air  from  them,  and  arrest  of  the  movements  of  the  air  in  the  tubes  of  the 
aifected  side.  Jaccoud  says  :  "  Regarded  as  a  sign  of  the  (juantity  of  the 
effusion,  the  modifications  of  the  respiratory  bruit  and  of  the  respiration  may 
then  be  arranged  in  an  increasing  scries,  as  follows :  diminution  of  the  vesic- 
ular murmur ;  feeble  respiration  (-sonj/ie  doux)  ;  no  sound  and  feeble  respira- 
tion ;  bronchial  respiration';  no  sound  and  bronchial  respiration;  no  sound 
and  cavernous  respiration  ;  general  absence  of  sound  {sUrncr  gaieraC).  The 
replacement  of  an  inferior  term  of  the  series  by  a  superior  term  implies  an 
augmentation  in  the  quantity  of  liquid,  and  in  general  the  passage  of  a 
superior  term  to  an  inferior  term  denotes  a  diminution  of  the  effusion."  But 
this  statement  relating  to  the  effect  upon  the  auscultatory  sounds  of  the 
increase  and  decrease  of  the  liquid  must  be  modified  as  regards  patients 
under  the  age  of  five  years.  In  such  patients  it  is  rare,  however  great  the 
effusion,  that  respiration  is  not  heard  when  the  ear  is  placed  over  the  liquid. 
This  is  due  to  the  small  size  of  the  pleural  cavity,  and  the  consequent  ready 
transmission  of  sound  from  the  centre  of  the  thorax  to  its  periphery.  Accord- 
ing to  the  amount  of  exudation  and  the  degree  of  compression,  the  respira- 
tory sound  is  a  faint  and  distant  vesicular,  or  broncho-vesicular,  or  bronchial 
murmur,  and  its  character  is  found  to  vary  from  one  to  the  other  of  these 
sounds  as  we  apply  the  ear  over  different  parts  of  the  chest. 

When  the  inflammation  is  active  and  the  exudation  occurs  rapidly,  bron- 
chial respiration  may  be  heard  as  early  as  the  second  or  third  day,  or  even  by 
the  close  of  the  first  day,  in  the  infrascapular  region.  If,  on  the  other  hand, 
the  inflammation  be  chiefly  plastic  or  the  exudation  of  liquid  be  slow  and  its 
quantity  small,  the  respiratory  murmur  may  be  vesicular,  though  faint  and 
distant,  during  the  whole  course  of  the  attack.  Sometimes  when  the  mur- 
mur is  vesicular  in  the  greater  part  of  the  lung,  broncho-vesicular  or  bron- 
chial respiration  is  heard  over  a  limited  area,  where  the  effusion  happens  to 
be  sufl^icient  to  produce  requisite  compression  of  the  lung. 

The  voice  of  the  patient  when  auscultated  over  the  affected  side  has  a 
character  which  corresponds  with  and  varies  according  to  the  respiratory 
murmur.  Vocal  resonance  is  feeble  or  absent  if  the  respiratory  murmur  be 
vesicular.  If  it  be  bronchial,  the  auscultated  voice  is  more  distinct,  having 
the  character  known  as  bronchophony,  or  when  there  is  a  moderate  quantity 
of  liquid  over  the  lung,  so  that  this  organ  vibrates,  it  may  have  that  modifi- 
cation of  bronchophony  known  as  aegophony.  Occasionally  we  can  hear  the 
voice  as  a  confused  and  distant  sound  when  the  quantity  of  liquid  is  so 
great  that  respiration  is  inaudible.  The  signs  derived  from  the  auscultated 
voice  are  not,  as  is  well  known,  pathognomonic  of  liquid  effusion.  Bronchoph- 
ony is  more  common  and  distinct  in  pneumonic  or  tubercular  solidification 
of  lung  than  in  pleurisy,  and  even  segophony  may  be  produced  without  the 
presence  of  a  liquid  by  "  pleural  membranes  realizing  certain  physical  con- 
ditions "  (Jaccoud).  But  since  the  auscultated  voice  is  weaker  in  children 
than  in  adults,  we  often  do  not  hear  it  in  infants  and  ill-conditioned  children, 
even  when  the  anatomical  conditions  as  regard  the  lungs  and  pleural  cavity 
are  favorable  for  its  transmission. 

In  children,  as  in  adults,  bronchial  rales  are  common  in  pleurisy,  dry  or 
moist ;  coarse  when  produced  in  the  larger  tubes,  or  fine  when  occurring  in 
the  finer  tubes. 

Diagnosis. — Ordinarily,    a    careful    observance    of    the    history,    symp- 
toms,  and    physical    signs   enable   the   physician    to   make   a   positive   diag- 
nosis.      Obscure    or    doubtful    cases    occur    chiefly    in    infancy.       Circum- 
scribed   pleurisy   or    pleurisy   attended   with    little   or    no    liquid   exudation 
46 


722  PLEURISY. 

is  obviously  likely  to  be  overlooked   and  its  symptoms  mistaken  for  those 
of  another  disease. 

Pleurisy  before  the  stage  of  exudation  may  be  mistaken  for  pneumonia, 
since  the  prominent  symptoms  in  the  commencement  of  the  two  diseases  are 
similar.  But  in  pleurisy  there  are  commonly  greater  acceleration  of  pulse 
and  respiration,  greater  suffering  as  evinced  by  the  features,  greater  tender- 
ness on  percussion  or  on  pressing  the  chest-wall,  and  a  more  decided  expira- 
tory moan,  while  the  patient  probably  endeavors  to  repress  respiration  on  the 
affected  side,  so  that  inflation  of  the  lungs  is  partial  and  shallow.  It  will  aid 
in  the  diagnosis  to  recollect  that  in  children  under  the  age  of  five  years  acute 
pneumonia  is  in  most  instances  catarrhal,  and  not  croupous,  and  is  preceded 
and  accompanied  by  severe  bronchitis,  being  due  to  downward  extension  of 
the  inflammation  from  the  bronchial  tubes.  It  therefore  does  not  begin  with 
the  abruptness  of  pleurisy. 

Pleurisy  with  effusion  may  be  mistaken  for  pneumonia  in  the  stage  of 
solidification,  for  hydrothorax,  or,  on  the  left  side,  for  pericardial  effusion,  or 
vice  versa.  But  the  percussion  sound  over  a  pleuritic  exudation  is  either 
tympanitic  or  flat,  while  over  a  lung  solidified  by  inflammation  it  has  some 
resonance,  though  dull.  There  is  also  a  sensation  of  greater  resistance  and 
solidity  in  percussing  over  a  pleuritic  exudation  than  over  an  inflamed  lung. 
Moreover,  the  respiratory  murmur,  whether  vesicular,  broncho-vesicular,  or 
bronchial,  is  more  distant  and  less  distinct  to  the  ear  of  the  auscultator 
when  applied  over  a  liquid  than   over  a  solidified  lung. 

A  pleuritic  exudation,  unless  slight,  also  changes  the  apex-beat  of  the 
heart,  pressing  it  toward  the  median  line  in  left  pleurisy,  and  away  from 
the  median  line  in  right  pleurisy,  as  has  been  stated  above — a  change  not 
observed  in  pneumonia.  Bulging  of  the  intercostal  spaces,  expansion  of 
the  chest-walls,  change  in  height  of  the  fluid  by  change  in  the  position  of 
the  child — important  signs  in  the  diagnosis  of  adult  pleurisy — are,  as  we 
have  seen,  commonly  absent  in  young  children,  even  when  there  is  abundant 
liquid  effusion,  but  they  are  sometimes  observed  in  children  of  a  more 
advanced  age.  Bronchophony  and  vocal  fremitus,  signs  of  pneumonic  solid- 
ification, are  absent  or  so  feeble  in  the  pneumonia  of  young  children  that 
their  absence  cannot  be  regarded  as  indicative  of  the  presence  of  pleuritic 
effusion,  except  in  children  over  the  age  of  four  or  five  years.  Moreover, 
these  signs,  when  present,  do  not  necessarily  indicate  pneumonia,  for  if  in 
pleuritic  effusion  the  ear  or  hand  be  placed  over  a  part  of  the  chest  where 
adhesions  have  united  the  lung  to  the  ribs,  and  the  child  be  of  such  an  age 
that  the  vocal  cords  have  sufiicient  vibration,  both  bronchophony  and  the  fre- 
mitus may  be  perceived.  The  absence  or  presence,  therefore,  of  vocal  fremitus 
and  bronchophony  affords  only  limited  assistance  in  the  differential  diagnosis 
of  pleurisy  and  pneumonia  in  young  children.  In  those  of  an  advanced 
age,  whose  vocal  cords  have  greater  vibration,  it  aids  in  the  discrimination 
of  doubtful  cases,  especially  if  the  examination  be  made  in  the  infrascap- 
ular  region,  which  corresponds  with  the  location  of  the  liquid,  if  any  be 
present. 

A  pleuritic  effusion  is  distinguished  from  hydrothorax  by  the  fact  that 
the  latter  is  usually  bilateral  and  of  slow  increase,  without  symptoms  refer- 
able to  the  chest,  except  when  there  is  considerable  effusion,  which  causes 
more  or  less  dyspnoea.  Pleurisy,  unlike  hydrothorax,  causes  fever  and  other 
constitutional  symptoms,  and  also  a  cough,  pain  in  the  chest,  and  early 
embarrassment  of  respiration.  Moreover,  hydrothorax  seldom  occurs,  except 
from  cardiac  or  renal  disease  or  scai'let  fever. 

A  greatly  distended  pericardial  sac  simulates  in  some  degree  a  pleuritic 
effusion  on  the  left   side,  but   the   absence   of   symptoms   which  pertain   to 


PROGNOSIS.  723 

pleurisy,  as  the  cough,  stitcli-like  pain  in  the  chest,  the  hjcalization  or  greater 
distinctness  of  the  dull  sound  on  percussion  in  the  cardiac  region,  absence 
or  feebleness  of  the  apex-beat,  and  indistinctness  or  distance  of  the  heart- 
sounds,  will  preserve  the  observant  physician  from  error  of  diagnosis. 

Proonosis. — In  mild  cases  attended  with  little  exudation  the  inflamma- 
tion soon  begins  to  abate,  and  by  the  close  of  the  second  week  the  symptoms 
have  nearly  disappeared.  In  plastic  and  sero-fibrinous  pleurisies  recovery  may 
be  confidently  expected,  unless  there  be  some  grave  complication,  or  perchance 
syncope  should  occur  from  large  and  rapid  effusion.  A  large  efiusion,  what- 
ever its  character,  especially  if  located  on  the  left  side,  often  causes  such  a 
twist  in  the  great  vessels  within  the  thorax  as  seriously  to  retard  the  circu- 
lation of  blood  and  endanger  life.  In  effusions  of  the  left  side  the  heart  is 
often  carried  so  far  toward  the  right  that  the  ascending  vena  cava,  where  it 
emerges  from  the  central  tendon  of  the  diaphragm,  is  bent  at  an  angle  so  as 
seriously  to  obstruct  the  return  of  blood  from  the  lower  half  of  the  body, 
and  consequently  a  reduced  quantity  of  blood  reaches  the  right  cavities  and 
the  pulmonary  artery.  The  result  is  a  diminished  flow  of  blood  in  the  .sys- 
temic circulation,  with  anaemia  of  important  organs,  as  the  brain.  The  great 
arteries  connected  with  the  heart  are  also  more  or  less  bent  in  cases  attended 
by  displacement  of  this  organ.  In  effusions  on  the  right  side  the  right  auricle 
and  ventricle  sometimes  do  not  expand  to  the  normal  extent  during  the  dias- 
tole, on  account  of  the  pressure  of  the  liquid,  and  the  result  is  similar  to 
that  in  eft'u.sions  on  the  left  side  as  regards  obstructed  circulation  and  anaj- 
mia  of  important  organs.  Therefore,  patients  with  large  pleuritic  effusions, 
whether  left  or  right,  are  liable  to  sudden  fainting  and  even  to  fatal  syn- 
cope. Fortunately,  with  our  present  improved  methods  of  thoracentesis 
children  need  not  perish  in  this  way  if  the  operation  be  resorted  to  at  the 
proper  moment.  There  is  another  danger.  When,  in  consequence  of  the  exu- 
dation, the  lung  is  so  compressed  that  its  function  is  nearly  or  quite  lost, 
the  sound  lung  obviously  receives  an  augmented  supply  of  blood.  It  is 
therefore  very  liable  to  sudden  congestions  and  transudation  of  serum 
(oedema).  If  this  occur,  the  dyspnoea  is  augmented  and  the  condition  is  one 
of  utmost  peril.     Death  may  result  from  this  state. 

The  prognosis  obviously  vai-ies  according  to  the  cause  of  the  inflamma- 
tion and  the  quantity  and  nature  of  the  exudation.  Idiopathic  pleurisies  do 
better,  as  a  rule,  than  those  which  occur  as  a  complication  or  sequel  of  some 
other  disease.  Absorption  is  more  rapid  in  the  beginning  of  convalescence, 
when  the  fluid  is  thin,  than  at  a  later  period,  when  it  has  greater  consistence. 
Fibrin,  whether  flocculent  or  laminated,  is  necessarily  slowly  absorbed,  first 
undergoing  fatty  degeneration  and  liquefaction.  Empyema,  if  not  relieved 
by  operative  measures,  continues  many  months  ;  even  after  pus  is  let  out  con- 
valescence is  slow.  In  the  very  considerable  number  of  empyemic  cases 
which  have  from  time  to  time  been  brought  to  the  class  of  children's  dis- 
eases in  the  Bureau  for  the  Relief  of  the  Out-door  Poor  the  histories  com- 
monly showed  that  the  disease  had  continued  from  three  to  six  months,  with 
progressive  loss  of  flesh  and  strength.  Nevertheless,  after  proper  evacuation 
of  the  pus  and  the  establishment  of  a  fistulous  opening  the  majority  have 
gradually  recovered,  death  in  the  unfavorable  cases  being  commonly  due  to 
extreme  prostration  with  perhaps  fatal  organic  changes,  as  amyloid  degenera- 
tion and  tuberculosis. 

Secondary  pleurisy  occurring  in  a  reduced  state  of  the  system,  as  after 
scarlet  fever,  and  pleurisy  complicated  by  a  grave  disease,  as  pericarditis  or 
pneumonia,  are  always  dangerous  to  life. 

It  is  the  common  belief  that  pleuritic  effusions  involve  greater  danger  on 
the  left  than  on  the  right  side,  from  the  fact  that  the  former  produces  more 


724  PLEURISY. 

immediate  and  direct  pressure  on  the  heart  and  causes  a  greater  twist  in  the 
vessels,  but  Leichtenstern '  states  that  in  52  cases  of  sudden  death  from  pleu- 
ritic effusions,  31  were  right  and  20  left  pleurisies.  The  walls  of  the  right 
cavities  of  the  heart,  upon  which  the  liquid  in  the  right  pleural  cavity 
directly  presses,  are  thinner,  and  therefore  more  yielding,  than  the  walls  of 
the  left  cavities.  The  records  of  the  cases  collected  by  Leichtenstern  show 
that  sudden  death  sometimes  results  from  extensive  and  far-reaching  thrombi 
in  the  right  cavities  of  the  heart  and  in  the  superior  vena  cava,  or  from  emboli 
detached  from  the  thrombi  and  intercepted  in  the  pulmonary  artery.  In 
grave  cases  attended  by  large  effusion  sudden  death  sometimes  occurs  after 
some  exertion  on  the  part  of  the  patient,  as  after  vomiting,  severe  coughing, 
or  hurried  rising  to  the  erect  position  or  lifting  a  heavy  weight.  It  is  believed 
that  under  such  circumstances  there  is  a  retarded  flow  of  blood  through  the 
lungs  and  into  the  left  cavities  of  the  heart  and  the  aorta,  so  that  sudden 
and  fatal  anaemia  of  the  brain  is  produced. 

As  already  stated,  death  may  occur  in  protracted  cases  from  amyloid 
degeneration  of  important  organs,  as  the  kidneys  and  liver.  This  can  some- 
times be  detected  by  enlargement  of  liver  and  spleen  and  the  occurrence  of 
albuminuria. 

It  is  evident  that  the  prognosis  varies  greatly  according  to  the  degree  of 
dyscrasia.  In  profound  blood-poisoning,  whether  scarlatinous,  uraemic,  or 
septicaemic,  pleurisy  is  always  grave.  Septic  pleurisy,  which  occurs  for  the 
most  part  in  new-born  infants  during  epidemics  of  puerperal  fever,  is  espe- 
cially so.  When  it  has  continued  a  few  hours  the  pinched  features  and  rapid 
sinking  show  that  we  have  to  deal  with  something  more  than  an  ordinary 
attack.^ 

'  Deutsche?.  Archivfilr  kh'n.  Med.,  Band  iv. 

^  The  following  case,  which  occurred  in  my  practice  during  the  epidemic  of  puer- 
peral fever  in  1881,  may  be  adduced  as  an  example:  Mrs.  T> ,  a  primipara,  was 

delivered  by  the  forceps,  after  a  tedious  labor,  at  9  p.  m.,  April  6th.  On  the  following 
morning  her  temperature,  without  the  occurrence  of  a  chill,  had  risen  to  105J°,  and  her 
pulse  varied  between  125  and  134.  She  was  in  a  critical  state  for  several  days  with  a 
temperature  varying  between  103°  and  1050°,  and  without  any  local  symptoms  either 
of  metritis  or  cellulitis,  but  finally  recovered.  The  baby,  healthy  and  vigorous  at  birth, 
had  been  allowed  to  obtain  what  nutriment  it  could  from  the  breast,  but  the  nurse 
remarked  that  she  "never  saw  a  child  sleep  so  much,"  and  I  gave  very  little  attention 
to  it,  as  my  time  was  devoted  wholly  to  the  mother.  On  the  10th,  M'hen  four  days  old, 
its  sleepiness  ceased,  and  it  became  constantly  fretful,  as  from  colic,  and  it  refused 
to  draw  the  nipple.  Early  in  the  morning  of  the  11th  I  was  summoned  to  it,  and 
was  astonished  at  its  altered  appearance,  its  shrunken  features,  and  its  evidently  dying 
state.  Percussion  upon  the  right  side  gave  a  flat  resonance  from  the  clavicle  to  the 
diaphragm,  and  there  was  some  raeteorism  in  the  abdomen.  The  thermometer  intro- 
duced into  the  rectum  showed  no  elevation  of  temperature,  and  no  unusual  heat  of 
surface  or  cough  had  been  noticed  by  the  nurse.  By  active  stimulation  the  infant  lived 
till  the  middle  of  tlie  afternoon.  The  autopsy  revealed  a  sero-fibrinous  exudation  fill- 
ing the  right  pleural  cavity,  producing  complete  carnification  of  the  lung,  so  that 
it  resembled  that  of  the  foetal  state,  and  soft  patches  or  flakes  of  fibrin  upon  the 
lungs.  By  an  oversight  the  peritoneum  was  not  examined.  Cases  like  this,  of  pleu- 
ritis  in  tlie  new-born,  produced,  it  is  thought,  by  the  wandering  micrococci  of  the 
septic  state,  occur  chiefly  during  epidemics  of  childbed  fever.  Some  years  ago  I  saw 
a  new-born  infant  in  one  of  the  institutions,  whose  mother  had  puerperal  fever,  die  in  a 
similar  manner,  and  the  autopsy  showed  that  the  cause  was  peritonitis.  The  following 
example  from  Trousseau's  clinical  lecture  on  erysipelas  of  new-born  infants  will  aid  in 
understanding  such  cases.  Speaking  of  Dr.  P.  Lorain,  he  says:  "During  the  epidemic 
at  the  Maternite,  where  this  able  and  laborious  observer  was  resident  pupil,  he  collected 
the  information  of  which  the  following  is  a  summary :  Of  106  stillborn  infants,  10  were 
found  to  have  died  from  peritonitis,  and  3  of  the  mothers  of  tliese  1 0  infants  were  car- 
ried off*  by  puerperal  fever  after  delivery.  Of  193  infants  born  alive,  50  died  of  the 
very  same  affections  which  proved  i'atal  to  the  lying-in  women.  The  most  frequent 
causes  of  death  were  peritonitis,  numerous  abscesses,  purulent  infection,  phlegmonous 


TRI'JA  TMENT.  725 

Pleurisy  is  also  very  severe,  and  oniiiiarily  fatal,  •when  it  is  caused  l)y  the 
entrance  of  some  pathological  product  into  the  pleural  cavity,  as  pus  or  decay- 
ing lung-substance. 

Trkatmknt. — It  will  be  proper,  in  considering  the  treatment,  to  describe 
that  which  is  appropriate  for  each  of  the  three  stages  into  which  writers 
have  for  convenience  divided  pleurisy  :  First,  the  stage  preceding  effusion  ; 
secondly,  that  of  effusion  ;•  and  thirdly,  that  of  absorption  and  convalescence. 
In  the  beginning  of  the  inflammation  appropriate  measures  should  l)e  promptly 
employed  for  the  i)urpose  of  reducing  the  inflammation  and  preventing  or 
diminishing,  so  f\ir  as  possible,  the  exudation  that  soon  follows.  The  abstrac- 
tion of  blood  is  now  properly  discarded  in  the  treatment  of  most  inflamnuitions 
of  infancy  and  childhood,  but  in  certain  cases  of  pleurisy  occurring  in  robust 
children  over  the  age  of  four  or  five,  or  even  three  years,  the  early  and  judi- 
cious employment  of  one  or  two  leeches  diminishes  the  pain  and  temperature, 
and  apparently  also,  to  a  certain  extent,  the  inflammation.  But  it  may  be 
stated  as  a  rule  that  the  loss  of  blood  is  not  only  not  required,  but  is  inju- 
rious, in  all  secondary  pleurisies,  and  in  the  primary  form  after  exudation  has 
occurred.  It  is  injurious  in  all  forms  of  pleurisy  in  pallid  and  cachectic 
children,  and  therefore  in  a  large  proportion  of  the  cases  occurring  in  the 
tenement-houses  and  institutions  of  the  cities.  The  flow  of  blood  from  the 
bites  if  leeches  are  employed  should  ordinarily  be  arrested  after  two  or  three 
hours,  but  if  slight  it  may  continue  longer  in  vigorous  children  of  eight  or 
ten  years. 

At  the  first  visit  of  the  physician  an  emollient  and  slightly  irritating 
poultice  should  be  ordered,  enveloping  the  entire  chest,  to  be  constantly 
worn,  except  as  it  is  temporarily  removed  during  the  application  of  the  leech 
and  the  subsequent  flow  of  blood.  The  poultice  should  be  so  mildly  irritat- 
ing that  it  causes  constant  redness  of  the  skin  without  pain,  and  it  should 
not  be  removed  except  when  a  fresh  poultice  is  prepared  to  replace  it.  Thus 
employed,  it  produces  constant  dilation  of  the  capillaries  of  the  skin,  and  by 
the  fluxion  caused  diminishes  the  engorgement  of  the  capillaries  of  the  costal 
pleura.  A  poultice  of  common  mustard,  with  flaxseed  in  powder,  one  part  to 
sixteen,  between  two  pieces  of  muslin,  and  so  wet  that  it  moistens  the  hand 
in  holding  it,  produces  this  effect.  Applied  morning  and  evening,  it  can  be 
constantly  worn  without  complaint  of  pain  produced  by  its  irritating  action. 
For  infants  under  the  age  of  eight  months  I  prefer  the  use  of  plain  flaxseed, 
with  camphoi-ated  oil  smeared  upon  its  under  surface.  The  oil  may  be 
applied  several  times  daily,  while  the  morning  and  evening  application  of  the 
poultice  is  sufficient.  Spongiopilin  or  compresses  of  flannel  wrung  out  of 
hot  water  and  covered  with  oil-silk  meet  the  indication,  and  possess  the 
advantage  of  being  lighter  and  cleaner  and  more  readily  applied  than  the 
poultice.  Redness  may  be  produced  by  applying  under  the  spongiopilin  a 
single  thickness  of  muslin  soaked  with  camphorated  oil,  or  for  children  of  a 
more  advanced  age  with  camphorated  oil  and  one-fourth  part  of  turpentine. 
Vesication,  formerly  much  employed,  has  properly  nearly  faljen  into  dis- 
use in  the  treatment  of  the  pleurisy  of  children.  While  it  is  liable  to 
increase  the  suffering,  it  has  apparently  no  tendency  to  diminish  the  inflam- 

swellings,  erysipelas,  gangrene  of  tlie  limbs,  putrid  infection,  or  some  otlier  remark- 
able septic  condition."  ....  "Mother  and  child  then  are  sul)ject  to  tlie  same  morbific 
influence."  Fartlier  on  Trousseau  says  of  the  infant  afiected  by  this  puerperal  poison : 
"It  will  cry  incessantly  from  pain.  A  state  of  restlessness  will  he  succeeded  by  col- 
lapse, which  will  close  the  scene  on  the  fifth,  sixth,  or  seventh  day.  On  e.xamining  the 
body  after  deatli  pus  will  be  found  in  the  celluhvr  tissue,  sometimes  suppurative  pletrn'sy, 
more  frequently  phlebitis  of  the  umbilical  vein  or  of  the  vena  porta,  or  peritonitis." 
An  interesting  incidental  fact  shown  by  these  statistics  is  that  the  cause  of  this  puer- 
peral disease  of  the  new-born  is  sometimes  operative  in  the  foetal  state. 


726  PLEURISY. 

mation  in  whichever  stage  employed,  and  there  is  no  certainty  that  it  stimu- 
lates the  absorbents  and  expedites  the  removal  of  the  liquid,  according  to  the 
old  theory.  A  case  is  reported  in  the  practice  of  one  of  the  New  York  phy- 
sicians in  which  a  blister  had  been  applied  when  the  inflammation  was  still 
active,  and  at  the  autopsy  the  portion  of  the  costal  pleura  which  lay  directly 
underneath  the  surface  that  had  been  vesicated  was  covered  by  a  thicker 
fibrinous  exudation  than  that  upon  the  contiguous  surface.  The  increased 
afflux  of  blood  caused  by  the  blister  had,  to  appearance,  extended  to  the 
costal  pleura  and  increased  the  pleurisy.  The  application  of  cold  bandages 
around  the  chest,  which  is  recommended  by  some,  seems  to  aggravate  the 
cough  in  certain  patients,  and  does  not  ordinarily  give  the  relief  of  moist  and 
warm  applications. 

Internal  Remedies. — The  indications  are  to  employ  such  medicines  as 
diminish  the  frequent  action  of  the  heart,  and  thus  retard  in  a  measure  the 
flow  of  blood  to  the  pleura,  and  such  as  diminish  the  pain  and  frequency  of 
the  cough,  which  by  increasing  the  friction  of  the  pleural  surfaces  tends  to 
increase  the  inflammation.  For  robust  children  over  the  age  of  three  years 
in  the  first  stage  of  primary  pleurisy  the  tincture  of  aconite  may  be  pre- 
scribed, half  a  drop  for  a  patient  of  three  years,  and  one  drop  for  one  of  six 
years,  every  third  hour  for  two  or  three  days,  or  until  the  required  effect  be 
produced  upon  the  pulse,  when  it  should  be  discontinued.  It  is,  as  a  rule, 
too  depressing  for  younger  patients.  Digitalis  is  a  better  and  safer  remedy 
for  children  under  the  age  of  three  years  for  all  secondary  pleurisies  and  for 
all  cachectic  cases.  Benefit  results  from  continuing  the  use  of  digitalis  in 
the  stage  of  exudation,  when  aconite  would  be  inadmissible.  A  child  of  two 
years  can  take  two  drops  of  the  officinal  tincture,  and  one  of  five  years  four 
drops,  every  two  or  three  hours. 

Antipyrine  is  an  effectual  antipyretic.  One  or  two  doses  reduce  tempera- 
ture two  or  three  degrees.  It  therefore  promises  to  be  a  useful  remedy  in 
the  first  stage  of  pleuritis  as  well  as  in  other  acute  diseases,  when  the  tem- 
perature is  so  high  as  to  involve  danger.  It  is  not  a  tonic,  and  it  seems  to 
impair  the  digestive  function.  It  is  therefore  most  useful  in  those  diseases 
which  are  not  attended  by  any  marked  prostration,  but  in  which  the  fever, 
from  its  intensity,  exhausts  the  strength.  If,  therefore,  in  the  commence- 
ment of  pleurisy  the  temperature  rises  above  103°,  it  may  properly  be  pre- 
scribed in  doses  of  four  grains  to  a  child  of  five  years,  and  be  repeated,  if 
necessary,  in  three  hours.  It  is  soluble  in  water,  and  it  may  be  employed 
as  an  enema  if  the  stomach  be  irritable.  Phenacetin  or  antifebrin  may  be 
employed  as  a  substitute  for  antipyrine. 

The  use  of  quinia  is  suggested,  since  it  is  an  antipyretic  and  tonic,  but  in 
my  practice  it  has  been  much  less  useful  in  pleurisy  than  in  pneumonia. 
This  agent,  in  whatever  form  given,  does  not  appear  to  exert  any  notable 
controlling  effect  either  on  the  fever  or  gravity  of  pleurisy.  Nevertheless,  I 
have  often  employed  it,  especially  in  secondary  pleurisies,  with  or  without 
digitalis,  and  it  probably  does  some  good  as  a  tonic.  The  salts  of  quinia,  as 
ordinarily  given  in  solution  to  young  children,  are  frequently  vomited.  When 
vomited,  a  soluble  salt,  as  the  bisulphate,  may  be  given  as  a  suppository,  or 
Squibb's  oleate  of  quinia  may  be  employed  by  inunction.  I  should,  however, 
add  that,  though  I  have  used  inunctions  of  the  oleate  in  pleurisy  during  the 
last  year,  ten  grains  of  the  alkaloid  at  a  time,  I  have  not  seen  any  marked 
beneficial  eff'ect.  To  meet  the  second  indication  in  the  treatment  of  the  first 
stage — namely,  to  relieve  the  pain  and  restlessness  and  to  diminish  the  cough, 
so  that  there  is  less  friction  of  the  pleural  surfaces — our  chief  reliance  must 
be  on  hyoscyamus  or  one  of  the  opiate  preparations.  The  following  formulae 
will  be  found  useful : 


TREATMENT.  727' 

R.  Tiiu't.  opii  (leoclorat.,  gtt.  xx ; 

Tinct.  digitalis,  gtt.  xl ; 

Syr.  pruni  virginiani,  Sj  ; 

Aqua^  5JS.S.     Misce. 

Dose:  One  tea.spoonful  (one  drachm)  every  three  hours  for  an  infant  of  eighteen 
months.  Tlie  tincture  of  hyoscyanuis  may  be  employed  in  place  of  the  opiate  in 
double  the  dose. 

For  a  child  of  three  years  : 

R.  Tinct.  ipecac,  comp. 

(Squibb's  liquid  Dover's  powder), 
Tinct.  digitalis,  da.  gtt.  xxxij; 

Syr.  pruni  virginiani,  5ij.     Misce. 

Dose:  One  teaspoonful  every  two  or  three  hours. 

For  a  robust  child  of  eight  years  with  primary  pleurisy : 

R.  Morph.  sulphat.,  gr.  j; 

Tine.  rad.  aconit.,  gtt.  xx  ; 

Syr.  pruni  virginiani,  Sy'ss.     Misce. 
Dose:  One  teaspoonful  every  three  hours. 

The  diet  in  the  first  stage  should  consist  of  milk  and  farinaceous  food, 
given  liberally.  The  meat  teas  or  the  expressed  juice  of  meat  may  be  added, 
and  in  secondary  pleurisies,  as  after  scarlet  fever,  it  is  often  proper  to  give  a 
moderate  amount  of  alcoholic  stimulants  from  the  first. 

Second  Stage. — Measures  employed  in  the  first  stage  have  been  designed 
to  diminish  the  inflammation  and  relieve  suff"ering.  The  duty  of  the  physician 
in  the  treatment  of  the  second  stage  is  chiefly  to  aid  in  the  removal  of  the 
inflammatory  product,  and  prevent,  so  far  as  possible,  its  further  formation. 
If  this  be  sero-fibrinous  and  its  quantity  be  small,  so  as  to  fill  only  the  lower 
portion  of  the  cavity,  little  aid  may  be  needed  from  therapeutics ;  but  a  larger 
efi"usion,  compressing  the  lung  and  displacing  the  heart,  requires  medicinal 
and  often  surgical  measures.  The  recommendations  of  Niemeyer,  that  the 
patient's  food  contain  little  liquid  and  that  his  drinks  be  restricted  as  a  means 
of  increasing  absorption  from  the  pleural  surface,  is  not  applicable  to  young 
children,  whose  diet  must  of  necessity  be  largely  liquid,  and  that  of  infants 
chiefly  milk. 

Attempts  to  stimulate  the  absorbents  by  external  treatment  of  the  chest 
are  of  doubtful  efficacy,  whether  by  the  application  of  small  blisters,  can- 
tharidal  collodion,  the  iodine  ointment  or  tincture,  or  a  stimulating  liniment. 
The  common  practice  of  treating  glandular  swellings  by  iodine  applications 
suggests  their  use  for  pleuritic  eflfusions,  and  of  the  agents  employed  locally 
to  hasten  absorption  they  are  probably  the  best,  but  they  should  not  be  used 
so  often  or  in  such  quantity  as  to  cause  pain  or  restlessness  from  their  irri- 
tating effect.     The  following  ointment  may  be  used : 

R.  Potas.  iodidi,  xij  ; 

Lanolin,  3ij.     Misce. 

To  be  rubbed  freely  over  the  side  of  the  chest  which  is  the  seat  of  the  sero-fibrinous 
exudation  three  or  four  times  daily. 

It  is  an  established  principle  in  therapeutics  that  the  removal  of  a  serous 
liquid  in  either  of  the  larger  cavities  of  the  body  is  hastened  by  such  rem- 
edies as  produce  an  abundant  liquid  secretion  or  transudation  from  any  of  the 
organs  or  surfaces.     Hence  in  the  treatment  of  pleuritic  effusions  those  med- 


728  PLEURISY. 

icines  which  act  on  the  skin,  causing  diaphoresis,  upon  the  intestines,  causing 
watery  stools,  and  upon  the  kidneys,  causing  diuresis,  are  at  once  suggested 
as  most  likely  to  be  efficacious.  But  sudorifics,  though  useful  for  dropsies 
having  a  renal  origin,  have  not  been  much  used  of  late  years  for  the  removal 
of  exudations  in  the  pleural  cavity,  experience  having  shown  that  they  are 
inadequate  for  this  purpose.  Recently,  however,  the  discovery  of  a  very 
active  agent  of  this  class,  jaborandi,  has  revived  in  a  measure  the  sudorific 
treatment  of  the  second  stage,  so  that  in  the  National  Dispensatory  of  Stille 
and  Maisch  this  diaphoretic  is  one  of  the  recommended  remedies.  But  the 
heart,  crippled  in  its  action  by  the  pressure  of  the  liquid,  badly  tolerates 
agents  of  a  depressing  nature,  and  jaborandi,  or  its  active  principle  pilocarpine, 
exerts  a  weakening  effect  on  this  organ.  It  therefore  should  be  used  with 
caution  in  this  disease.  It  is  probably  best  in  most  instances  not  to  employ 
it,  inasmuch  as  we  possess  other  and  efficient  remedies. 

The  fact  that  sero-fibrinous  exudations  have  been  known  to  diminish  rap- 
idly during  attacks  of  diarrhoea  suggests  the  use  of  purgatives  ;  but,  although 
an  open  state  of  the  bowels,  as  two  or  three  daily  stools,  aids  in  absorption^ 
free  purgation  is  badly  borne  by  young  or  feeble  children,  as  it  reduces  the 
strength,  and  therefore  is  not  to  be  recommended  as  a  therapeutic  measure. 
Moreover,  there  is  not  the  need  of  employing  severe  or  exhausting  medicines 
for  the  removal  of  the  liquid  which  existed  in  former  times,  since  we  are  able 
to  accomplish  this  quickly,  easily,  and  safely  by  the  excellent  aspirating 
instruments  now  in  common  use. 

Diuretics,  on  the  other  hand,  are  apparently  more  useful,  while  they  are 
less  exhausting,  than  sudorifics  or  cathartics.  Digitalis,  combined  with  the 
citrate  or  acetate  of  potassium,  has  stood  the  test  of  experience,  and  is  now 
more  widely  used  than  any  other  agent  of  this  class.  Being  both  a  diuretic 
and  heart-tonic,  it  possesses  properties  which  render  it  especially  serviceable 
in  the  treatment  of  pleuritic  effusions.  The  following  is  a  useful  prescription 
for  a  child  of  five  years : 

R.  Potassii  acetatis,  ,^ij  ; 

Infus.  digitalis,  ,^iij.     Misce. 

Give  one  teaspoonful  every  three  hours. 

It  is  a  matter  of  observation  that  absorption  occurs  more  rapidly,  and  a 
sero-fibrinous  is  less  likely  to  become  a  purulent  effusion,  if  the  bodily  con- 
dition be  good.  Hence  tonics,  especially  the  bitter  vegetables,  are  sometimes 
useful,  and  a  diuretic  in  combination  with  a  tonic,  as  the  acetate  of  potassium 
in  decoction  of  cinchona,  may  often  be  prescribed  with  advantage. 

Still,  however  judicious  the  treatment,  hygienic  and  medicinal,  many 
cases  require  surgical  interference,  and  the  number  of  such  is  larger  in  the 
city  than  in  the  country,  and  in  tenement-houses  than  in  the  better  walks  of 
life,  since  the  cachexia  so  common  in  city  children  increases  the  liability  to 
purulent  exudations. 

Thoracentesis. — The  indications  for  the  operation  are  the  following : 

1st.  Dyspnoea  due  to  the  presence  of  the  liquid,  whether  it  be  sero- 
fibrinous, purulent,  or  hemorrhagic.  Usually  when  dyspnoea  occurs  the 
pleural  cavity  is  full,  and  if  there  be  parenchymatous  disease  of  either  lung 
a  moderate  quantity  of  liquid  may  cause  such  embarrassment  of  respiration 
that  thoracentesis  is  indicated. 

2d.  A  fiat  percussion  sound  over  the  entire  affected  side,  with  displace- 
ment of  the  heart,  even  if  there  be  no  present  dyspnoea,  is  also  an  indication 
for  the  operation,  for  dyspnoea  may  occur  suddenly  with  other  alarming  symp- 
toms between  the  visits  of  the  physician.     Moreover,  experience  has  shown 


TREATMENT.  729 

that  absorption  from  a  distoiidcd  pleural  cavity  is  very  tardy,  in  consequence 
of  compression  of  the  absorbents,  whereas  if  a  portion  of  the  liquid  bo 
removed  absorption  of  the  remainder  is  more  rapid.  The' patient  with  full 
pleural  cavity  and  lung  totally  compressed  lies  on  the  affected  side,  and  is 
usually  uncomfortable  in  any  other  position,  and  the  withdrawal  of  a  portion 
of  the  liquid — as,  for  example,  one  half — the  operation  being  discontinued 
when  the  patient  begins  to  cough  or  evince  distress,  produces  no  ill-effect  and 
increases  the  comfort. 

3d.  A  moderate  effusion,  without  material  decrease  in  quantity  after  some 
weeks  of  observation,  also  indicates  the  need  of  surgical  interference,  since 
long  compression  of  a  lung  involves  risks.  There  is  danger  that  catarrhal 
ending  in  cheesy  pneumonia  and  tubercles  may  occur  in  a  lung  whose  func- 
tion is  long  suspended ;  besides,  the  longer  compression  has  existed  the  more 
tardy,  difficult,  and  incomplete  will  be  the  inflation  when  the  liquid  is  removed, 
on  account  of  the  altered  state  of  the  alveoli  and  the  presence  of  fibrinous 
bands  over  the  lung.  Thus,  in  a  case  recently  under  observation  only  partial 
inflation  of  the  lung  occurred  after  letting  out  the  liquid,  so  that  the  ribs  and 
shoulder  on  the  affected  side  are  permanently  depressed  and  unequivocal 
symptoms  of  tuberculosis  are   now   present. 

4th.  If  the  inflammation  extend  to  the  pericardium,  so  as  to  cripple  the 
heart's  action,  or  if  there  be  any  serious  pre-existing  heart  disease,  the  liquid, 
even  in  moderate  quantity,  may  by  pressure  so  embarrass  and  retard  the 
heart's  action  that  its  cavities  are  not  properly  filled,  so  that  passive  conges- 
tion of  certain  organs  and  dangerous  anaemia  of  others,  especially  of  the 
brain,  may  result.  Under  such  circumstances  an  early  performance  of  tho- 
racentesis is  indicated. 

5th.  Empijema. — The  presence  of  pus  in  the  pleural  cavity  affords  in  itself, 
in  a  large  proportion  of  cases,  sufficient  indication  of  the  need  of  thoracente- 
sis. In  recent  cases  with  only  moderate  constitutional  disturbance  and  embar- 
rassment of  respiration,  if  we  ascertain  by  the  hypodermic  syringe  that  the 
liquid  is  only  slightly  clouded  by  leucocytes,  surgical  interference  may  be 
postponed  while  the  acute  inflammation  is  treated.  Thus,  in  case  of  aa 
infant  of  two  months  thin  pus  was  withdrawn  on  the  fourth  day  of  acute 
pleuritis,  and,  although  thoracentesis  was  early  performed,  it  appeared  prob- 
able, from  the  subsequent  course  of  the  case,  that  it  would  have  been  as  well 
had  the  operation  been  deferred.  If  spontaneous  evacuations  of  pus  have 
occurred  through  one  of  the  intercostal  spaces,  producing  a  fistula  from 
which  there  is  a  daily  oozing,  or  if  it  be  probable,  from  the  symptoms  and 
signs,  that  pus  is  escaping  from  the  pleural  cavity  into  a  bronchial  tube,  and 
is  being  gradually  expectorated — a  mode  of  cure  which,  as  I  have  elsewhere 
stated,  is  not  infrequent  in  children — thoracentesis  may  be  deferred.  In  the 
case  of  an  infant  aged  six  months  recently  under  treatment  for  empyema  of 
the  left  side  we  removed  four  ounces  of  pus  and  washed  out  the  pleural 
cavity.  The  opening  having  closed,  and  the  physical  signs  indicating  the 
reaccumulation  of  a  considerable  quantity  of  liquid,  we  were  preparing  for  a 
second  operation  when  the  parents  and  nurse  called  our  attention  to  the  fact 
that  there  were  occasional  severe  attacks  of  coughing,  during  which  the 
breath  presented  a  very  decidedly  purulent  odor.  Although  there  was  no 
external  expectoration,  as  the  sputum  was  swallowed,  thoracentesis  was  post- 
poned, and  the  result  justified  the  decision,  for  the  patient  gradually  conva- 
lesced. Except  under  circumstances  like  the  above,  empyema,  when  clearly 
diagnosticated  by  the  employment  of  the  hypodermic  syringe,  should  be 
promptly  treated   by  evacuation   of  the  pus. 

Inxfrnments  to  be  Useff,  and  Modr  of  Opcralutg. — Ingenious  instruments 
for  tapping  the  chest  have  been  invented  by  Dr.  Chadbourne  of  New  Yoik, 


730  PLEURISY. 

Dr.  A.  M.  Phelps  of  Chateaugay,  Franklin  co.,  N.  Y.,  and  others,  which  by 
India-rubber  packing  totally  exclude  air  while  the  operation  is  performed 
with  facility  and  little  pain.  That  devised  by  Dr.  Chadbourne  has  a  canula 
with  two  arms,  one  for  attachment  by  means  of  tubing  to  the  exhausting 
receiver,  and  the  other  is  designed  to  facilitate  irrigation  of  the  pleural 
cavity. 

Phelps's  apparatus  has  a  third  tube,  entering  the  bottle  through  the  stop- 
ple, and  a  glass  tube  passes  from  the  stopple  to  nearly  the  bottom  of  the  bot- 
tle. With  this  apparatus,  by  reversing  the  movement  of  the  syringe,  the 
liquid  can  be  withdrawn  from  the  chest,  the  bottle  emptied  of  it,  the  water 
used  for  irrigation  be  conveyed  into  the  bottle,  from  the  bottle  to  the  chest, 
and  back  into  the  bottle,  without  changing  the  position  of  the  bottle  or 
removing  the  stopple.  I  would  suggest  the  use  of  the  trocar  and  canula 
instead  of  the  sliding  aspirator  point,  which  plays  outside  the  canula,  as 
an   improvement  in   this  instrument. 

The  instrument  which  I  have  been  in  the  habit  of  employing  is  of  sim- 
pler construction.  The  canula  is  about  the  size  of  the  smallest  needle  of 
Dieulafoy's  aspirator — the  proper  size,  in  my  opinion,  for  thoracentesis  for 
both  sero-fibrinous  and  purulent  exudations.  I  greatly  prefer  the  use  of  the 
exhausting-bottle  rather  than  the  exhausting-pump  without  the  bottle,  as  it 
is  more  convenient  and  produces  greater  suction  from  its  greater  size.  The 
canula  is  provided  with  an  arm  which  connects  it  by  tubing  with  the  exhaust- 
ing-bottle. Beyond  this  arm  the  body  of  the  canula,  sufficiently  expanded  to 
contain  India-rubber  packing,  extends  about  one  and  a  half  inches  and  is 
provided  with  a  stopcock.  Through  this  packing  the  trocar  is  introduced, 
and  after  the  puncture  it  is  withdi'awn  to  the  stopcock,  which  is  then 
turned  to  prevent  the  admission  of  air.  Then  the  obturator  is  introduced 
in  place  of  the  trocar,  so  as  to  remove  any  obstruction  which  may  enter  the 
canula. 

The  tubing  which  extends  from  the  arm  of  the  canula  to  the  bottle 
should  be  firm,  with  a  somewhat  larger  bore  than  that  of  the  canula,  and 
its  point  of  attachment  to  the  bottle  should  also  be  provided  with  a  stop- 
cock. A  short  glass  tube  introduced  into  this  tubing  near  the  canula  is 
convenient  for  noticing  the  character  of  the  fluid,  which,  if  it  be  thick  pus, 
may  flow  with  difiiculty  and  not  reach  the  bottle.  A  bottle  of  sufficient 
capacity  to  hold  two  quarts  obviously  produces  more  suction  power  than  one 
of  less  size,  and  is  therefore  preferable  for  certain  cases,  and  its  sides  should 
be  marked  to  indicate  ounces  and  drachms.  The  tube  which  connects  the 
canula  with  the  bottle  enters  through  the  stopple,  and  proceeding  from  the 
stopple  is  another  tube  similar  to  the  first,  to  which  the  syringe  is  attached. 
The  syringe  has  two  points  for  attachment  to  the  tube  and  a  double  action 
in  its  interior,  so  that  attached  by  one  point  it  exhausts  the  air  from  the 
bottle,  and  attached  by  the  other  point  it  condenses  air  in  the  bottle.  The 
stopcock  between  the  canula  and  the  bottle  should  always  be  closed  when 
the  syringe  is  used,  whether  for  exhaustion  or  condensing.  It  is  very 
important  that  this  should  be  constantly  borne  in  mind  when  working 
the  syringe,  or  air  may  be  thrown  into  the  pleural  cavity  and  much  harm 
done. 

Mode  of  Operating  for  Sero-fihrinous  Exudations. — In  the  following 
remarks  I  shall  state  what  I  consider  the  best  method  for  performing 
thoracentesis,  having  formed  my  opinion  from  the  cases  which  I  have 
witnessed  and  been  able  to  follow  in  institutions  and  in  family  practice. 
A  mode  of  treatment  which  may  be  safe  and  proper  for  the  adult  is  not 
always  the  best  for  the  child,  and,  as  there  are  diff"erent  opinions  and  differ- 
ent modes  of  procedure,   and  as  many   who  are  familiar  with  adult  cases 


TREATMENT.  731 

recommend  similar  treatment  for  the  child  to  that  which  they  have 
employed  with  success  for  the  older  and  more  robust  cases,  I  shall 
advise  the  abandonment  of  certain  measures  which  are  in  common  use 
and  the  substitution  of  others.  The  hypodermic  syringe  should  be  first 
used  at  the  point  where  it  is  proposed  to  perform  the  operation,  the  dis- 
infected needle  being  inserted  about  one  inch,  for  I  hold  it  unjustifiable  to 
tap  the  chest  without  first  ascertaining  that  there  are  no  adhesions  at 
the  site  selected  for  puncture,  and  at  the  same  time  ascertaining  the 
character  of  the  liquid.  Incision  of  the  skin  with  the  knife  and  spraying 
the  surface  with  ether  are  not  required  as  preliminary  treatment,  since  the 
puncture  is  quickly  and  easily  performed  with  a  small  trocar  and  with  very 
little  pain.  The  rule  is  established  by  many  observations  that  the  operation 
should  be  performed  in  or  near  the  vertical  line  passing  through  the  angle  of 
the  scapula  and  between  the  eighth  and  ninth  ribs  or  one  of  the  adjacent  inter- 
costal spaces.  I  have  elsewhere  stated  that  a  point  a  little  external  to  this 
line  is  preferable,  as  the  lung  is  less  liable  to  be  injured.  The  instrument 
should  obviously  be  inserted  no  farther  than  will  be  sufficient  to  reach  the 
liquid,  and,  since  from  measurements  which  I  have  made  the  thickness  of 
the  thoracic  wall  in  rather  fleshy  children  is  about  half  an  inch,  penetration 
to  the  depth  of  one  inch  will  ordinarily  be  sufficient  to  pass  the  fibrinous 
layer.  We  are  liable  to  puncture  more  deeply  than  is  necessary  without 
some  safeguard,  and  incur  the  risk  of  wounding  the  lung.  India-rubber 
tubing  may  cover  the  instrument  to  within  one  inch  of  the  end,  or  a  cord 
may  be  tied  snugly  around  the  instrument  at  one  inch  from  the  tip.  The 
sensation  communicated  to  the  fingers  will,  however,  be  the  best  guide  to  the 
careful  operator  as  regards  the  exact  depth  to  which  the  instrument  should 
be  carried.  The  trocar  should  now  be  withdrawn,  the  obturator  introduced 
in  its  place,  the  air  exhausted  from  the  bottle,  and  then  the  stopcock  turned 
to  allow  the  liquid  to  escape. 

It  should  flow  slowly,  as  it  probably  will  through  so  small  a  canula,  but 
the  flow  can  be  regulated  by  the  stopcock.  The  quantity  to  be  removed 
depends  upon  the  age  and  condition  of  the  child,  the  size  of  the  cavity,  and 
the  quantity  of  the  liquid,  but  if  the  patient  begin  to  cough  or  feel  uncom- 
fortable after  the  removal  of  one-half,  or  even  one-third  of  the  liquid,  the 
canula  should  be  withdrawn.  The  sensation  of  insufficient  breath  is  no 
longer  experienced,  and  the  remaining  liquid  is  progressively  absorbed.  This 
operation  is  one  of  the  easiest  in  surgery,  while,  with  the  precautions  men- 
tioned above,  no  ill  eff"ect  need  be  apprehended.  One  operation  is,  in  most 
instances,  all  that  is  required,  though  if  need  be  it  can  be  repeated  after  some 
days,  and  it  is  very  seldom  that  the  lung  does  not  fully  expand  to  fill  the 
chest  if  the  operation  be  performed  at  the  proper  time. 

Mode  of  Operating  for  Empyema. — It  will  aid  in  understanding  this  part 
of  our  subject  to  remember  that  all  pleuritic  exudations  contain  pus-cells,  and 
that  the  only  anatomical  diff'erence  between  sero-fibrinous  exudations  and 
empyema  is  in  the  proportion  of  these  cells.  There  is,  therefore,  no  fixed 
and  definite  boundary-line  between  the  two  kinds  of  exudation.  The  term 
"  empyema  "  is,  as  all  know,  applied  by  common  usage  to  the  liquid  when  it 
contains  so  many  leucocytes  or  pus-cells  that  a  turbid  appearance  is  imparted 
to  it.  Absorption  is  slow  and  difficult  or  impossible  if  the  liquid  contain  a 
large  amount  of  solid  ingredients — to  wit,  fibrin  and  pus-cells — while  liquid 
containing  only  a  small  proportion  of  these  constituents  more  readily  enters 
the  absorbents.  In  other  words,  thin  pus  may  be  absorbed  and  removed  from 
the  system  by  natural  methods,  or  by  the  same  instrument  and  operation 
which  we  have  recommended  for  sero-fibrinous  exudations,  while  a  thick 
liquid  adherent  to  the  pleura  or  sinking  heavily  in  dependent  portions  of  the 


732  PLEURISY. 

cavity  disappears  very  slowly,  losing  by  absorption  only  a  little  of  the  liquor 
puris,  vrhile  the  bulk  of  it  cannot  be  absorbed,  so  that  the  only  relief  is  by 
evacuation  through  an  opening.  Often  in  practice,  after  the  acute  symptoms 
of  an  empyema  have  in  a  measure  abated,  the  physical  signs  indicate  some 
diminution  of  liquid  in  successive  weeks,  but  further  removal  soon  comes  to 
a  standstill  and  the  resources  of  surgery  must  be  tried. 

The  same  small  trocar  and  canula,  or  a  little  larger,  should  be  used  for 
tapping  the  chest  of  an  empyemic  child  which  we  have  recommended  for 
sero-fibrinous  exudation  and  with  the  same  precautions.  If  the  liquid  be  thin 
and  but  slightly  turbid,  if  it  be  but  little  removed  from  sero-fibrin  in  its  cha- 
racter, it  will  flow  through  the  canula,  even  if  it  be  necessary  to  use  the 
obturator  often  to  remove  obstructions.  Having  withdrawn  all  the  liquid 
which  will  flow  through  the  opening,  unless  severe  coughing  or  some  unpleas- 
ant symptom  occur,  which  is  an  indication  to  discontinue  the  withdrawal,,  the 
instrument  is  removed  and  the  aperture  may  be  closed  with  adhesive  plaster. 
In  exceptional  instances,  if  the  pus  be  thin  and  the  pus-cells  few  in  propor- 
tion to  the  amount  of  serum,  one  aspiration  may  be  sufficient  to  effect  a 
cure  :  but  usually  the  cavity  refills.  If  the  pus  be  thick,  it  will  almost 
inevitably  refill,  and  it  is  better  to  make  a  free  incision  with  a  bistoury  at 
once.  If  the  pus  be  thin  and  the  cavity  after  aspiration  refill  in  a  few  weeks, 
free  incision  is  preferable  to  a  second  aspiration,  for  as  a  rule  the  lung  should 
not  be  compressed  by  pus  more  than  four  to  six  weeks,  for  by  longer  com- 
pression it  might  be  seriously  injured. 

Therefore  if  the  chest  refill  after  one  or  at  most  two  aspirations,  an  incision 
should  be  made  with  the  knife  at  the  same  point  as  that  selected  for  aspiration — 
that  is,  between  the  eighth  and  ninth  ribs  and  in  the  line  passing  perpendicularly 
through  the  lower  angle  of  the  scapula.  An  incision  should  be  made  with  a 
sharp-pointed  bistoury  a  little  nearer  the  ninth  than  the  eighth  rib,  sufficiently 
large  to  admit  the  blunt-pointed  bistoury,  and  with  this  the  incision  should 
be  extended  to  the  distance  of  one-third  to  one-half  inch,  which  will  allow 
the  pus  to  flow  out  freely.  The  opening  should  then  be  covered  by  oakum 
confined  by  long  strips  of  adhesive  plaster.  Pus  may  or  may  not  continue  to 
flow  into  the  oakum.  If  it  do  not,  the  opening  will  close,  if  left  to  itself, 
within  two  or  three  days.  No  tent  or  drainage-tube  is  employed,  for  reasons 
to  be  mentioned  hereafter.  The  physician  should  return  after  twelve  or 
twenty-four  hours,  not  later,  and  should  introduce  through  the  opening  the 
ordinary  gum-elastic  male  catheter,  warmed  so  as  to  be  flexible  and  strongly 
bent  at  its  middle.  The  point  should  be  directed  to  the  bottom  of  the  cavity. 
Perhaps  the  soft  rubber  catheter  might  be  preferable,  but  I  have  never  used 
it,  being  satisfied  with  the  other.  The  catheter  should  be  attached  by  tubing 
to  the  exhausting-syringe  or  bottle,  and  any  pus  in  the  depending  portions  of 
the  cavity  will  be  readily  removed.  I  have  generally  at  this  visit  removed 
from  the  bottom  of  the  cavity  two  or  three  ounces,  sometimes  very  thick,  and 
such  as  would  not  readily  flow  from  the  opening.  Every  day  or  twice  daily 
the  operation  should  be  repeated  ;  which  will,  I  think,  more  effectually  remove 
the  pus  than  washing  out  the  cavity,  and  the  opening  cannot  close.  This 
operation  detains  the  physician  only  a  few  moments.  The  catheter  should  be 
a  No.  X.,  and  it  is  the  best  possible  probe.  By  the  close  of  the  first  week 
the  opening  becomes  fistulous. 

After  each  removal  of  the  pus  long  strips  of  adhesive  plaster  firmly 
applied  over  the  ribs,  from  the  sternal  region  downward  and  backward, 
facilitate  approximation  of  the  pleural  surfaces  and  obliteration  of  the  cavity. 
During  convalescence  the  patient,  if  old  enough,  should  be  directed  to  make 
full  inspirations,  which  serve  to  expand  the  lungs. 


TREATMENT.  73:; 

That  so  simple  and  important  an  operation  as  thoracentesis  shoukl  luive 
been  known  and  practised  by  tlie  ancients — even,  it  is  said,  by  Hippocrates — 
and  liavc  fallen  into  disuse  till  it  was  revived  in  our  own  times  by  IJowditch 
and  Trousseau  seems  remarkabh;.  'J'his  was  j)robably  in  part  due  to  the  bad 
instruments  employed,  and  in  part  to  the  fact  that  in  olden  times  the  opera- 
tion was  performed  in  the  anterior  walls  of  the  chest,  where  adhesions  are 
fretjuently  present.  But  there  are  certain  accidents  and  unfavorable  results 
of  the  operation  which  may  be  profitably  considered,  since  they  can  nearly 
always  be  avoided : 

1st.  The  Admission  of  Air  into  the  Pleural  Cairity. — This  is  unnecessary 
and  can  be  avoided ;  but  those  who  have  often  witnessed  the  operation  as 
ordinarily  performed  have  remarked  the  fact  that  the  admission  of  more  or 
less  air  is  common. 

The  entrance  of  a  certain  amount  of  air  into  a  serous  cavity  when  the 
serous  membrance  is  in  its  normal  state  does  not  appear  to  be  productive  of 
harm  with  ordinary  precautions  as  regards  temperature,  etc.,  as  in  ovariotomy, 
in  which  air  is  admitted  into  the  largest  serous  cavity  in  the  body  ;  and  the 
moderate  admission  of  air  into  the  pleural  cavity  when  the  pleura  is  healthy 
does  not,  as  a  rule,  produce  any  ill  effect.  Thus,  a  case  is  related  of  a  man 
who  suffered  from  heart  disease,  and  was  led  to  think  that  the  pressure  of  a 
small  amount  of  air  internally  might  be  substituted  for  external  pressure, 
which  always  gave  relief.'  He  was  his  own  instrument-maker  and  operator. 
He  constructed  a  small  tube  about  as  slender  as  a  common  pin,  to  which  a 
bladder  was  attached  filled  with  air.  The  point  of  this  was  thrust  through 
an  intercostal  space  till  it  penetrated  the  pleural  cavity,  and  air  was  made 
to  enter  by  compressing  the  bladder.  Relief  always  followed  and  the 
patient's  health  improved.  This  treatment  was  continued  two  or  three  years. 
Dr.  Lizars,  who  was  present  at  the  meeting  of  the  medical  society  before 
which  this  case  was  related,  stated  that  he  had  performed  a  similar  operation 
on  four  or  five  patients  affected  with  aneurisms,  with  some  apparent  benefit 
and  in  no  case  with  injury. 

But  the  condition  is  very  different  if  there  be  inflammatory  products  in 
the  cavity.  It  is  a  fact  known  to  all  observers  that  animal  liquids  withdrawn 
from  the  circulation  and  escaped  from  the  vessels  through  injury  or  disease 
remain  in  a  closed  cavity  for  a  lengthened  period  without  putrefactive  change 
— as,  for  example,  a  clot  of  blood  under  the  scalp  or  pericranium  of  a  new- 
born infant — but  if  air  be  admitted  it  becomes  offensive  within  a  few  hours. 
The  admission  of  air  into  the  pleural  cavity  which  contains  exuded  products 
undoubtedly  promotes  puti-efactive  changes  in  the  latter,  and  the  admission 
of  even  a  small  amount  of  air,  containing,  as  it  does,  micro-organisms  which 
multiply  rapidly  in  the  animal  fluids,  and  which  appear  to  be  the  active 
agents  in  putrefaction,  sufiices  to  convert  sero-fibrin  or  laudable  pus  into  an 
offensive,  irritating,  and  poisonous  liquid,  which  increases  the  constitutional 
disturbance  and  the  gravity  of  the  disease. 

Air  in  the  pleural  cavity,  in  proportion  to  its  quantity,  also  tends  to  pre- 
vent the  approximation  to  each  other  of  the  pleural  surfaces  and  the  oblitera- 
tion of  the  cavity,  which  is  required  in  all  empyemic  cases,  since  this  is  the 
mode  of  cure.  Obviously,  the  entrance  of  air  does  less  harm  if  there  be 
a  fistulous  opening  and  pus  escape  as  soon  as  it  forms  than  in  a  closed  cavity, 
but  it  should  in  all  instances  be  avoided,  as  never  beneficial  and  likely  to  do 
harm  in  the  manner  indicated.  It  is  never  a  necessary  accident  of  thoracen- 
tesis, since  it  can  be  avoided  by  the  use  of  proper  instruments  provided  with 
India-rubber  packing  and  stopcocks.  There  can  be  no  doubt,  also,  that  the 
point  of  the  aspirator  has  often  so   pricked  and  torn  the   lung  that   air  has 

^  London  Lancet,  January  15,  1831. 


734  PLEURISY. 

entered  the  cavity  from  this  organ — a  result  avoided  by  judiciously  using  the 
trocar  and  canula. 

2d.  Injury  to  the  Lung  hy  the  Surgical  Insti-uments  Used. — The  lung  is 
sometimes  injured  by  the  point  of  the  hypodermic  needle  employed  for 
diagnosis.  Cases  are  reported  in  the  hospitals  of  Nevr  York  of  the  break- 
ing off  and  loss  of  the  needle  in  the  lung  from  sudden  and  strong  move- 
ment of  this  organ,  as  in  coughing.  The  most  severe  injury  is,  however, 
commonly  produced  by  the  aspirator  needle,  and  some  very  serious  cases 
of  this  accident  have  occurred  in  VT^hich  the  needle  so  pierced  and  tore 
the  lung  that  not  only  air  escaped  from  it,  but  also  a  considerable  quantity 
of  blood.  It  is  obvious  that  the  danger  of  injuring  the  lung  is  greater  in 
recent  than  in  chronic  cases,  and  greater  in  sero-fibrinous  than  in  purulent 
pleuritis,  for  a  thickened,  infiltrated,  and  firm  pleura  affords  protection  to  the 
lung.  It  is  very  difficult  to  avoid  injuring  this  organ  if  suction  be  made  and 
the  liquid  be  withdrawn  with  the  unguarded  point  of  the  aspirator  needle 
projecting  into  the  chest.  The  removal  of  the  liquid  necessitates  the 
impinging  of  the  lung  upon  the  point  of  the  instrument  even  if  it  be  held 
very  obliquely,  and  in  recent  cases,  when  there  is  a  little  thickening  and 
infiltration  of  the  pleura,  the  surface  of  this  organ  may  be  pricked  or  torn 
sufficiently  to  allow  air  to  escape  and  hemorrhage  occur,  when  the  operator 
who  holds  the  needle  can  scarcely  believe  that  such  an  accident  were  possi- 
ble, so  slight  has  been  the  sensation  communicated  to  the  fingers.  Thus, 
thoracentesis  was  performed  on  an  infant  of  two  months  who  had  severe 
empyema  of  short  duration.  The  instrument  was  held  by  myself  obliquely^ 
and  it  entered  the  pleural  cavity  only  a  short  distance,  and  yet  the  lung  was 
injured  in  three  places,  from  which  it  was  probable,  from  the  signs  and 
symptoms,  that  air  had  escaped.  The  specimen  showing  the  injury  was 
exhibited  to  the  Pathological  Society  in  1879.  Obviously,  to  prevent  this 
injury  aspiration  should  be  performed  through  the  covered  needle,  as  that  of 
Phelps's  or  Potain's,  or  the  trocar,  which  I  have  recommended  above  and 
prefer.  I  must  here  repeat  what  has  been  stated  above,  not  to  plunge  the 
trocar  to  a  greater  depth  than  is  needed,  which  is  about  one  inch.  The  end 
of  the  canula  may  also  injure  the  lung  if  it  be  pressed  in  too  deeply,  since  it 
is  necessarily  rather  sharp  from  its  small  size. 

3d.  Waf.hing  out  the  Pleural  Cavity. — Since  the  aspirator  has  come  into- 
general  use,  it  is  the  common  practice  to  wash  out  the  pleural  cavity  with 
carbolized  water  in  the  treatment  of  empyema.  The  proportion  of  carbolie 
acid  to  water  commonly  employed  is  about  one  part  to  eighty,  and  at  a  tem- 
perature of  100°.  From  a  discussion  at  the  meeting  of  the  New  York  Sur- 
gical Society,  Oct.  12,  1880,  it  appears  that  the  use  of  carbolized  water 
involves  risk  of  carbolic-acid  poisoning  in  case  the  liquid  be  only  partially 
removed  after  it  is  thrown  into  the  pleural  cavity  ;  and  the  late  Prof.  Erskine 
Mason  was  in  the  habit  of  employing  salicylic  acid,  one  part  to  the  hundred 
of  water,  in  place  of  carbolic  acid,  since  it  possesses  all  the  advantages  with 
none  of  the  possible  risks  of  the  latter.  He  stated  that  it  promptly  deodor- 
izes fetid  pus  even  in  the  proportion  of  one  part  to  two  hundred.  The  use 
of  carbolic  acid  would  probably  be  entirely  safe  if  the  liquid  were  removed 
immediately  after  washing  the  cavity,  but  for  some  reason  this  is  not  always- 
possible.  In  case  of  an  infant  with  empyema  under  treatment  by  Drs.  Lock- 
row,'  Billington,  and  myself,  after  removing  the  pus  by  trocar  and  canula 
attached  to  the  exhausting-bottle,  and  once  washing  out  the  pleural  cav- 
ity, the  liquid  was  thrown  in  a  second  time,  giij,  into  the  left  pleural  cavity  of 
an  infant  of  five  months,  but  not  a  drop  of  it  could  be  removed.  There 
was,  however,  no  symptom  which  we  could  refer  to  the  carbolic  acid.  In 
view  of  these  facts  and  the  possible  danger  of  carbolic-acid  poisoning,  the- 


TREATMENT.  735 

use  of  salicylic  acid  appears  to  be  preferable,  at  least  for  cbildrcn,  who  are 
less  able  to  resist  the  action  of  poisonous  agents  than  adults. 

In  this  connection  I  must  state  my  conviction  that  washing  out  the  pleu- 
ral cavity  is  unnecessary  if  empyema  be  treated  as  recommended  above,  and 
it  may  be  injurious.  But  it  is  proper  treatment  when  the  pus  has  under- 
gone decomposition,  is  offensive  to  the  smell,  and  therefore  poisonous.  If  it 
be  putrid,  its  immediate  disinfection  as  well  as  removal  from  the  pleural 
cavity  appears  to  be  clearly  indicated,  but  in  the  common  form  of  empyema, 
as  the  pus  escapes  through  the  opening  which  has  been  made  and  the  suppu- 
rative cavity  becomes  smaller,  adhesions  of  the  pulmonary  and  costal  sur- 
faces occur,  which  the  injection  of  water  may  tear  up  and  destroy,  and  thus 
the  obliteration  of  the  cavity  is  retarded.  Letting  out  the  pus  and  approx- 
imation of  the  pleural  surfaces  to  each  other  are  the  indications  as  regards 
surgical  measures.  Besides,  washing  out  the  pleural  cavity  is  not  devoid  of 
danger.  Alarming  symptoms  may  be  developed  unexpectedly  and  rapidly, 
even  when  the  operation  is  slowly  and  cautiously  performed.  The  infant  of 
five  months  with  empyema  whose  case  I  have  alluded  to  furnished  a  striking 
example  of  this.  Four  ounces  of  pus  had  been  removed  through  a  small 
canula  from  the  left  pleural  cavity,  and  without  removing  the  canula  the 
cavity  had  been  once  washed  out.  It  was  proposed  to  repeat  the  washing, 
as  the  infant  had  thus  far  tolerated  the  operation  and  was  in  an  unusually 
favorable  state  for  a  case  of  empyema.  The  patient  was  in  a  semi-erect 
position,  and  three  ounces  of  water  at  a  temperature  of  100°  had  entered 
the  cavity  from  the  inverted  bottle,  when  he  began  to  cough,  fretted,  and 
became  very  restless.  Immediately,  Dr.  Lockrow  applied  the  suction-point 
of  the  syringe  to  the  tubing,  and  attempted  to  withdraw  the  liquid,  but 
with  no  result.  The  patient's  face  assumed  a  deadly  pallor,  he  frothed  at 
the  mouth,  his  lips  were  compressed,  and  breathing  ceased.  He  was  to  all 
appearances  dead.  He  was  immediately  placed  upon  the  back  by  Dr.  Billing- 
ton,  and  by  prompt  resort  to  artificial  respiration  the  terrible  suspense  was 
soon  ended  by  the  gasps  of  the  child  and  the  return  in  a  few  moments  of 
consciousness  and  normal  respiration.  It  seemed  to  me  that  this  untoward 
accident  was  due  to  the  flow  of  water  against  the  heart,  so  that  it  prevented 
full  dilatation  of  its  cavities,  and  consequently  diminished  the  flow  of  blood 
into  the  aorta  and  pi'oduced  anaemia  of  the  brain.  Lichtenstern  says  :  "  Va- 
rious causes  which  sometimes  quite  interrupt  or  impede  the  flow  of  blood  to 
the  left  heart,  such  as  severe  paroxysms  of  coughing,  vomiting,  lifting  heavy 
burdens,  may  give  rise  to  a  suddenly  fatal  anaemia  of  the  left  heart,  and 
secondarily  of  the  brain.  The  anaemia  of  the  lungs  or  brain  found  in  many 
cases  is  only  of  secondary  importance.  It  frequently  happens  after  thora- 
centesis with  aspiration  that  an  anasmia  is  produced  in  the  partially  distend- 
ed lung,  and  this  may  lead  to  death  by  asphyxia.  In  sudden  death  during, 
immediately,  or  a  short  time  after  thoracentesis  by  aspiration  the  cause  is 
anaemia,  either  of  the  heart  or  brain.  In  cases  in  which  severe  syncope  and 
sudden  death  are  observed  during  the  irrigation  of  the  pleural  cavity  the 
cause  is  either  direct  mechanical  concussion  of  the  easily-exhausted  heart 
by  the  stream  of  water  thrown  in,  or  shock."' 

4th.  T/ie  Use  of  Tent  ami  Drainage-tube  in  Empyema . — With  due  regard 
for  the  opinions  of  the  experienced  surgeons  who  employ  and  recommend  the 
tent  and  drainage-tube,  but  whose  observations  have  been  largely  upon  adult 
cases  of  empyema,  I  cannot  recommend  their  employment  for  children,  unless 
perhaps  the  tent  for  a  day  or  two  after  the  incision  ;  but  the  tent  is  not  neces- 
sary if  the  catheter  be  daily  introduced  in  the  manner  which  I  have  advised. 

'  Deuisches  Archiv  fur  klin.  MecL,  Band   iv.,  4   Heft.  ;    London  Med.  Record,  Dec.  15, 
1880. 


736  PLEVBISY. 

The  drainage-tube  almost  necessarily  admits  air  during  inspiration,  but  this 
is  not  the  most  serious  objection  to  it.  Cachectic  children  with  poorly  nour- 
ished tissues  badly  tolerate  pressure  upon  an  open  wound  by  a  hard  substance. 
It  is  liable  to  cause  ulceration  and  enlarge  the  opening,  and  continued  pres- 
sure of  the  tube  may  cause  periostitis  upon  the  edge  of  the  rib  and  necrosis. 
Scrofulous  and  feeble  children  are  very  prone  to  both  caries  and  necrosis  from 
even  slight  pressure  or  bruises  upon  the  surface  of  the  bone — a  result  to  which 
adults  are  much  less  liable.  In  a  paper  published  by  Mr.  W.  Thomas^  on 
the  treatment  of  empyema  by  resection  of  one  or  more  ribs,  9  cases  are 
detailed,  in  3  of  which  necrosis  had  occurred  from  pressure,  it  is  stated,  of 
drainage-tubes,  thus  necessitating  the  removal  of  the  diseased  portion.  Dur- 
ing the  year  1881  a  wasted  empyemic  infant  was  brought  to  one  of  the  insti- 
tutions of  this  city  for  treatment.  After  letting  out  the  pus  a  drainage-tube 
was  introduced  and  secured.  At  the  next  visit  ulceration  had  so  enlarged 
the  opening  that  a  large  amount  of  air  entered  the  chest  with  a  whistling 
noise  at  each  inspiration,  and  was  expelled  during  expiration,  and  necrosis  of 
the  portion  of  the  rib  against  which  the  tube  pressed  had  also  occurred.  Air 
was  finally  excluded  by  covering  the  opening  with  a  cloth  smeared  on  each 
side  with  a  concentrated  solution  of  gutta-percha  in  chloroform,  but  the  case 
after  some  days  ended  fatally.  The  escape  of  the  drainage-tube  into  the 
pleural  cavity,  which  has  occurred  by  breaking  of  the  threads  which  secured 
it,  is  so  rare  an  accident  that  it  does  not  constitute  an  objection  to  the  intro- 
duction of  the  tube  ;  but  aspiration  daily  or  twice  daily  through  the  catheter 
so  completely  removes  the  pus  that  drainage  is  not  required,  and  the  risk  of 
injury  by  the  pressure  of  the  tube  is  therefore  avoided. 

5th.  I  have  witnessed  in  a  few  instances  the  burrowing  of  pus  under  the 
skin  at  the  point  where  an  incision  had  been  made  to  let  out  the  pus.  This 
complication  may  lead  to  more  or  less  ulceration  or  sloughing,  and  it  greatly 
increases  the  danger  of  poisoning.  But  infiltration  of  pus  will  almost  never 
occur  if  the  incision  be  direct  through  the  tissues,  and  not  with  the  skin 
pushed  to  one  side,  so  that  it  forms  a  covering  or  valve  when  it  returns,  as 
was  once  recommended  in  the  books  as  a  means  of  excluding  air.  But  air 
does  not  enter  the  cavity  through  a  direct  opening  if  it  be  properly  covered 
after  the  pus  has  escaped.  Burrowing  of  pus  and  pyaeniic  poisoning  there- 
from cannot  then  be  regarded  as  an  accident  of  the  mode  of  operation  which 
I  have  recommended. 

Exsection  of  a  Portion  of  One  or  More  Ribs. — This  operation  has 
now  been  performed  a  considerable  number  of  times  in  Europe  and  in  this 
country,  and,  from  the  published  accounts,  certain  cases  have  apparently 
recovered  more  rapidly  in  consequence.  Thus  in  one  case  a  fistulous  open- 
ing, spontaneously  established,  had  continued  several  months  with  little 
diminution  in  the  discharge  and  very  slow  progress  toward  recovery,  when 
by  this  operation,  which  produced  a  larger  opening  and  a  freer  escape  of  pus 
and  falling  in  of  the  chest-wall,  so  as  to  obliterate  the  cavity,  the  patient 
rapidly  convalesced. 

The  alleged  benefit  from  the  exsection.  which  consists  in  the  removal  of 
an  inch  or  a  little  more  of  one  or  more  ribs  in  or  near  the  site  for  the  usual 
performance  of  thoracentesis,  is,  that  there  is  a  readier  escape  of  pus  and  the 
facility  for  washing  out  the  pleural  cavity  is  increased,  and  the  thoracic  wall 
and  lung  are  more  readily  approximated,  so  as  to  produce  obliteration  of 
the  pleural  cavity.  The  greatest  benefit  is  claimed  for  it  in  those  cases  in 
which  the  intercostal  spaces  are  small  and  the  ribs  lie  close  to  each  other. 

Without  denying  that  certain  cases  have  apparently  be^n  benefited  by  the 
operation,  I  must  say  that  I  have  not  yet  met  a  case,  either  in  family  or  hos- 

1  Bimiincjkam  Med.  Bee,  1880,  N.  S.  vol.  ill. 


NERVOUS  COUGH.  737 

pital  practice,  in  which  I  could  conscientiously  recommend  the  operation, 
except  where  necrosis  had  occurred  from  a  periostitis  produced  by  the  irri- 
tating property  of  the  pus  or  the  pressure  of  a  drainage-tube.  The  gum- 
elastic  catheter,  introduced  as  recommended  above,  will  pass  through  any 
intercostal  space  which  I  have  yet  observed,  so  as  to  allow  free  evacuation 
of  the  pus  by  suction,  if  it  be  not  incapsulated  by  fibrinous  bands,  and  allow 
also  the  free  washing  out  of  the  pleural  cavity  if  this  be  desired. 

There  are  also  serious  objections  to  the  exsection  in  case  of  a  child.  The 
system,  exhausted  by  suppurative  inflammation,  is  in  poor  condition  to  tole- 
rate an  operation  of  any  severity,  and,  although  we  are  directed  to  preserve 
as  far  as  possible  the  periosteum  from  injury  by  the  knife,  and  be  careful  not 
to  wound  the  intercostal  vessels,  there  are  necessarily  more  or  less  shock  and 
hemorrhage  and  consequent  danger  of  hastening  the  death  of  the  patient.  In 
one  of  the  cases,  that  of  an  infant,  reported  by  an  advocate  of  the  operation, 
it  seems  to  me  that  death  was  largely  attributable  to  the  exsection. 

In  order  that  exsection  aid  materially  in  the  approximation  of  the  lung 
and  ribs,  it  is  necessary  to  remove  portions  of  two  or  more  ribs,  and  the 
greater  the  operation  the  greater  the  risk.  But  what  is  needed  is  not  depres- 
sion of  the  ribs,  which  may  produce  permanent  deformity,  but  expansion  of 
the  lung,  and  this  is  promoted  by  the  integrity  and  resiliency  of  the  ribs. 


CHAPTER   IX. 

NERVOUS  COUGH. 

A  NERVOUS  cough  sometimes  occurs  in  children,  especially  between  the 
ages  of  two  or  three  and  ten  years.  It  may  result  from  disease  of  the  brain, 
from  the  second  as  well  as  first  dentition,  from  some  irritant  in  the  intestines, 
as  worms,  and  also  from  spinal  irritation.  Irritation  in  the  external  ear  from 
the  presence  of  a  foreign  substance  excites  a  cough  in  some  children.  A 
similar  fact  is  noticed  by  many  adults — namely,  that  attempts  to  remove  the 
wax  from  the  ear  by  an  instrument  excites  a  cough.  Occasionally  there 
appears  to  be  no  local  cause,  but  a  state  of  anasmia  or  a  highly  developed 
nervous  temperament,  to  which  it  seems  proper  to  ascribe  the  cough.  Occur- 
ring under  these  last  circumstances,  it  corresponds  with,  and  is  sometimes 
accompanied  by,  functional  disturbance  in  the  action  of  the  heart,  as  palpi- 
tation. 

A  nervous  cough  is  short,  painless,  and  without  ex})ectoration.  It  usually 
attracts  little  attention  at  first,  but  from  its  long  duration  the  friends  finally 
become  anxious  lest  it  betoken  some  serious  disease.  At  times  it  may  nearly 
subside  if  the  patient  lead  a  quiet  life  and  the  general  health  improve,  and 
there  are  periods  of  recrudescence  if  the  opposite  conditions  obtain.  It  may 
have  a  spasmodic  character,  especially  in  times  of  mental  excitement,  but  in 
a  less  degree  than  the  cough  of  pertussis.  If  not  properly  treated  it  usually 
continues  several  weeks  or  months,  disappearing  as  the  general  health  and  the 
tone  of  the  nervous  system  improve.  It  is  not  in  itself  a  serious  disease,  nor 
does  it  lead  to  any  ailment  or  produce  any  injury  of  the  respiratory  organs, 
but  it  is  an  unpleasant  malady,  and  is  liable  to  be  mistaken  for  incipient 
tuberculo.sis  if  it  occur  in  one  decidedly  cachectic  and  belonging  to  a  family 
predisposed  to  phthisis. 

Treatment. — If  there  be  a  local  cause  of  the  cough,  measures  calcu- 
47 


738  NERVOUS  COUGH. 

lated  to  remove  this,  or  at  least  to  palliate  its  effects,  are  obviously  required. 
Especially  should  constipation  or  any  abnormality  in  the  digestive  function 
be  corrected.  But  in  many  cases  there  is  no  apparent  local  ailment  vphich 
produces  the  cough  by  its  irritative  action,  and  the  remedial  measures  must 
then  be  twofold — to  wit,  first,  those  designed  to  improve  the  general  state ; 
and,  secondly,  those  designed  to  relieve  the  cough.  Such  measures  are  also 
required  in  most  cases  in  which  there  is  a  local  cause,  provided  that  the 
cough  do  not  cease  when  treatment  calculated  to  remove  this  cause  has 
been  employed. 

For  constitutional  treatment  no  remedy  is  so  useful  in  ordinary  cases  as 
iron.  The  following  example  shows  the  benefit  which  may  result  from  the 
use  of  this  agent,  since  in  this  case  it  effected  a  cure  without  the  aid  of  other 

measures :  B ,  aged  eleven  years,  pallid  and  of  spare  habit,  but  active 

and  with  good  appetite,  had  been  treated  for  this  malady  by  different  physi- 
cians but  without  improvement.  His  mother  had  died  of  tuberculosis,  and 
some  at  least  of  the  physicians  believed  that  he  was  in  the  commencement 
of  the  same  disease.  Finally,  he  was  placed  under  the  care  of  the  late 
Dr.  Cammann,  who,  detecting  the  nature  of  the  malady,  wrote  the  follow- 
ing prescription : 

R.  Ferri.  subsulphat.,  .^ss  ; 

Acid,  nitric,  C^ss; 

Aq.  destillat.,  fgss.     Misce. 

Dose :  Three  drops  four  times  daily  in  sweetened  water. 

The  cough  disappeared  in  a  surprisingly  short  time.  If  the  appetite  be 
poor,  the  vegetable  tonics  are  required  in  combination  with  iron. 

If  the  cough  be  frequent  and  troublesome,  medicines  which  exert  a  direct 
controlling  effect  upon  it  are  required  in  addition  to  the  treatment  employed 
to  improve  the  general  state.  For  this  purpose  no  remedy  is  so  useful  as  the 
bromides,  employed  alone  or  in  combination  with  belladonna.  If  there  be  no 
decided  anaemia,  and  no  local  cause  of  the  cough,  the  bromides  and  belladonna 
usually  effect  a  cure  without  the  employment  of  constitutional  measures,  or  if 
the  case  seem  to  require  iron  it  may  be  given  in  the  interval.  The  following 
is  the  prescription  for  a  child  of  three  years : 

R.  Tinct.  belladonnse,  gtt.  xxxij  ; 

Potas.  bromid., 
Amraon.  bromid.,        da.  ^j  ; 
Syr.  simplic,  ^jj.     Misce. 

Dose :  One  teaspoonful  three  times  daily. 

In  18*71, 1  was  asked  to  prescribe  for  a  German  boy,  aged  eight  and  a  half 
years,  who  had  a  cough  of  this  kind  of  two  months'  duration,  which  latterly 
had  been  frequent  and  annoying.  Within  a  week  he  was  entirely  relieved 
without  other  remedy  by  the  employment  of  tincture  of  belladonna,  drops  v, 
and  bromide  of  ammonium,  gr.  v,  twice  daily.  Outdoor  exercise  or  country 
residence  and  other  regimenal  measures  which  improve  the  general  health 
are  useful  in  ordinary  cases. 


SECTIOlSr  III. 

DISEASES    OF    THE    DIGESTIVE    APPARATUS. 


CHAPTER   I. 

SIMPLE  STOMATITIS,   ULCEROUS  STOMATITIS,  FOLLICULAR 

STOMATITIS. 

Diseases  of  the  digestive  system  are  very  frequent  in  infancy  and  child- 
hood. They  are  for  the  most  part  readily  recognized,  and  are  more  easily  and 
quickly  controlled  by  therapeutic  agents,  if  rightly  applied,  than  are  the  dis- 
eases of  any  other  system.  If  misunderstood  and  improperly  treated,  they 
may,  even  when  mild  and  very  manageable  in  their  commencement,  become 
chronic  and  obstinate,  or  even  fatal,  or  they  may  lead  to  other  and  more  dan- 
gerous diseases.  It  is  necessary,  then,  that  the  physician  should  understand 
thoroughly  the  pathology  as  well  as  therapeutics  of  the  digestive  system,  that 
he  may  make  timely  and  correct  use  of  the  required  remedies. 

The  diseases  of  the  buccal  cavity  in  early  life  are  for  the  most  part  inflam- 
matory, one  of  the  most  interesting  of  which — to  wit,  sprue  or  thrush — we 
have  already  treated  of  among  the  diseases  of  the  newly-born.  The  mildest 
of  these  diseases  is  that  known  as 

Simple  or  Catarrhal  Stomatitis. 

This  form  of  catarrh  occui's  usually  before  the  completion  of  the  first 
dentition,  and  it  is  most  frequent  under  the  age  of  one  year.  Giving  rise  in 
itself  to  no  severe  symptoms,  and  often  being  connected  with  other  grave 
and  dangerous  maladies,  it  is,  doubtless,  in  many  cases  overlooked.  It  is 
sometimes  confined  to  a  portion  of  the  buccal  surface  or  is  more  intense  in 
one  part  than  in  another.  In  other  cases  the  catarrh  is  uniform  or  nearly  so, 
aff^ecting  the  entire  cavity  of  the  mouth. 

Causes. — The  common  cause  of  simple  stomatitis  in  infants  is  the  same 
as  that  of  most  cases  of  gastro-intestinal  inflammation  at  that  age.  This  is 
the  use  of  indigestible  and  therefore  irritating  food,  uncleanliness,  personal 
and  domiciliary  ;  in  fine,  all  those  agencies  which  impair  the  general  health 
and  enfeeble  the  digestive  organs.  Therefore,  stomatitis,  like  entero-colitis, 
is  more  common  in  the  city  than  in  the  country,  and  among  the  city  poor 
than  those  in  the  better  walks  of  life.  Infants  deprived  of  the  mother's 
milk  and  given  a  diet  which,  with  all  care  of  preparation,  is  a  poor  substi- 
tute for  the  natural  aliment,  are  very  liable  to  this  disease.  Beaumont  ascer- 
tained from  his  experiments  on  St.  Martin  that  irritative  changes  produced  in 
the  stomach  by  indigestible  substances  were  soon  followed  by  similar  changes 

739 


740  STOMATITIS. 

in  tlie  buccal  mucous  membrane.  Since  in  young  infants  any  kind  of  arti- 
ficial food  is  less  digestible  than  breast-milk,  it  is  evident  why  those  who  are 
prematurely  weaned  or  are  carelessly  fed  are  so  liable  to  stomatitis.  This 
inflammation  is  also  sometimes  due  to  irritating  substances  taken  into  the 
mouth,  as  drinks  habitually  too  hot  or  too  cold.  Stomatitis  is  also  present 
in  measles  and  scarlet  fever.  It  then  corresponds  with  the  cutaneous  erup- 
tion, and  disappears  when  that  subsides. 

Another  cause  is  dentition.  The  gum  over  the  advancing  tooth  first 
becomes  inflamed,  and,  other  causes  perhaps  conspiring,  the  inflammation 
extends  over  more  or  less  of  the  buccal  surface.  When  due  to  dentition  the 
stomatitis  is  more  frequently  partial  than  when  it  arises  from  a  constitutional 
cause.  Mercury,  in  whatever  form  introduced  into  the  system,  excreted 
from  the  salivary  glands  and  flowing  over  the  buccal  surface,  is  an  occasional 
though,  now-a-days,  rare  cause. 

Symptoms  ;  Appearances. — Stomatitis,  like  other  mucous  inflammations, 
is  characterized  by  increased  redness  and  more  or  less  thickening  of  the 
inflamed  buccal  membrane,  by  rapid  proliferation  and  exfoliation  of  epi- 
thelial cells,  and  by  an  increased  functional  activity  of  the  muciparous  fol- 
licles. The  heat  of  the  mouth  is  sometimes  augmented  in  an  appreciable 
degree.  The  gums  in  severe  cases  are  swollen  and  spongy,  and  bleed  readily 
if  rubbed  or  pressed.  The  tongue  is  usually  covered  with  a  light  fur,  and 
the  salivai'y  secretion  is  frequently  augmented  to  such  an  extent  as  to  dribble 
from  the  corners  of  the  mouth.  Often  there  is  little  suff'ering,  but  in  other 
instances  the  patients  are  fretful,  experience  pain  from  the  contact  of  solid 
food,  and,  if  nursing,  may  even  wean  themselves  from  dread  of  pressure  of 
the  nipple. 

Simple  stomatitis  is  not  difficult  of  detection,  provided  that  attention  be 
directed  to  the  mouth.  Inspection  informs  us  of  its  presence  and  extent. 
A  favorable  termination  may  be  confidently  predicted,  unless  there  be  a  state 
of  marked  cachexia  or  a  grave  coexisting  disease.  If  circumstances  are 
unfavorable,  simple  stomatitis  may  terminate  in  a  more  severe  form,  as  the 
ulcerous  or  diphtheritic. 

Treatment. — The  physician  should  endeavor  to  ascertain  the  cause,  and, 
if  possible,  should  remove  it  by  appropriate  medicinal  and  hygienic  measures. 
Sometimes  no  special  treatment  is  required,  as  in  measles  or  scarlet  fever. 
When  the  primary  aflfection  terminates  the  stomatitis  disappears  of  itself. 
If  dentition  be  the  cause  and  there  be  much  fever  and  fretfulness,  it  has 
been  the  common  practice  to  scarify  the  gums,  but  this  operation  is  not  often 
advisable.  A  few  doses  of  bromide  of  potassium  relieve  the  fretfulness,  and 
mucilaginous  and  mild  astringent  lotions  suffice  for  the  catarrh.  Borax  is  a 
good  local  remedy  used  either  with  honey  or  with  glycerin  and  water — one 
part  of  borax  to  three  of  honey,  or  a  drachm  of  borax  to  an  ounce  of  water 
and  two  drachms  of  glycerin.  A  weak  solution  of  alum  is  also  a  useful  topical 
remedy.  With  either  of  these  agents  in  a  favorable  condition  of  system,  and 
without  any  serious  coexisting  disease,  the  stomatitis  is  relieved. 

Ulcerous  Stomatitis. 

In  ulcerous  stomatitis  the  anatomical  characters  are  those  of  severe  simple 
stomatitis,  with  the  additional  element  which  gives  it  the  name  by  which  it  is 
designated. 

The  inflammation  usually  begins  upon  the  gums  and  extends  along  the 
buccal  surface.  Little  white  points  soon  appear  upon  the  under  surface  of 
the  mucous  membrane,  producing  slight  prominence  of  it.  These  points, 
which    are    inflammatory    exudations,   mainly    fibrinous,    gradually   enlarge. 


ULCEROUS  STOMATITIS.  741 

Some  unite  and  f^ive  rise  to  large  irregular  ulcerations  ;  others  remain  isolated, 
producing  ulcers  which  are  smaller  and  of  more  regular  shape.  There  is, 
indeed,  no  uniformity  as  regards  the  size  and  form  of  the  ulcers.  In  the 
folds  of  the  buccal  membrane  they  are  usually  elongated,  while  inside  the 
lips  or  where  the  surface  is  smooth  the  circular  or  oval  form  predominates. 
It  is  a  noteworthy  fact  that  the  exudation  underlies  the  mucous  membrane, 
obstructing  its  nutrient  vessels,  so  that  the  ulcer  which  results  causes  destruc- 
tion of  the  mucous  layer  and  cure  is  effected  by  cicatrization. 

Ulcerous  stomatitis  is  usually  confined  to  that  part  of  the  buccal  surface 
which  covers  the  gums  or  is  in  their  immediate  vicinity,  but  in  some  instances 
it  affects  nearly  every  part  of  the  cavity  of  the  mouth. 

If  the  disease  be  severe,  considerable  swelling  occurs  around  the  ulcers, 
but  the  swollen  part  is  soft  and  cushiony  and  not  very  tender  on  pressure. 
The  soft  and  yielding  nature  of  the  swelling  serves  as  a  means  of  diagnosis 
between  this  disease  and  the  premonitory  stage  of  gangrene,  since  in  the  latter 
affection  the  swollen  part  is  more  indurated. 

If  the  disease  grow  worse,  more  ulcers  appear,  and  those  already  present 
grow  deeper  and  wider  and  their  edges  more  vascular. 

If,  on  the  other  hand,  there  be  improvement,  the  swelling  subsides,  the 
ulcers  become  more  clean,  their  bases  approach  the  level  of  the  mucous  mem- 
brane, and  present  a  granulating  appearance.  Finally,  the  mucous  layer  is 
reproduced.  A  considerable  time  after  the  ulcers  are  healed  the  new  mem- 
brane which  occupies  their  site  has  a  I'edder  hue  than  the  adjacent  surface. 

Causes. — Ulcerous  like  simple  stomatitis  is  most  frequent  in  the  families 
of  the  poor.  Personal  uncleanlincss,  poor  food,  a  residence  in  apartments 
dirty,  humid,  or  in  other  respects  insalubrious,  favor  its  development.  In 
fine,  a  cachectic  condition,  however  produced,  is  a  common  predisposing 
cause.  Ulcerous  stomatitis  frequently  occurs  when  the  system  is  reduced  or 
enfeebled  by  acute  diseases,  as  after  the  essential  fevers  and  thoi-acic  and 
intestinal  inflammations.  In  protracted  entero-colitis  of  infants  it  is  some- 
times severe  and  obstinate,  and  a  case  in  which  this  complication  arises 
usually  ends  unfavorably.  The  abuse  of  mercury  is  an  occasional  cause  of 
this  form  of  stomatitis,  as  well  as  of  simple  catarrh.  Jaccoud  states  that 
Bergeron  established  the  fact  that  ulcerous  stomatitis  is  propagated  among 
soldiers  by  contagion,  and  he  adds  "  it  is  very  probable  that  it  is  the  same  in 
infants." 

Symptoms. — The  symptoms  in  ulcerous  stomatitis  are  more  severe  than 
in  the  simple  form.  There  are  more  pain,  more  salivation,  and  more  fretful- 
ness.  The  ulcerated  surface  is  sometimes  very  tender,  so  that  there  is  but 
little  sleep.  Drinks,  unless  bland  and  lukewarm,  are  painful,  and  if  the  ulcers 
be  on  the  lips  or  the  front  of  the  mouth  the  infant  nurses  less  eagerly  than 
usual,  and  even  with  reluctance,  sometimes  weaning  itself.  Occasionally 
the  submaxillary  glands  are  tumefied,  hard,  and  tender.  The  breath  has  an 
offensive  odor.  In  mild  cases,  in  which  the  stomatitis  is  of  limited  extent, 
this  odor  may  scarcely  be  noticed,  but  in  severe  cases  it  is  almost  like  that 
exhaled  from  putrid  substances.     The  fever  is  in  most  instances  slight. 

Prognosis. — A  favorable  prognosis  may  be  given  unless  the  patient  be  in 
a  decidedly  cachectic  condition  or  there  be  a  serious  coexisting  disease,  under 
which  circumstances  the  case  may  be  protracted.  If  death  occur  it  is  due  to 
the  cachexia  or  to  some  pathological  state  quite  distinct  from  the  stomatitis, 
most  frequently  entero-colitis.  Ulcerous  stomatitis  when  the  ulcers  are  small 
and  the  inflammation  of  limited  extent  is  of  course  more  easily  cured  than 
when  it  is  extensive  and  the  ulcers   are  large. 

This  disease  is  very  liable  to  return  unless  the  general  health  be  good. 

Treatment. — The  physician   should  endeavor  to  ascertain  the  cause  of 


742  STOMATITIS. 

the  stomatitis,  and  so  far  as  possible  should  remove  the  patient  from  its  influ- 
ence. It  is  often  necessary,  in  order  to  ensure  speedy  recovery,  to  recommend 
a  change  in  regimen,  especially  as  regards  diet  and  cleanliness.  If  the 
patient  live  in  damp,  dark,  and  dirty  apartments,  the  family  should  seek  a 
better  residence,  and  he  should  be  taken  daily  into  the  open  air. 

Tonic  remedies  are  generally  required.  The  ferruginous  preparations 
may  be  advantageously  given,  or  the  vegetable  tonics,  or  the  two  in  combina- 
tion. In  selecting  the  internal  remedies  we  must  regard  the  antecedent  dis- 
ease, if  there  be  any,  which  the  buccal  inflammation  complicates  and  on 
which  it  depends.  For  that  large  proportion  of  cases  in  which  there  is 
chronic  intestinal  inflammation  the  liquor  ferri  nitratis,  with  tincture  of 
Colombo,  administered  in  simple  syrup,  will  be  found  useful.  For  local  treat- 
ment Trousseau  recommends  occasional  applications  of  nitrate  of  silver  or 
muriatic  acid  as  a  caustic,  and  in  the  intervals  a  wash  of  equal  parts  of  borax 
and  honey. 

The  chloride  of  lime  is  also  considerably  used  in  Paris.  It  is  recom- 
mended by  Rilliet  and  Barthez.  It  is  applied  dry  to  the  ulcerated  surface 
twice  daily,  and  in  the  interval  the  mouth  is  washed  with  simple  water.  This 
treatment  is  continued  till  the  ulcers  present  a  healthy  appearance  and  begin 
to  cicatrize.  Then  a  weak  solution  of  chloride  of  lime  is  employed,  one 
grain  to  forty-flive  of  the  vehicle.  By  this  treatment  a  cure  is  usually 
efi'ected.  Bouchut  prefers  using  chloride  of  lime  with  honey,  one  drachm  to 
the  ounce. 

But  painful  applications  are  not  required.  The  remedy  which  is  most 
employed  in  this  country  and  in  Great  Britain  is  chlorate  of  potassium.  It 
often  acts  like  a  specific  for  this  as  well  as  other  forms  of  stomatitis.  It 
may  be  given  dissolved  in  water  with  sugar  or  with  one  of  the  syrups,  to 
render  it  more  palatable.  The  dose  is  about  two  or  three  grains  every  two 
hours.  It  should  be  allowed  to  run  over  the  aff"ected  part,  as  it  is  believed  to 
have  a  local  action. 

R.  Potass,  chlorat.,  .^ss-j  ; 

Mellis,  ^ss ; 

Aquae,  ^ij. 
One  teaspoonful  every  two  hours. 

Of  all  topical  remedies  in  common  use,  chlorate  of  potassium  is  probably 
the  most  efiicacious.  Some  physicians  prefer  the  chlorate  of  sodium  on  account 
of  its  greater  solubility.  If  this  wash  be  too  painful  in  consequence  of  the 
irritable  state  of  the  ulcers,  it  may  be  mixed  with  mucilage  or  be  employed 
less  frequently,  and  borax  applied  in  the  interval. 

Aphthous  Stomatitis. 

Aphthous  stomatitis  may  occur  at  any  age,  but  it  is  most  frequent  in 
childhood.  It  is  sometimes  designated  follicular  stomatitis,  but  the  disease 
aff"ects  the  contiguous  mucous  surface  as  well  as  the  seat  of  the  follicles.  At 
first  a  vascular  injection  is  observed,  and  within  a  few  hours  a  whitish  exuda- 
tion occurs  immediately  under  the  epithelium  and  upon  the  corium  in  small 
round  or  oval  isolated  spots.  The  smallest  of  these  patches  are  not  larger 
than  a  pin's  head,  but  most  of  them  have  a  diameter  of  one  or  two  lines, 
and  they  cause  slight  prominence  of  the  surface.  In  two  or  three  days  the 
exudation  softens,  and  the  epithelium  which  covers  it  is  thrown  ofi",  producing 
an  ulcer,  superficial,  without  induration  of  its  edges,  but  sensitive  to  the 
touch.  It  heals  in  one  or  two  weeks,  leaving  only  a  reddish  spot  or  stain, 
which   soon  fades.     Sometimes  two  or  more  aphthae  unite,  forming  a  patch 


APHTHOUS  STOMATITIS.  743 

and  an  ulcer  of  correspondinj^^ly  large  size.  The  seat  of  aphthous  stomatitis 
is  usually  the  internal  surface  of  the  lips  and  cheeks,  the  gums,  tongue,  and 
occasionally  the  roof  of  the  mouth. 

Causes. — Probably  in  most  instances  the  exciting  cause  is  some  derange- 
ment of  the  digestive  organs  which  may  not  be  appreciable.  We  sometimes 
observe  this  form  of  stomatitis  in  cases  of  diarrhfea.  Occasionally,  especially 
in  spring  and  autumn,  two  children  in  a  family  are  affected  at  the  same 
time,  or  two  or  more  in  a  school,  so  that  the  disease  presents  an  epidemic 
character.  Children  surrounded  by  bad  hygienic  conditions,  as  in  the  tene- 
ment-houses of  cities,  are  more  liable  to  this  as  well  as  other  forms  of 
stomatitis  than  are  children  who  live  in  clean  and  airy  localities  and  have 
nutritious  and  wholesome  diet. 

Symptoms. — The  constitutional  symptoms  in  a  large  proportion  of  cases 
of  aphthai  are  slight.  In  twelve  children  affected  with  this  disease  Billard 
found  the  pulse  from  sixty  to  eighty  beats  per  minute. 

The  ulcers  are  painful,  as  is  indicated  by  the  cries  of  the  child  when 
they  are  pressed,  and  its  fretfulness.  Solid  food,  and  even  drinks,  unless 
bland  and  unirritating,  are  badly  tolerated.  The  salivary  secretion  is  also 
augmented. 

In  those  rare  cases  in  which  the  ulcers  become  confluent  or  gangrenous 
the  state  of  the  patient  is  really  serious.  There  is  then  often  gastro-intestinal 
disease.  The  symptoms  indicate  proiBtration.  The  pulse  is  feeble,  the  coun- 
tenance pallid,  and  the  body  and  limbs  become  wasted. 

Diagnosis. — This  is  easy.  The  only  disease  with  which  it  is  liable  to  be 
confounded  is  ulcerous  stomatitis.  In  the  ulcerous  form  there  is  antecedent 
and  accompanying  stomatitis  affecting  a  considerable  part,  if  not  the  entire 
buccal  cavity,  while  in  the  follicular  form  the  inflammation  is  ordinarily  con- 
fined to  the  immediate  vicinity  of  the  ulcers.  The  character  of  the  ulcers 
serve's  also  as  a  means  of  distinction.  In  ulcerous  stomatitis  there  is  great 
variety  as  to  size  and  form,  while  in  aphthous  stomatitis  there  is  great 
uniformity  in  both  these  respects.  The  small  circular  ulcers  are  character- 
istic of  the  follicular  inflammation.  Before  the  ulcerative  stage  the  circum- 
scribed character  of  the  eruption  serves  to  distinguish  this  form  of  stomatitis 
from  other  local  diseases  affecting  the  cavity  of  the  mouth. 

Prognosis. — Aphthous  stomatitis  usually  ends  favorably,  but  if  the 
ulcers  became  concrete  or  gangrenous  the  health  is  seriously  affected,  and  a 
more  cautious  prognosis  should  be  expressed.  The  unhealthy  appearance  of 
the  mouth  and  the  real  danger  are  more  often  due  to  the  depressing  effect  of 
some  concomitant  disease  than  to  the  stomatitis. 

Treatment. — In  ordinary  aphthous  stomatitis,  which  is  discrete  and 
attended  by  little  or  no  constitutional  disturbance,  local  remedies  suffice  to 
cure  the  disease.  Demulcent  drinks  or  applications  to  the  mouth  should 
be  used,  as  the  mucilage  from  gum  acacia,  marshmallow,  or  flaxseed.  Mild 
astringent  lotions  with  the  demulcent  are  also  beneficial.  The  mel  boracis  is 
one  of  the  best  and  most  agreeable  applications.  It  may  be  placed  in  the 
mouth  with  a  spoon  or  applied  with  a  camel's-hair  pencil.  If  there  be  much 
tenderness  of  the  ulcers,  with  restlessness,  a  small  quantity  of  some  opiate 
should  be  added  to  the  lotion  or  it  may  be  administered  separately. 

With  this  simple  treatment  the  ulcers  generally  soon  heal  and  the  health 
of  the  patient  is  restored.  If,  however,  the  ulcers  be  painful  and  not  disposed 
to  heal,  or  be  healing  tardily,  they  may  be  touched  lightly  with  a  pencil  of 
nitrate  of  silver,  or,  as  Barrier  recommends,  hydrochloric  acid  in  honey  of 
roses.  This  diminishes  the  tenderness  and  expedites  the  healing  process.  A 
better  remedy  is  iodoform,  two  drachms  to  one  ounce  of  ether,  and  applied  to 
the  ulcers  by  a  camel's-hair  pencil. 


744  GANGRENE   OF  THE  MOUTH. 

If,  as  may  in  rare  cases  occur,  the  ulcerations  be  numerous  and  accom- 
panied by  considerable  fever,  there  may  be  symptoms  indicative  of  cerebral 
congestion  or  even  premonitory  of  convulsions.  In  such  cases  laxatives  and 
the  soothing  eifect  of  one  of  the  bromides,  and  sometimes  of  the  warm  foot- 
bath, are  required. 

If  there  be  an  unhealthy  appearance  of  the  ulcers,  if  they  gradually 
enlarge  or  become  concrete  or  gangrenous,  indicating  a  cachectic  state, 
tonics  should  be  employed  with  nutritious  and  easily-digested  diet,  and 
antihygienic  influences  should  so  far  as  possible  be  removed. 


CHAPTER    II. 

GANGEENE  OF  THE  MOUTH. 

The  diseases  of  the  mouth  which  we  have  been  considering  are  attended 
by  little  danger,  but  the  one  which  we  are  next  to  consider  is  among  the 
most  fatal  of  early  life.  It  is  gangrene  of  a  portion  of  the  cheek  or  gums, 
or  of  both.  It  is  described  by  writers  under  various  names,  as  cancrum  oris, 
noma,  necrosis  infantilis,  aqueous  cancer  of  infants. 

Anatomical  Characters. — Gangrene  of  the  mouth  is  sometimes  pre- 
ceded by  ulceration  of  the  mucous  membrane  at  the  point  where  it  is  about 
to  commence,  but  in  other  cases  this  membrane  is  entire.  The  tissues  at  the 
point  of  attack,  which  is  most  frequently  the  inside  of  the  cheek,  become 
inflamed,  thickened,  and  indurated.  The  induration  extends,  and  soon  the 
purple  hue  of  gangrene  appears  and  increases.  The  next  stage  in  the  {)rog- 
ress  of  gangrene  is  sloughing  of  the  portion  the  vitality  of  which  is  lost. 

The  slough  does  not  present  the  appearance  of  uniform  decay.  While 
the  color  is  generally  dark,  there  are  in  the  mass  fibres  of  connective  tissue, 
or  even  blood-vessels,  which  remain  unchanged  or  are  but  partly  decomposed. 
After  separation  or  sloughing  of  the  part  where  the  vitality  is  first  lost,  the 
surface  of  the  excavation,  if  the  disease  be  not  checked,  has  a  dark,  jagged, 
and  unhealthy  appearance.  Commencing  with  the  mucous  membrane  and  the 
tissue  immediately  underlying  it,  the  disease  extends  on  the  one  side  toward 
the  skin  and  on  the  other  toward  the  deeper-seated  structures  of  the  jaw. 
According  to  Billard,  the  swelling  which  precedes  and  suiTOunds  the  gangrene 
is  in  great  part  cedematous. 

This  disease  is  occasionally  primary,  but  in  a  large  proportion  of  cases  it 
is  secondary.  Occurring  secondarily,  its  symptoms  are  often  masked  by  those 
of  the  antecedent  and  coexisting  aff'ection.  Under  such  circumstances 
attention  is  sometimes  first  directed  to  the  mouth  by  the  loosening  of  one  or 
more  of  the  teeth  or  the  appearance  on  the  skin  of  a  livid  circular  spot  which 
indicates  the  approach  of  the  disease  to  the  cutaneous  surface.  The  mucous 
membrane  presents  a  dark-red  appearance  to  the  distance  of  a  few  lines 
beyond  the  point  of  gangrene.  It  covers  tissues  which  are  inflamed  and 
indurated  and  about  to  become   gangrenous. 

The  tongue  is  usually  more  or  less  swollen,  unless  the  disease  be  mild; 
an  ofi'ensive  odor  arises  from  the  gangrene,  due  to  the  evolution  of  sulphur- 
etted hydrogen  and  other  gases.  There  is  great  difference  in  the  extent  of 
the  destruction  and  the  gravity  of  the  disease  in  diff'erent  cases.  It  may 
sometimes  be  arrested  by  proper  applications  and  a  favorable  change  in  the 
general  health  of  the  child  at  an  early  period,  when  there  is  little  loss  of  sub- 


AGE— SYMPTOMS.  745 

stance.  In  other  cases  it  extends  till  it  perforates  the  check  or  even  destroys 
a  considerable  part  of  the  side  of  the  face,  and,  extending  inward,  attacks  the 
periosteum  of  the  maxillary  bone,  destroying  the  gum  and  teeth  and  denud- 
ing the  alveoli.  Recovery,  if  it  take  place  at  all  under  such  circumstances, 
is  with  the  loss  of  a  portion  of  the  bone  and  with  deformity. 

The  duct  of  Steno  is  sometimes  included  in  the  gangrenous  portion,  but 
it  commonly  resists  the  destructive  process  and  remains  pervious. 

Age. — The  age  at  which  gangrene  of  the  mouth  occurs  is  usually  between 
two  and  six  years.  In  29  cases  collated  by  Ililliet  and  Barthez,  21  were 
between  the  ages  of  two  and  six  years,  and  the  remaining  8  between  six  and 
twelve  years.  Of  the  ca.ses  which  have  fallen  under  my  observation,  most 
were  between  the  ages  of  two  and  six  years.  It  is  seen  that  the  period  of 
greatest  frequency  of  gangrene  of  the  mouth  is  different  from  that  in  which 
the  ordinary  forms  of  stomatitis  occur. 

Gangrene  of  the  mouth  may,  however,  occur  under  the  age  of  one  year. 
Billard  reported  3  cases  under  the  age  of  one  month,  but  in  2  of  these  the 
disease  does  not  appear  to  have  been  sufficiently  marked  to  render  it  certain 
that  they  were  genuine   cases. 

Causes. — Gangrene  of  the  mouth  usually  occurs  in  those  whose  systems 
are  reduced  or  cachectic.  It  is  therefore  more  frequent  among  the  poor  than 
those  in  comfortable  circumstances — in  the  city  than  in  the  country.  It  is 
more  frequently  observed  in  asylums  for  children  than  in  private  practice. 
Most  of  the  cases  which  I  have  seen  have  been  in  these  institutions.  If  the 
constitution  be  good,  it  can  only  occur  in  those  long  deprived  of  pure  air  and 
wholesome  nutriment  or  those  enfeebled  by  disease. 

Among  the  diseases  which  have  been  known  to  terminate  in  or  be  followed 
by  gangrene  of  the  mouth  are  the  pulmonary  and  intestinal  inflammations, 
whooping  cough,  and  the  fevers,  both  eruptive  and  the  non-eruptive.  Rilliet 
and  Barthez  have  published  a  table  of  98  cases  in  which  gangrene  resulted 
from  various  diseases.  In  49  of  these  the  antecedent  disease  was  measles, 
in  5  scarlet  fever,  6  whooping  cough,  9  intermittent  fever,  9  typhoid  fever, 
7  mercurial  salivation,  and  5  enteritis.  It  is  seen  that  the  essential  fevers 
were  the  most  frequent  cause  of  the  gangrene.  Of  46  cases  collected  by 
MM.  Bouley  and  Caillault  the  antecedent  disease  was  measles  in  all  but  5. 
In  this  city  also  a  larger  number  result  from  measles  than  from  any  other 
disease. 

One  reason  why  so  many  cases  of  gangrene  occur  as  a  sequel  of  measles 
is  probably  because  this  disease  is  accompanied  by  stomatitis.  Simple  or 
ulcerous  stomatitis  often  precedes  gangrene. 

Diseases  sometimes  terminate  in  gangrene  of  the  mouth  in  consequence 
of  injudicious  treatment  which  has  lowered  the  vitality  of  the  system.  Ril- 
liet and  Barthez  mention  the  case  of  a  child  four  years  old  in  whom  gangrene 
commenced  at  the  twenty-ninth  day  of  primitive  pneumonia.  The  child  had 
been  reduced  by  the  application  of  twelve  leeches,  three  scarifications,  a  large 
blister,  and  by  a  poor  diet. 

The  misuse  of  mercury  was  once  a  much  more  frequent  cause  of  gan- 
grene than  at  present,  at  least  in  this  country,  since  this  agent  was  formerly 
much  more  employed  than  now.  In  fact,  most  of  the  affections  of  infancy 
and  childhood  in  which  mercurials  were  formerly  employed  are  now  treated 
without  it. 

Symptoms. — Gangrene  of  the  mouth  so  often  occurs  in  connection  with 
other  diseases  that  its  symptoms  are  in  a  large  proportion  of  cases  blended 
with  those  which  arise  from  a  distinct  pathological  state. 

There  is  usually  prostration  more  and  more  pronounced  as  the  gangrene 
extends.     The  features  are  ordinarily  pallid,  but  occasionally  their  normal 


746 


GANGRENE   OF  THE  MOUTH. 


color  is  preserved  for  a  time ;  the  expression  of  the  face  is  melancholy,  but 
composed.  Sometimes  the  child  is  fretful  if  disturbed ;  at  other  times  it 
will  quietly  consent  to  an  examination.  The  suffering  is  not  proportionate  to 
the  gravity  of  the  disease.  There  is  less  pain  often  than  in  some  of  the  forms 
of  stomatitis  which  are  unattended  with  danger. 

As  the  disease  advances  the  body  and  limbs  gradually  waste,  the  eyes  are 
hollow,  or,  if  the  gangrene  be  near  the  orbit,  the  eyelids  become  oedematous  ; 

Fig.  46. 


the  lips  are  infiltrated  ;  and  both  the  lips  and  nostrils  are  often  incrusted.  If 
the  cheek  be  perforated,  alimentation  is  rendered  difficult  and  the  appearance 
of  the  child  is  melancholy  in  the  extreme. 

The  tongue  is  usually  moist ;  it  is  occasionally  swollen.  The  saliva  flows 
from  the  mouth,  either  pure  or  mixed  with  offensive  sanguinolent  matter. 
Unless  the  disease  be  slight  there  is  the  peculiar  gangrenous  odor.  The 
appetite  is  sometimes  poor ;  at  other  times  it  is  preserved  through  the  whole 
sickness.  There  is  no  vomiting  or  looseness  of  the  bowels,  unless  from  a 
complication.  The  thirst  is  usually  great,  and  the  pulse  is  accelerated  and 
feeble  except  in  mild  cases. 

The  skin  in  the  commencement  of  gangrene  is  hot.  When  the  vital  force 
is  much  reduced,  and  especially  as  the  disease  approaches  a  fatal  termination, 
the  face  and  limbs  become  cold  and  the  surface  generally  presents  a  waxen 
or  ashy  appearance.  No  derangement  occurs  of  the  respiratory  system. 
Those  cases  which  are  attended  by  a  cough  or  accelerated  respiration  are 
really  cases  of  bronchitis  or  pneumonia  coexisting  with  the  gangrene. 

Diagnosis. — Gangrene  of  the  mouth  is  easily  diagnosticated.  In  those 
cases  in  which  ulceration  precedes  the  gangrene  it  may  be  mistaken  in  its  first 
stage  for  that  form  of  ulcerous  stomatitis  in  which  the  ulcers  assume  an 
unhealthy  appearance.  The  following  are  the  distinguishing  features  of  the 
two  affections :  Around  the  ulcer  where  gangrene  is  about  to  commence  the 
tissues  are  greatly  thickened  and  indurated  or  oedematous,  while  ulcerous 


PROGNOSIS.  747 

stomatitis  begins  with  a  submucous  deposit  of  fibrin,  and  is  attended  by  little 
thickening  of  the  surrounding  parts  and  little  or  no  induration  or  a'dema.  In 
ulcerous  stomatitis  the  skin  over  the  seat  of  the  disease  presents  its  normal 
appearance,  whereas  in  gangrene  it  presents  a  distended  and  shining  appear- 
ance. The  destructive  process  in  ulcerous  stomatitis  is  also  more  limited 
than  in  gangrene.  Deep  ulcerations  do  not  occur  or  are  rare.  Ulcerous 
stomatitis  is  more  readily-  healed,  and  it  leaves  no  eschar,  contraction,  or 
deformity. 

The  differential  diagnosis  of  gangrene  of  the  mouth  from  those  cases  of 
follicular  stomatitis  in  which  the  ulcers  occupying  the  seat  of  the  follicles 
assume  a  gangrenous  appearance  must  be  made  by  a  consideration  of  the  same 
facts  or  particulars  which  serve  to  distinguish  it  from  ulcerous  stomatitis. 

Malignant  pustule,  of  rare  occurrence  in  the  child,  resembles  this  disease 
in  some  of  its  features.  But  the  pustule  always  begins  on  the  skin,  while 
gangrene  is  a  disease  of  the  mucous  surface  primarily.  In  gangrene,  there- 
fore, the  chief  destruction  is  of  the  mucous  membrane  and  of  the  submucous 
tissue,  while  in  malignant  pustule  the  chief  destruction  is  of  the  skin  and  the 
subcutaneous  tissue. 

Prognosis. — This  depends  not  only  on  the  extent  of  the  gangrene,  but 
the  nature  of  the  disease,  if  there  be  one,  which  gave  rise  to  it,  and  the 
degree  of  cachexia.  If  it  occur  in  connection  with  or  as  a  sequel  to  one  of 
the  less  debilitating  diseases,  and  there  be  considerable  vigor  of  system,  it 
may  often  be  arrested  when  it  has  destroyed  only  the  mucous  and  subcuta- 
neous tissues,  so  that  no  deformity  results.  The  friends  may  congratulate 
themselves  if  the  case  terminate  so  favorably.  In  the  graver  cases,  when 
the  gangrene  extends  until  it  destroys  the  periosteum  of  the  maxillary  bone 
on  the  affected  side,  and  perhaps  perforates  the  cheek,  if  the  child  recover  it 
is  with  the  permanent  loss  of  teeth,  tedious  separation  of  the  necrosed  bone, 
and  a  cicatrix  which  may  interfere  with  the  free  use  of  the  jaw.  Death  is, 
however,  the  more  common  termination  of  severe  cases.  Occasionally  the 
gangrene  destroys  the  continuity  of  a  blood-vessel,  causing  abundant  hem- 
orrhage and  accelerating  the  fatal  result.  In  most  cases,  however,  there  is 
little  or  no  hemorrhage  in  consequence  of  coagulation  in  the  vessels. 

Another  serious  complication  sometimes  arises — to  wit,  gangrene  of  other 
parts,  as  of  the  external  genital  organs.  The  English  editor  of  Bouchut's 
treatise  on  diseases  of  children  relates  the  following  interesting  case,  from 
the  Transactions  of  the  Edinburgh  MeiUco-Chir.  Society:  An  infant  eight 
months  old  became  affected  with  gangrene  of  the  face,  head,  and  hands. 
'■'■  The  right  ear  and  the  entire  hairy  scalp  were  of  an  intensely  black  color, 
and  on  both  cheeks  patches  existed  about  the  size  of  a  half-crown  piece. 
The  right  thumb  and  the  backs  of  both  hands  were  similarly  affected.  The 
child  was  noted  to  have  been  restless  and  feverish  on  May  22d,  and  on  the 
23d  a  slightly  darkened  ring  was  found  to  have  formed  round  the  thumb, 
about  the  middle  of  the  first  phalanx  ;  in  a  few  hours  the  whole  thumb  was 
gangrenous  and  the  dorsum  of  the  hand  became  involved.  On  the  ear  the 
gangrene  commenced  with  the  appearance  of  a  flea-bite,  and  subsequently 
extended  rapidly  to  the  scalp,  assuming  a  remarkably  regular  form  and  giv- 
ing to  the  child  the  appearance  of  wearing  a  black  skull-cap.     The  pulse  was 

observed  to  be  very  feeble Death  took  place  in  twelve  hours  from  the 

first  appearance  of  gangrene  on  the  thumb,  the  child  being  sensible  and  con- 
tinuing to  suck  well  up  to  a  few  minutes  before  death." 

Rilliet  and  Barthez  state  that  pneumonitis  frequently  occurs  in  the  course 
of  gangrene  of  the  mouth.  Such  a  complication  evidently  diminishes  mate- 
riallv  the  chance  of  recovery. 

Whether  the  result  be  favorable  or  unfavorable,  it  is  evident  from  the 


748  GANGRENE  OF  THE  MOUTH. 

nature  of  the  disease  that  the  duration  is  very  different  in  different  cases. 
The  physician's  attendance  may  be  required  for  a  week  or  two  or  for  several 
weeks. 

Treatment. — As  gangrene  of  the  mouth  is  eminently  a  disease  of  debil- 
ity, all  antihygienic  influences  should  be  removed  and  the  most  nourishing 
diet,  together  with  tonics,  be  recommended.  The  ferruginous  preparations  or 
the  bitter  vegetables  are  required. 

As  soon  as  the  physician  is  called  he  should  endeavor  to  arrest  the  gan- 
grene, accelerate  detachment  of  the  slough,  and  produce  a  healthy  and  gran- 
ulating state  of  the  surrounding  tissues.  This  is  best  effected  by  applying  a 
highly  stimulating  or  even  escharotic  agent  to  the  inflamed  surface  under- 
neath and  around  the  gangrene.  For  this  purpose  a  great  variety  of  sub- 
stances have  been  used  by  different  physicians,  such  as  acetic,  sulphuric, 
nitric,  and  hydrochloric  acids,  nitrate  of  silver,  the  acid  nitrate  of  mercury, 
chloride  of  antimony,   carbolic  acid,  and  even  the  actual  cautery. 

M.  Taupin  recommends,  after  removing  a  considerable  part  of  the  gan- 
grenous substances  with  scissors  or  some  instrument,  the  application  of  strong 
muriatic  acid,  and,  when  the  slough  is  detached,  of  dry  chloride  of  lime. 

Rilliet  and  Barthez  advise  the  use  twice  daily  of  muriatic  acid  or  the 
acid  nitrate  of  mercury,  applied  by  a  brush  upon  and  around  the  slough, 
followed  immediately  by  the  application  of  dry  chloride  of  lime,  when  the 
mouth  is  to  be  thoroughly  washed  with  w^ater  from  a  syringe.  They  direct 
in  the  interval  frequent  ablution  with  water.  After  the  slough  has  separated, 
the  escharotic  is  to  be  discontinued  and  the  chloride  of  lime  used  alone.  If 
gangrene  extend  to  the  skin,  a  crucial  incision  is  to  be  made  and  the  eschar- 
otic applied,  after  which  powdered  cinchona  is  introduced  and  retained  by  a 
plaster.  This  treatment  is  to  be  continued  till  the  gangrene  is  arrested  and 
the  decayed  portion  removed.  Barrier,  Valleix,  and  most  French  writers 
recommend  essentially  the  same  treatment — namely,  the  application  of  undi- 
luted escharotic  agents. 

A  safer,  less  painful,  and  in  many  cases  successful  treatment  is  that 
employed  by  many  British  and  American  physicians — to  wit,  the  use  of 
escharotic  agents  diluted,  or,  if  applied  in  their  full  strength,  such  as  are 
least  active  and  penetrating.  Some  employ  from  the  first  topical  treatment 
which  is  astringent  and  stimulating  rather  than  escharotic,  and  they  report 
satisfactory  results. 

Dr.  Gerhard  believes  "  the  best  local  applications  are  the  nitrate  of  silver, 
if  the  slough  be  small  in  extent ;  if  much  larger,  the  best  escharotic  is  the 
muriated  tincture  of  iron,  applied  in  the  undiluted  state.  After  the  prog- 
ress of  the  disease  is  arrested  the  ulcer  will  improve  rapidly  under  an  astrin- 
gent stimulant,  such  as  the  tincture  of  myrrh  or  the  aromatic  wine  of  the 
French   Pharmacopoeia." 

The  local  treatment  recommended  by  Evanson  and  Maunsell  differs  from 
that  advised  by  any  of  the  writers  from  whom  I  have  quoted.  A  knowledge 
of  this  treatment,  from  which  I  have  myself  seen  good  results,  will  be  best 
imparted  by  quoting  from  these  authors  :^  "  The  lotion  which  we  have  found 
by  far  the  most  successful  is  a  solution  of  sulphate  of  copper  as  employed 
by  Coates  in  the  Children's  Asylum.     His  formula  is  as  follows: 

R.  Cupri  sulph.,  .^ij  ; 

Pulv.  cinchonse,  .Iss; 

Aquae,  ^iv.     Misce. 

"  This  is  to  be  applied  twice  a  day  very  carefully  to  the  full  extent  of  the 
ulcerations  and  excoriations.     The  addition  of  the  cinchona  is  only  useful  by 

^  Diseases  of  Children,  2d  Amer.  ed.,  p.  188. 


TREATMENT.  749 

retaining  the  sulphate  of  copper  lunger  in  contact  with  the  edges  of  the  gums. 
A  solution  of  the  sulphate  of  zinc,  3J  to  an  ounce  of  water,  by  itself  or  com- 
bined with  tincture  of  myrrh.  Dr.  (.'oates  found  to  be  also  useful  in  some 
cases." 

A  moment's  reflection  will  show  us  that  the  above  treatment  is  preferable, 
provided  that  it  is  equally  effectual  in  arresting  the  gangrene,  to  the  treat- 
ment by  the  strong  acids  which  are  in  common  use,  and  the  efficiency  of 
which   cannot  be  questioned. 

The  purpose  in  applying  the  acid  is  to  establish  a  healthier  state  of  the 
tissues.  It  cauterizes  and  destroys  whatever  soft  tissue  it  comes  in  contact 
with  ;  besides,  it  produces  a  strong  corrosive  action  on  the  teeth  and  bone. 
Therefore  in  gangrene  affecting  the  jaw  there  is  great  danger  that  it  will 
destroy  the  periosteum,   and   consequently   increase  the   necrosis. 

Dr.  West,'  who  advocates  the  use  of  the  acid,  says :  "  In  one  of  the  cases 
that  I  saw  recover  the  arrest  of  the  disease  appeared  to  be  entirely  owing  to 
this  agent,  though  the  alveolar  processes  of  the  left  side  of  the  lower  jaw, 
from  the  first  molar  tooth  backward,  died  and  exfoliated,  apparently  from 
having  been  destroyed  by  the  acid."  No  such  result  follows  the  use  of  the 
solution  of  sulphate  of  copper. 

In  one  of  these  severe  cases  in  which  the  disease  resulted  from  scarlet 
fever,  and  in  which  there  was  so  much  debility  that  an  unfavorable  prog- 
nosis was  made,  I  succeeded  in  arresting  the  disease  by  the  use  of  Dr. 
Coates's  prescription.  The  child  recovered  with  the  loss  of  two  teeth  and 
the  corresponding  portion  of  the  maxillary  bone.  From  the  good  effects 
which  I  have  observed  from  iodoform  as  an  application  for  gangrenous  vul- 
vitis following  measles  it  has  occurred  to  me  that  it  may  also  be  useful  in 
gangrene  of  the  mouth. 

If,  after  employing  the  milder  treatment  for  two  or  three  days,  the  gan- 
grene continue  to  spread,  the  strong  muriatic  acid  should  be  cautiously 
applied  by  a  camel's-hair  pencil  or  small  swab  in  such  a  way  that  it  comes  in 
contact  only  with  the  diseased  surface.  Its  use  should  be  immediately  fol- 
lowed by  an  alkaline  wash,  as  a  solution  of  sodium  bicarbonate. 

In  1881  an  epidemic  of  measles  occurred  in  the  New  York  Foundling 
Asylum  during  the  attendance  of  Drs.  O'Dwyer  and  Lee.  The  number  of 
children  affected  with  it  was  165,  and,  since  many  of  them  were  cachectic, 
we  were  not  surprised  that  gangrene  appeared  as  a  complication  or  sequel  in 
7  cases.  In  a  girl  of  three  and  a  half  years  it  appeared  upon  the  upper 
jaw  at  the  base  of  the  teeth  ;  in  two  girls  of  four  years  it  appeared  upon 
the  inside  of  the  cheek  and  upon  the  vulva,  and  not  upon  the  gums  ;  in  a 
boy  of  three  years  it  attacked  the  lower  jaw,  destroying  four  teeth  with 
their  sockets,  and  the  upper  jaw,  destroying  five  teeth,  with  the  correspond- 
ing portion  of  the  maxillary  bone,  so  that  all  the  incisors  and  one  canine 
were  lost,  as  well  as  the  cartilaginous  portion  of  the  nasal  septum.  Gan- 
grene also  occurred  in  the  groin  in  this  case.  Another  boy  of  three  and  a 
half  years  lost  two  incisors  from  gangrene  of  the  jaw.  The  treatment  by 
muriatic  acid  was  employed,  and,  according  to  the  house  physician,  Dr.  Kort- 
right,  there  was  no  further  extension  of  the  gangrene  after  the  first  applica- 
tion in  any  of  the  cases.  All  lived  except  the  first,  who  had  broncho-pneu- 
monia. The  remaining  two  patients,  aged  respectively  four  years,  died  of 
diphtheria  and  pneumonia  before  treatment  could  be  tested.  One  of  them 
had  commencing  gangrene  of  the  lower  jaw,  the  other  of  the  soft  palate. 
Recently,  in  the  Foundling  Asylum  carbolic  acid  has  been  used  as  an  eschar- 
otic  in  one  or  two  cases,  instead  of  the  strong  acid,  and  with  such  a  result 
as  to  encourage  its  further  use. 

'  Diseases  of  Children,  4tli  Ajiier.  ed. 


750  DENTITION. 

The  gases  arising  from  the  gangrenous  mass  are  not  only  highly  offensive 
to  others,  but  they  are  doubtless  injurious  to  the  patient,  who  is  constantly 
inhaling  them.  To  remove  the  fetor,  chlorine  or  carbolic  acid,  properly  dilu- 
ted, should  be  occasionally  used  between  the  applications  of  the  sulphate  of 
copper.  Labarraque's  solution,  one  part  to  eight  or  ten  parts  of  water,  is  an 
eligible  form  for  its  use.  When  the  gangrene  is  removed  and  the  granula- 
tions present  a  healthy  appearance,  all  danger  is  usually  past  and  convales- 
cence is  fully  established.  Then  no  energetic  topical  treatment  is  required. 
A  mild  stimulating  lotion,  like  the  tincture  of  myrrh,  as  recommended  by 
Dr.  Gerhard,  suffices,  with  the  aid  of  tonics  and  nutritious  diet. 


CHAPTER    III. 

DENTITION. 

The  opinion  formerly  entertained  in  the  profession,  and  now  prevalent  in 
the  community,  that  many  infantile  maladies  arise  directly  or  indirectly  from 
dentition  is  erroneous.  Still,  there  are  physicians  of  experience  who  believe 
that  teething  is  a  common  cause  of  certain  maladies,  especially  of  functional 
derangements,  even  of  organs  remote  from  the  mouth.  On  the  other  hand, 
equally  good  observers — and  the  number  is  increasing — almost  wholly  ignore 
the  pathological  results  of  dentition.  They  say  that  as  it  is  strictly  a  phys- 
iological process  it  should,  like  other  such  processes,  be  excluded  from  the 
domain  of  pathology. 

A  moment's  reflection  will  show  how  important  it  is  to  understand  the 
exact  relation  of  dentition  to  infantile  diseases.  Every  physician  is  called  now 
and  then  to  cases  of  serious  disease,  inflammatory  and  non-inflammatory,  which 
have  been  allowed  to  run  on  without  treatment,  in  the  belief  that  the  symp- 
toms were  the  result  of  dentition.  I  have  known  acute  meningitis,  pneumo- 
nia, and  entero-colitis,  even  with  medical  attendance,  to  be  overlooked,  and 
the  symptoms  attributed  to  teething  during  the  very  time  when  appropriate 
treatment  was  most  urgently  demanded.  Many  lives  are  lost  from  neglected 
entero-colitis,  the  friends  believing  the  diarrhoea  to  be  symptomatic  of  denti- 
tion, a  relief  to  it,  and  therefore  not  to  be  treated.  Such  mistakes  are  trace- 
able to  the  erroneous  doctrine,  once  inculcated  in  the  schools,  and  still  held 
by  many  of  the  laity,  that  dentition  is  directly  or  indirectly  a  common  cause 
of  infantile  diseases  and  derangements. 

I  shall  endeavor  to  point  out  what  is  really  ascertained  in  regard  to  the 
pathological  relations  of  dentition. 

The  first  dentition  commences  at  the  age  of  about  six  months  and  termi- 
nates at  the  age  of  two  and  a  half  years.  The  corresponding  teeth  of  the 
two  sides  pierce  the  gum  at  about  the  same  time.  The  two  inferior  central 
incisors  first  appear  at  about  the  age  of  six  or  seven  months,  followed,  in  the' 
order  in  which  they  are  mentioned,  by  the  upper  central  incisors,  upper  lat- 
eral incisors,  lower  lateral  incisors,  the  four  anterior  molars,  the  four  canines,, 
and,  lastly,  the  four  posterior  molars. 

The  incisors  usually  appear  in  rapid  succession,  so  that  all  are  in  sight  by 
the  age  of  one  year.  From  the  age  of  one  year  to  eighteen  months  the 
anterior  molars  appear,  and  from  the  age  of  sixteen  to  twenty-four  months 
the  canines,  and  from  twenty-four  to  thirty  months  the  posterior  molars. 
This  order  is   not  always  preserved.     Sometimes  the  upper  central  incisors- 


PATHOLOGICAL  RESULTS  OF  DENTITION.  751 

appear  before  the  lower,  and  sometimes  tlie  lower  lateral  before  the  upper 
lateral.  In  rare  cases  there  have  been  teeth  at  birth.  T  have  seen  but  one 
or  two  infants  with  such  premature  dentition.  Retarded  dentition  is  much 
more  common.  Those  who  have  rickets  or  are  feeble  either  constitutionally 
or  by  disease  often  have  no  teeth  till  considerably  after  the  usual  period. 
In  such  the  first  incisors  may  not  appear  till  the  age  of  twelve  months,  or 
even  later. 

Pathological  Results  of  Dentition. — The  evolution  of  the  teeth  is 
commonly  attended  by  more  or  less  turgescence  around  the  dental  bulbs. 
This  is  greater  with  some  of  the  teeth  than  with  others.  Thus  the  superior 
incisors  cause  more  swelling  than  do  their  congeners  of  the  inferior  jaw.  The 
turgescence,  although  attended  by  more  or  less  congestion,  is  physiological 
within  certain  limits,  and  not  a  disease. 

But  sometimes  there  is  an  unusual  amount  of  swelling  around  the  dental 
follicles ;  the  afflux  of  blood  to  them  is  greatly  augmented  ;  they  are  the 
seat  of  such  a  degree  of  tenderness  and  pain  that  the  infant  is  fretful.  It 
carries  the  finger  often  to  the  mouth,  indicating  the  seat  of  its  suffering.  The 
surface  over  the  follicles  presents  greater  redness  than  in  ordinary  dentition, 
and  the  salivary  secretion  is  considerably  increased.  There  is  now  actual 
gingivitis. 

Occasionally  the  inflammation  affects  a  greater  extent  of  the  buccal  sur- 
face than  that  lying  directly  over  the  follicles,  so  that  most  writers  speak  of 
stomatitis  as  one  of  the  results  of  dentition.  In  a  few  cases  I  have  known 
such  a  degree  of  inflammation  over  the  advancing  tooth  that  a  small  abscess 
formed,  producing  much  pain  and  restlessness  till  it  was  opened  by  the 
lancet. 

The  pathological  results  of  dentition  whicfi  I  have  mentioned,  though  they 
may  interfere  more  or  less  with  nursing  or  feeding,  are  not  dangerous.  They 
are  easily  detected.  They  result  directly  from  the  rapid  growth  and  aug- 
mented sensitiveness  of  the  dental  follicles. 

There  are  other  supposed  accidents  of  dentition  occurring  in  distant  parts 
of  the  system  in  consequence  of  the  relation  and  interdependence  of  organs 
which  exist  through  the  system  of  nerves. 

Some  children  previously  to  the  eruption  of  the  teeth  are  aff"ected  with 
diarrhoea,  occasionally  accompanied  by  irritability  of  stomach.  Certain  writers 
have  supposed  that  gastro-intestinal  catarrh  is  present  in  these  cases ;  others 
that  there  is  simply  a  hypersecretion,  an  increased  activity  of  the  intestinal 
follicular  apparatus — that  it  is,  in  other  words,  one  of  the  forms  of  non- 
inflammatory diarrhoea.  Barrier  believes  that  the  diarrhoea  of  dentition 
depends  usually  on  what  he  calls  a  "  subinflammatory  turgescence  limited  to 
the  gastro-intestinal  follicular  apparatus."  He  believes  that  in  occasional  cases 
it  is  due  to  defective  or  altered  innervation.  It  would  then  be  analogous  or 
similar  to  that  form  of  diarrhoea  which  occurs  in  the  adult  from  the  emotions. 
Bouchut  calls  the  diarrha^a  of  dentition  nervous  diarrhoea.  It  is  certain, 
however,  that  in  most  cases  of  diarrhoea  which  are  attributable  to  dentition 
there  are  other  causes,  such  as  unsuitable  food  or  residence  in  an  insalubrious 
localit}'.  It  is  certain,  as  regards  city  infants,  that  the  chief  causes  of  diar- 
rhoea during  the  period  of  dentition  are  strictly  antihygienic,  dentition  being 
quite  subordinate  as  a  cause,  and  probably  ordinarily  not  operating  at  all  as 
such.  But  when,  as  sometimes  happens,  at  each  period  of  dental  evolution 
the  infant  is  aifected  with  diarrhoea,  the  influence  of  teething  is  apparent. 
Such  cases  enable  us  to  see  that  teething  may  really  sustain  a  causal  relation 
to  certain  diseases  not  located  in  the  buccal  cavity. 

Among  the  more  common  pathological  results  of  difficult  dentition  are 
certain  aff'ections  referable  to  the  cerebro-spinal  system.     Eclampsia  is  one 


752  DENTITION. 

of  the  admitted  results.  Barrier  attributes  convulsions  in  the  teething  infant 
to  excitement  of  the  nervous  system  arising  from  the  pain  which  is  felt  in 
the  gums,  and  to  a  determination  of  blood  to  the  dental  apparatus,  in  which 
afflux  the  whole  vascular  system  of  the  head  participates. 

In  most  cases  of  convulsions  occurring  during  the  period  of  dental  evolu- 
tion a  careful  examination  discloses  other  causes  in  addition  to  the  state  of  the 
gums.  Difficult  dentitiun  must  then  be  considered  not  so  frequently  a  direct 
as  a  co-operating  or  predisposing  cause,  producing  a  sensitive  state  of  the 
nervous  system,  or  possibly  an  afflux  of  blood  to  the  head,  of  which  Barrier 
speaks,  and  which  by  an  additional  stimulus,  perhaps  trivial  in  itself,  ends  in 
convulsions.  In  exceptional  instances  eclampsia  occurs  mainly  from  denti- 
tion, or  if  there  are  other  causes  they  are  quite  subordinate.  This  may  hap- 
pen when  several  teeth  penetrate  the  gum  at  or  about  the  same  time.  Infants 
who  are  burned  or  scalded  are  very  liable  to  clonic  convulsions.  This  is,  in 
fact,  the  chief  danger  as  regards  life  from  such  accidents.  So  the  swollen 
and  tender  gum,  if  several  teeth  are  about  emerging,  may  aflfect  the  cerebro- 
spinal system  like  the  burn  or  scald  and  produce  the  same  nervous  phenomena. 
Thus  in  a  case  already  alluded  to  in  the  chapter  on  Convulsions,  five  incisors 
pierced  the  gum  within  about  two  weeks,  and  in  this  period  there  were  two 
attacks  of  eclampsia  with  an  interval  of  a  few  days.  The  attacks  were  not 
severe,  and  the  most  careful  examination  could  discover  no  other  cause  than 
the  simultaneous  development  of  so  many  dental  follicles.  Previously  and 
since  the  infant  has  been  well. 

Dentition  sometimes,  though  rarely,  occasions  also  tonic  contraction  of 
certain  muscles.  The  following  case  occurred  in  the  practice  of  the  late  Dr. 
A.  S.  Church  of  this  city,  the  history  of  which  he  communicated,  as  follows : 

Case. — "  H ,  seven  months   old,  was  first  visited  April  3,  1863.      The 

patient  had  been  fretful  for  several  days,  but  about  daylight  on  the  morning  of 
my  first  visit  it  commenced  crying,  and  had  not  ceased  for  a  moment  at  the  time 
of  my  visit,  9  A.  M.  The  bowels  were  somewhat  constipated  and  tympanitic ; 
abdominal  muscles  very  tense.  The  pain  was  supposed  to  be  in  the  abdomen, 
and  a  brisk  cathartic,  to  be  followed  by  an  anodyne,  was  ordered.  Some  relief 
followed,  but  on  the  ensuing  and  for  several  consecutive  mornings  the  pain 
returned,  each  day  lasting  longer,  until  the  child  only  ceased  crying  while  under 
the  influence  of  a  full  anodyne.  The  gum  over  the  upper  incisors  was  consid- 
erably swollen,  hot,  and  dry,  but  the  parents  would  not  consent  to  have  it  scarified. 
For  the  first  week  there  was  no  fever,  no  vomiting,  and  not  the  least  indication 
that  the  nervous  system  was  suffering.  About  the  10th  the  thumbs  were  noticed 
to  be  flexed  during  the  attack  of  pain,  and  about  the  15th  the  flexors  of  the  toes 
were  contracted  and  the  hands  were  turned  backward  and  outward,  but  only  while 
the  child  was  awake.  About  the  20th  there  was  constant  contraction  of  the 
flexors  of  both  extremities,  with  opisthotonos,  and  constant  rolling  of  the  head, 
loss  of  ajipetite,  progressive  emaciation,  coated  tongue,  and  highly-inflamed  gums. 
Consent  was  finally  obtained  to  relieve  the  inflamed  gum,  and  free  incisions  were 
made,  and  the  following  night  the  child  slept  comfortably  for  three  hours  with- 
out opiates.  In  three  days  the  gums  were  freely  cut  again,  and  the  teeth  soon 
made  their  appearance.  All  symptoms  of  disease  had  now  ceased,  the  child 
became  playful,  and  on  the  30th  the  patient  was  discharged." 

More  recently  a  child  of  about  eighteen  months,  seen  by  me  in  consulta- 
tion, had  tonic  contraction  of  the  flexors  of  the  left  thigh  and  leg,  continuing 
nearly  a  month,  so  that  the  thigh  was  flexed  on  the  body  and  the  leg  on  the 
thigh.  The  infant  was  cutting  five  teeth  at  the  time,  and  the  gums  were 
considerably  swollen  over  them.  The  normal  state  of  the  afi"ected  limb 
was   not  restored  until  these  teeth  had  penetrated  the  gum. 

The  opinion  has  been  prevalent  in  the  profession  that  painful  and  difficult 
dentition  is  one  of  the  chief  causes  of  infantile  paralysis,  but  it  is  now  com- 


DIA  GNOSLS—  TRKA  TMENT.  753 

monly  admitted  that  it  is  only  a  subordinate  or  nsniote  cause,  if  indeed  it  is 
proper  to  consider  it  as  a  cause  at  all.     (See  art.  Paralysis.) 

Some  writers  express  the  opinion  that  acute  meningitis  occasionally  results 
from  teething.  The  facts,  however,  that  are  relied  upon  to  prove  this  are 
uncertain.  The  occurrence  of  meningitis  during  dentition  is  probably  in  most 
instances  a  coincidence. 

Teething  less  frequently  disturbs  the  respiratory  system  than  either  the 
digestive  or  cerebro-spinal.  A  cough  occurs  in  some  infants  at  each  period 
of  dental  evolution.  It  is  attended  by  little  expectoration,  but  appears  to  be 
associated  with,  in  at  least  certain  cases,  an  inflammatory  turgescence  of  the 
bronchial  mucous  membrane. 

Acceleration  of  pulse  is  often  observed  at  the  time  of  greatest  swelling 
and  tenderness  of  the  gum.  It  subsides  with  the  protrusi(.n  of  the  tooth. 
The  fever  of  dentition  is  irregular,  sometimes  presenting  a  remittent  form,  like 
remittent  fever  or  the  fever  premonitory  of  meningitis.  Eczema  and  certain 
other  cutaneous  diseases  are  common  during  dentition,  but  their  dependence 
on  it  as  a  cause  has  not  been  demonstrated. 

Diagnosis. — The  accidents  of  dentition  which  are  located  in  the  mouth 
are  easily  diagnosticated,  except  the  odontalgia  which  writers  describe,  and 
which  is  not  necessarily  attended  by  any  perceptible  anatomical  alteration  of 
the  gums.  Those  accidents  which  pertain  to  remote  and  concealed  organs 
are  usually  detected  with  ease,  though  it  is  often  difficult  to  determine  with 
certainty  their  relation  to  dentition. 

When  similar  symptoms  arise  at  each  epoch  of  teething  and  subside  with 
the  subsidence  of  the  gingival  turgescence,  teething  must  be  regarded  as  the 
cause.  Or,  if  the  disease  be  such  as  is  known  to  be  produced  occasionally 
by  difficult  teething,  and  if,  after  a  careful  examination,  we  can  discover  no 
other  cause,  while  the  gums  are  swollen,  especially  over  two  or  more  advan- 
cing teeth,  it  is  proper  to  refer  the  malady  to  dentition. 

It  is  evident  that  we  must  often  be  in  doubt  whether  the  disease  we  are 
treating  be  due  at  all  to  the  state  of  the  gums,  or,  if  so,  whether  directly  or 
indirectly  or  to  what  extent;  but  as  a  rule  if  any  other  cause  be  apparent  we 
may  properly  regai'd  the  influence  of  dentition  as  quite  subordinate. 

Treatment. — It  is  obvious  that  remedial  measures  in  cases  of  difficult 
dentition  must  be  twofold — namely,  those  directed  to  the  state  of  the  gums, 
and  those  designed  to  relieve  the  derangements  or  diseases  to  which  denti- 
tion has  given  rise.  If  there  be  diarrhoea,  this  should  be  controlled  by 
proper  remedies,  so  as  to  reduce  the  number  of  evacuations  to  two  or  three 
daily.  It  is  well  to  state  to  the  friends  of  the  child  who  believe  that 
diarrhoea  is  salutary  during  the  period  of  teething  that  this  number  is 
quite  sufficient,  and  that  more  frequent  evacuations  endanger  the  safety  of 
the  child. 

The  nervous  aff'ections,  as  convulsions,  require  .such  soothing  and  deriva- 
tive measures  as  are  recommended  in  our  remarks  on  Diseases  of  the  Nervous 
System.  The  bromide  of  potassium  I  have  found  especially  useful  and  safe 
in  cases  of  fretfulness  and  nervous  excitement  due  to  dentition.  Demulcent 
and  soothing  lotions  are  sometimes  useful  in  cases  of  painful  dentition,  and 
the  infant  may  be  allowed  to  hold  in  its  mouth  an  India-rubber  or  ivory 
ring,  which  seems  to  give  considerable  relief. 

Mothers  often  attempt  to  "  rub  through  a  tooth,"  as  they  term  it,  by 
means  of  a  ring  or  thimble.  This  should  be  discouraged.  So  great  friction 
cannot  fail  to  have  an  injurious  eff'ect  by  increasing  the  swelling  and  inflam- 
mation, unless  the  tooth  have  already  reached  the  mucous  membrane. 

We  come  now  to  a  subject  which  has  engaged  the  attention  of  many 
physicians  of  ample  expei'ience,  and  in  reference  to  which  there  is  still  a  dif- 
48 


754  DENTITION. 

ference  of  opinion  among  the  highest  authorities  in  medicine.  I  refer  to 
scarification  of  the  gums. 

The  gum-lancet  is  much  less  frequently  employed  than  formerly.  It  is 
used  more  by  the  ignorant  practitioner,  who  is  deficient  in  the  ability  to 
diagnosticate  obscure  diseases,  than  by  one  of  intelligence,  who  can  discern 
more  clearly  the  true  pathological  state.  Its  use  is  more  frequent  in  some 
countries,  as  England,  under  the  teaching  of  great  names,  than  in  others, 
as  France,  where  the  highest  authorities,  as  Rilliet  and  Barthez,  dis- 
countenance it. 

It  is  well  to  bear  in  mind,  as  aiding  in  the  elucidation  of  this  subject,  the 
remark  made  by  Trousseau,  that  the  tooth  is  not  released  by  lancing  the  gum 
over  the  advancing  crown.  The  gum  is  not  rendered  tense  by  pressure  of 
the  tooth,  as  many  seem  to  think,  for  if  so  the  incision  would  not  remain 
linear,  and  the  edges  of  the  wound  would  not  unite,  as  they  ordinarily  do 
by  first  intention  within  a  day  or  two.  This  speedy  healing  of  the  incision 
unless  the  tooth  be  on  the  point  of  protruding  is  an  important  fact,  for  it 
shows  that  the  efi'ect  of  the  scarification  can  last  only  one  or  two  days.  The 
early  repair  of  the  dental  follicle  is  probably  conservative,  so  far  as  the 
development  of  the  tooth  is  concerned.  It  may  help  us  to  understand  how 
active,  how  powerful,  the  process  of  absorption  is,  if  we  reflect  that  the  roots 
of  the  deciduous  teeth  are  more  or  less  absorbed  by  the  advancing  second 
set,  without  much  pain  or  suff"ering  from  the  pressure.  If  the  calcareous 
particles  of  the  teeth  are  so  readily  absorbed,  what  is  the  foundation  for  the 
belief  that  the  fleshy  substance  of  the  gum  is  absorbed  with  such  difficulty  ? 
Too  much  importance  has  evidently  been  attached  to  the  supposed  tension 
and  resistance  of  the  gum  in  the  process  of  dentition. 

Follicles  in  the  period  of  development  are  especially  liable  to  inflamma- 
tion. We  see  this  in  the  follicular  stomatitis  and  enteritis  so  common  when 
the  buccal  and  intestinal  follicles  are  in  a  state  of  most  rapid  growth.  Does 
not  this  law  in  reference  to  the  follicles  hold  true  of  those  by  which  the  teeth 
are  formed,  so  that  the  period  of  their  enlargement  and  greatest  activity, 
which  corresponds  with  the  growth  and  protrusion  of  the  teeth,  is  also  the 
period  when  they  are  most  liable  to  congestion  and  inflammation  ?  It  seems 
probable  that  the  dental  follicles  are  most  liable  to  become  inflamed,  and 
therefore  tender,  from  various  causes  apart  from  dentition  at  the  time  of  their 
greatest  functional  activity. 

If  there  be  no  symptoms  except  such  as  occur  directly  from  the  swelling 
and  congestion  of  the  gum,  the  lancet  should  seldom  be  used.  The  patho- 
logical state  of  the  gum  which  would,  without  doubt,  require  its  use  is  an 
abscess  over  the  tooth.  As  to  the  symptoms  which  are  general  or  referable 
to  other  organs,  as  fever  and  diarrhoea,  the  lancet  should  not  be  used  if  the 
symptoms  can  be  controlled  by  other  safe  measures.  All  co-operating  causes 
should  first  be  removed,  when  in  a  large  propoition  of  cases  the  patient  will 
experience  such  relief  that  scarification  can  be  deferred. 

If  the  state  of  the  infant  be  one  of  immediate  danger,  as  in  eclampsia, 
and  it  be  not  quickly  relieved  by  the  ordinary  remedies,  scarification  may 
not  only  be  proper,  but  required  to  ensure  safety.  For  in  such  cases  all 
measures,  provided  that  they  are  safe  and  simple,  which  can  possibly  give 
relief,  should  be  employed  without  delay.  But  I  can  recall  to  mind  only  three 
accidents  of  dentition  which  would  be  likely  to  be  benefited  by  scarification — 
namely,  suppurative  inflammation  in  the  dental  follicle,  extreme  fretfulness 
continuing  day  after  day,  and  convulsions.  But  since  the  bromide  of  potas- 
sium and  hydrate  of  chloral  have  come  into  use  as  nervous  sedatives  and  as 
efiicient  remedies  for  clonic  convulsions,  scarification  of  the  gums  is  much  less 
ftiequently  required,  for  even  severe  eclampsia  commonly  yields  to  these  medi- 


TREATMENT.  755 

cines  if  the  condition  of"  the  bowels  be  attended  to.  In  some  instances  I  have 
found  that  the  elixir  anisi  (aniseed  cordial)  of  the  National  Formulary,  con- 
taining as  it  does  anethol  and  the  oils  of  fennel  and  bitter  almonds,  admin- 
istered in  doses  of  ten  drops  to  an  infant  of  one  year,  is  apparently  more 
quieting  in  cases  of  restlessness  than  the  bromide.  It  may  be  given  with 
the  bromide. 

Second  Dentition. 

The  fact  is  well  established,  though  often  overlooked  in  practice,  that 
second  dentition  occasionally  deranges  tiie  functions  of  organs  and  gives  rise 
to  pathological  symptoms.  Killiet  and  Barthez  mention  particularly  neuralgic 
pains,  rebellious  cough,  and  diarrhoea  as  effects  which  they  have  observed. 
Rilliet  relates  the  case  of  a  girl  eleven  years  old  who  had  a  very  obstinate 
and  protracted  cough,  the  paroxysms  lasting  often  half  an  hour  to  one  hour. 
This  cough  immediately  and  permanently  disappeared  when  the  molars  pierced 
the  gums. 

Dr.  James  Jackson  '  says  :  "  I  have  seen  persons  between  twenty  and 
thirty  years  of  age  much  affected  by  a  wwlom  tooth  not  yet  protruded,  and 
distinctly  relieved  by  cutting  the  gum.  But  I  think  the  most  common  period 
of  suffering  from  the  second  dentition  is  from  the  tenth  to  the  thirteenth 
year.  The  most  characteristic  affections  are  wasting  of  flesh  and  nervous 
diseases.  The  boy  loses  his  comeliness  and  his  complexion  is  less  clear,  while 
emaciation  takes  place  in  every  part,  though  mostly  perhaps  in  the  face. 
The  nervous  symptoms  are  various,  but  the  most  common  are  a  change  iu 
the  temper  and. a  loss  of  spirits.  With  these  there  is  some  loss  of  strength. 
The  patient  is  unwilling  to  engage  in  play,  and  soon  becomes  tired  when  he 
does  do  it.  Among  the  distinct  symptoms  which  are  not  uncommon  I  may 
mention  pain  in  the  head  and  in  the  eyes.  The  headache  is  not  commonly 
severe,  but  it  is  such  as  inclines  the  patient  to  keep  still.  The  eyes  are  not 
only  painful,  but  are  often  affected  with  the  morbid  sensibility  to  which  these 
organs  are  subject.  I  have  known  boys  truly  anxious  to  pursue  their  studies 
obliged  to  give  them  up  on  this  account ;  and  these,  not  having  the  disposi- 
tion to  play,  will  of  choice  pass  the  day  with  their  mothers  and  increase  their 
troubles  for  the  want  of  air  and  exercise.  Nervous  affections  of  a  more  severe 
character  are  sometimes  manifested." 

Whether  the  symptoms  which  have  been  attributed  to  second  dentition 
have  always  been  due  to  this  cause  is  questionable.  Practically,  however,  it 
matters  little  whether  we  recognize  dentition  as  the  cause  or  assign  some- 
thing else.  Hygienic  and  medicinal  measures  to  improve  the  general  health 
will  usually  sufl&ce  to  relieve  the  patient.  Elsewhere  I  have  related  the  case 
of  a  boy  of  nervous  temperament,  about  seven  years  old,  who  recovered 
immediately  from  a  cough  which  had  lasted  for  several  weeks  by  taking  a 
mixture  of  iron  and  nitric  acid.  Many  do  well  without  medicine,  simply  by 
hygienic  measures.  Dr.  Jackson  says  :  "  The  remedies  which  I  have  found 
most  useful  are  as  follows :  First,  a  relief  from  study  or  from  regular  tasks, 
yet  using  books  so  far  as  they  afford  agreeable  occupation  or  amusement. 
Second,  exercise  in  the  open  air,  preferring  the  mode  most  agreeable  to  the 
patient,  and  in  more  grave  cases  the  removal  from  town  to  country." 
^  Letters  to  a   Youiuj  Physician. 


756  CATARRHAL  PHARYNGITIS. 


CHAPTEH  IV. 

CATAREHAL  PHARYNGITIS,  PERIPHARYNGEAL  ABSCESS, 
OESOPHAGITIS. 

Catarrhal  Pharyngitis. 

Children  of  all  ages  are  liable  to  inflammation  of  the  pharynx.  In  its 
mildest  form  it  often,  doubtless,  escapes  detection  in  the  young  infant.  In 
older  patients  it  is  revealed  by  pain  in  swallowing  solid  food  and  more  or  less 
tumefaction  below  the  ears,  apparent  to  the  sight.  It  is  said  to  be  less  fre- 
quent in  infancy  than  in  childhood.  In  the  adult  and  in  children  over  the 
age  of  four  or  five  years  inflammation  of  the  pharyngeal  surface  is  often  con- 
fined to  the  portion  of  membrane  which  covers  or  immediately  surrounds  the 
tonsils.  It  occurs  in  connection  with  inflammation  of  these  glands.  But  in 
infancy  and  early  childhood  this  limitation  is  comparatively  rare.  Catarrhal 
inflammation  of  the  fauces  at  this  age  is  ordinarily  general,  the  tonsils  par- 
ticipating in  the  morbid  state. 

Pharyngitis  is  primary  or  secondary.  The  secondary  form  occurs  in  mea- 
sles, scarlet  fever,  bronchitis,  croup,  pneumonia,  and  occasionally  in  other 
aff'ections.  As  these  diseases  are  common,  physicians  are  oftener  called  to  treat 
patients  who  have  the  secondary  form  than  the  primary.  Rilliet  and  Barthez 
met  83  secondary  to  16  primary  cases. 

Anatomical  Characters. — The  pathological  anatomy  of  pharyngitis  is 
ascertained  by  depressing  the  tongue  and  inspecting  the  fauces.  The  faucial 
surface  is  seen  to  be  redder  than  in  health,  with  more  or  less  swelling  accord- 
ing to  the  intensity  of  the  inflammation.  In  the  primary  inflammation  the 
color  is  commonly  bright  red,  almost  like  that  of  arterial  blood.  If,  on  the 
other  hand,  the  inflammation  occur  in  connection  with  a  constitutional  malady, 
the  hue  is  often  darker.  In  grave  cases  of  scarlet  fever  or  measles  it  is  some- 
times even  livid,  indicating  a  vitiated  state  of  the  blood — a  condition  of  real 
danger.  The  tonsils  are  tumefied  so  as  to  project,  though  not  to  the  extent 
which  we  observe  in  the  adult.  They  are  less  firm  than  in  the  normal 
state.  The  follicles  of  the  throat  are  enlarged  and  active,  pouring  out  a 
muco-purulent  secretion.  This  is  sometimes  seen  in  a  layer  over  the  tonsil 
or  the  posterior  portion  of  the  fauces.  In  a  case  of  primary  pharyngitis 
examined  after  death  by  Rilliet  and  Barthez  the  tonsils  were  softened,  infil- 
trated with  pus,  and  slightly  enlarged.  A  layer  of  bloody  mucus  lay  on  the 
pharyngeal  surface,  which  was  dark  red  and  thickened.  The  submaxillary 
glands  were  also  swollen  and  somewhat  softened. 

If  the  inflammation  be  intense  the  deep-seated  portions  of  the  tonsils 
become  involved,  and  even  sometimes  the  adjacent  connective  tissue.  In  such 
cases  by  applying  the  fingers  in  the  hollows  below  the  ears  the  tonsils  can  be 
felt. 

Causes. — The  usual  cause  of  primary  pharyngitis  is  exposure  to  cold. 
It  also  occasionally  occurs  from  the  use  of  drinks  too  hot  or  containing  some 
irritating  substance.  I  have  met  it  in  the  most  intense  form  caused  by  swal- 
lowing boiling  water,  and  in  one  case  from  acetic  acid  taken  through  mis- 
take. When  it  occurs  in  the  eruptive  fevers  it  is  usually  part  of  a  more 
extensive  phlegmasia  in  which  the  buccal  and  perhaps  laryngeal  and  nasal 
surfaces  participate. 


SYMPTOMS— DIA  GNOSIS.  757 

Symptoms. — Fever,  with  thirst  and  loss  of  appetite,  is  common,  and  is 
usually  proportionate  in  intensity  to  the  extent  and  severity  of  the  inflamma- 
tion. At  first  there  is  dryness  of  the  faucial  surface,  and  this  is  succeeded 
by  a  more  or  less  abundant  viscid  secretion.  Swallowing  is  painful,  except 
in  mild  cases.  The  muscles  of  the  anterior  half  arches,  which  by  their  con- 
traction close  the  opening-  from  the  pharyngeal  to  the  buccal  cavity,  and  those 
of  the  posterior  arches,  which  close  the  opening  to  the  nasal  cavity,  both 
which  sets  lie  a  little  under  the  mucous  membrane,  are  often  so  infiltrated 
with  serum  that  their  contractile  power  is  diminished,  and  if  the  same  happen 
with  the  constrictor  mu.scles,  which  carry  downward  the  food,  swallowing 
becomes  difficult,  and  in  the  attempt  more  or  less  of  the  ingesta  is  liable  to 
return  into  the  mouth  or  enter  the  nostril.  During  health  the  air  passes 
through  the  nostrils  in  the  pronunciation  of  two  letters  only — namely,  v  and 
m — but  in  severe  pharyngitis,  in  consequence  of  the  swelling  and  the  impair- 
ment of  the  action  of  the  muscles  concerned  in  speech,  the  air  passes  through 
the  nostrils  with  the  utterance  of  many  words,  producing  the  nasal  tone  of 
voice.  Sometimes  the  inflammation  traverses  the  Eustachian  tube  to  the 
middle  ear,  causing  earache,  which  may  be  relieved  by  the  escape  of  pus  down 
the  tube  or  by  perforation  of  the  drum  into  the  external  ear. 

The  breath  is  foul,  but  not  fetid  ;  the  respiration  normal  or  but  slightly 
accelerated  ;  there  is  commonly  no  cough,  but  it  is  sometimes  present,  due  to 
the  extension  of  the  inflammation  to  the  upper  part  of  the  larynx  or  to  the 
collection  of  mucus  around  the  aperture  of  the  glottis.  In  most  cases  of 
pharyngitis  a  light  fur  covers  the  tongue,  and  stomatitis  of  a  mild  grade 
is  present,  as  shown  by  redness  of  the  buccal  surface  and  increased  mucous 
secretion. 

Chronic  pharyngitis,  which  is  so  common  in  adults,  and  which  is  produced 
in  some  by  gastric  derangements,  and  in  others  by  excessive  smoking  or  the 
prolonged  use  of  intoxicating  drinks,  and  in  others  still  by  the  syphilitic  or 
mercurial  cachexia,  is  comparatively  rare  in  children. 

Prognosis. — In  mild  cases  of  pharyngitis  convalescence  commences 
within  a  week.  If  the  inflammation  be  dependent  on  a  constitutional  malady, 
it  may  continue  considerably  longer,  especially  if  the  glands  of  the  neck  and 
the  connective  tissue  be  much  involved.  The  prognosis  in  secondary  pharyn- 
gitis is  less  favorable  than  in  that  of  the  primary  form.  In  fatal  cases  there 
is  usually  a  vitiated  state  of  the  blood,  either  from  the  coexisting  constitu- 
tional  disease   or  from  previous  cachexia. 

Pharyngitis  may,  however,  become  dangerous  from  complications  to  which 
it  gives  rise.  The  proximity  of  the  inflammation  to  the  brain  or  its  efi"ect 
upon  the  cerebro-spinal  axis  through  the  medium  of  the  nerves  sometimes 
gives  rise  to  clonic  convulsions.  In  a  recent  case  of  primary  pharyngitis  in 
my  practice  repeated  and  violent  convulsions  occured  in  an  infant  about  one 
year  old  from  this  cause.  They  commenced  at  the  inception  of  the  inflamma- 
tion, and  constituted  the  only  real  danger.  Pharyngitis  may  interfere  mate- 
rially with  nutrition  in  consequence  of  the  dysphagia,  but  in  most  cases  of 
primary  pharyngitis  this  symptom  does  not  continue  sufficiently  long  to 
endanger  the  life  of  the  patient.  In  grave  constitutional  afi'ections,  as  scarlet 
fever,  the  difficulty  of  swallowing  and  the  consequent  innutrition  augment 
the  danger.  As  regards,  therefore,  the  prognosis  in  catarrhal  pharyngitis, 
whether  primary  or  secondary,  it  may  be  stated  as  a  rule  that  it  is  not,})er  se, 
a  fatal  disease,  but  is  only  so  from  complications  or  from  aggravating  the  pri- 
mary malady  with  which  it  is  associated. 

Diagnosis. — This  is  not  difficult,  provided  that  attention  be  directed  to 
the  throat ;  but  the  physician  often  fails  to  discover  it  at  his  first  visit  from 
neglecting  to  examine  this  part.     In  many  cases  the  local  symptoms  are  not 


758  CATARRHAL  PHARYNGITIS. 

well  marked,  and  in  the  absence  of  these  the  febrile  reaction  may  at  first  be 
referred  to  some  other  cause  than  the  true  one.  Inspection  not  only  reveals 
the  presence  of  inflammation,  but  enables  us  to  determine  whether  it  be 
simple  pharyngitis  or  diphtheritic  or  ulcerative.  In  some  instances  simple 
pharyngitis  resembles  the  diphtheritic,  from  the  presence  of  confervoid 
growths  upon  the  inflamed  surface,  usually  the  Leptothrix  buccalis.  The 
diflferential  diagnosis  is  based  on  the  easy  removal  and  soft  pultaceous  charac- 
ter of  the  confervse  and  the  appearance  under  the  microscrope. 

Treatment. — 3Iild  cases  of  simple  phai-yngitis  require  little  treatment. 
With  moderate  counter-irritation  over  the  throat  and  the  use  of  laxative  med- 
icines the  inflammation  soon  subsides.  The  oleum  camphoratum  may  be 
occasionally  rubbed  over  the  throat  and  retained  upon  it  by  flannel.  The 
effect  is  increased  by  the  application,  once  or  twice  daily,  of  mustard  or  tinc- 
ture of  iodine,  or  by  adding  to  the  liniment  one-fourth  or  one-third  of  its 
quantity   of  turpentine. 

Some  children  seem  to  be  most  relieved  by  a  muslin  compress  frequently 
wrung  out  of  cool  water  or  a  light  India-rubber  bag  containing  ice.  Fre- 
quently rubbing  the  neck  with  warm  oil  or  camphorated  oil  and  binding  upon 
it  a  rind  of  salt  bacon  are  popular  modes  of  treatment,  and  no  doubt  are  pro- 
ductive of  benefit. 

In  the  severe  forms  of  this  inflammation,  occurring  independently  of  any 
other  disease,  more  active  measures  are  sometimes  required. 

If  there  be  stupor  or  restlessness,  with  unusual  heat  of  head,  and  start- 
ing or  twitching  of  the  limbs  which  threatens  convulsions,  two  to  five  grains 
of  the  bromide  of  potassium  given  every  two  or  three  hours  produce  a  calm- 
ative eff"ect. 

Diaphoretic  and  sometimes  cardiac  sedatives  are  also  indicated,  such  as 
liquor  ammonise  acetatis,  spiritus  astheris  nitrosi,  ipecacuanha,  and  aconite. 
Medicines  of  this  kind  may  be  variously  combined  according  to  the  age  and 
condition  of  the  patient  and  the  severity  of  the  disease. 

As  the  symptoms  abate  the  intervals  between  the  doses  may  be 
increased. 

In  cases  attended  by  much  tenderness  and  dysphagia  great  relief  is  often 
obtained  by  hot  poultices  frequently  applied  over  the  neck. 

Topical  treatment  of  the  pharynx  is  recommended  by  most  authors. 
Rilliet  and  Barthez  use  for  this  purpose  nitrate  of  silver  or  powdered 
alum.  The  former  has  been  most  employed  by  physicians.  It  may  be 
applied  in  the  proportion  of  ten  grains  to  the  ounce  two  or  three  times 
daily.  I  prefer  the  following  mixture,  used  with  the  hand-atomizer  every 
hour  to  two  hours : 


R. 

Cocaini  muriat., 

gr. 

Glyceriti  acidi  tannici, 

3j; 

Sodii  biborat., 

3j; 

Ammon.  chloridi. 

Glycerinse, 

*^j  ; 

Aquae, 

iv. 

Misce. 

This  can  of  course  be  used  as  a  gargle  by  those  old  enough,  or  more  con- 
tinuously by  the  steam-atomizer. 

The  treatment  of  secondary  pharyngitis  will  be  described  in  connection 
with  the  treatment  of  the  diseases  which  it  complicates.  Suffice  it  here  to 
say  that  this  form  of  inflammation  must  not  be  treated  by  those  depressing 
remedies  which  may  be  useful  in  cases  of  idiopathic  pharyngitis. 


PERIPHARYNGEAL  ABSCESS.  759 


Peripharyngeal  Abscess. 

Every  practitioner  should  bear  in  luind  the  fact  that  an  abscess  occasion- 
ally forms  between  the  pharynx  and  vertebral  column  (retropharyngeal)  or 
upon  the  side  of  the  pliarynx  in  the  submucous  connective  tissue.  This  con- 
stitutes a  disease  which  is  likely  to  be  fatal,  but  which  can  ordinarily  be 
promptly  relieved  by   the  surgeim. 

Yet  if  we  look  over  the  records  of  peripharyntreal  abscess  we  shall  see 
that  in  a  large  proportion  of  fatal  cases  the  disease  was  supposed  to  be  some- 
thing else,  and  so  treated  until  its  nature  was  revealed  by  post-mortem  exam- 
ination. The  most  complete  monograph  on  this  malady  with  which  I  am 
acfjuainted  was  published  by  Dr.  Allen '  of  this  city,  under  the  title  of 
"  Retropharyngeal  Abscess."  To  this  paper  I  am  largely  indebted  for  the 
facts  contained  in  this  article. 

Age  ;  Causes. — This  abscess  may  occur  at  any  age.  but  it  is  most  com- 
mon in  infancy  and  childhood.  It  is  more  frequent  in  the  first  two  years  of 
life  than  at  any  other  period.  Of  the  cases  collated  by  Dr.  Allen  in  which 
the  age  is  stated,  20  were  under  ten  years  and  21  over  this  age.  The  abscess 
occurs  in  some  patients  from  caries  of  the  vertebral  column,  and  in  others 
from  inflammation  developed  in  the  connective  tissue  or  small  lymphatic 
glands  lying  immediately  outside  the  pharynx,  or  from  a  catarrhal  pharyn- 
gitis. Whichever  the  cause,  there  is  usually  a  scrofulous  or  reduced  state 
of  system. 

Writers  describe  two  kinds  of  peripharyngeal  abscess,  the  primary  and 
secondary.  This  distinction  is  based  on  the  fact  whether  or  not  the  inflam- 
mation which  leads  to  the  abscess  be  dependent  on  an  antecedent  patholog- 
ical state. 

In  the  primary  form  the  cause  is  usually  atmospheric,  or  it  is  some  irri- 
tating substance  which  has  been  swallowed,  and  which,  lodging  in  the 
pharynx,    produces   phlegmonous   pharyngitis. 

The  cause  is  mentioned  in  20  cases  of  the  primary  form,  collated  by  Dr. 
Allen,  as  follows :  exposure  to  cold,  10  cases  ;  lodgment  of  bone  in  pharynx, 
8  cases ;  blow  with  a  fencing-foil,  1  case.  In  the  last  case  the  button  of  a 
fencing-foil  passed  through  the  right  nostril  into  the  pharynx. 

The  secondary  form  occasionally  occurs  after  measles  and  scarlet  fever. 
The  inflammation  of  the  pharynx  common  in  those  diseases  extends  to  the 
subjacent  connective  tissue,  and,  aided  by  the  dyscrasia  of  the  patient,  becomes 
suppurative.  Such  cases  have  been  observed  by  Rilliet  and  Barthez.  The 
most  common  cause  of  the  secondary  form  is,  however,  caries  occurring  in 
the  cervical  vertebrae. 

When  thus  occurring  it  is  similar,  both  as  regards  cause  and  nature,  to 
lumbar  abscess.  It  would  follow  the  same  chronic  course,  and  would  prop- 
erly be  described  in  connection  with  it,  were  it  not  for  its  proximity  to  the 
air-passages,  which  renders  the  symptoms  so  urgent  and  dangerous.  In  a  few 
recorded  cases  the  abscess  was  a  sequel  of  erysipelas.  In  19  cases  of  second- 
ary abscess  in  Dr.  Allen's  collection  the  cause  is  assigned  as  follows :  erysip- 
elas of  face,  2  ;  inflammation  following  a  fall  upon  the  inferior  maxilla,  1 ; 
after  cerebritis,  1  ;  syphilis,  4  ;  caries  of  the  cervical  vertebrae.  G  ;   scrofula.  5. 

The  plausible  opinion  is  expressed  by  Mr.  Fleming^  that  the  suppuration 
begins  in  a  large  proportion  of  cases  in  the  small  lymphatic  glands  which  lie 
in  the  connective  tissue  external  to  the  pharynx.  The  late  Prof.  George  T. 
Elliot^  has  recorded  the  case  of  an  infant  of  seven  months  in  whom  peri- 
pharyngeal abscess  immediately  followed  and  was  apparently  due  to  parotiditis. 

1  N.  Y.  Jour,  of  Med.,  for  November.  1851. 

^  Dublin  Jour,  of  Med.  Sci,  vol.  xviii.  '  Obstet.  Clinic  N.  Y. 


760  PERIPHARYNGEAL  ABSCESS. 

In  rare  instances  the  abscess,  or  the  local  disease  which  leads  to  it,  appears 
to  exist  from  birth.  Thus  Dr.  E.  0.  Hocken  relates  ^  the  history  of  an  infant 
which  died  at  the  age  of  nine  weeks.  It  had  always,  when  taking  the  breast, 
thrown  back  its  head  as  if  nearly  suffocated.  The  walls  of  the  abscess 
were  thick  and  firm,  described  by  the  writer  as  cartilaginous.  Occasionally 
there  is  no  apparent  cause  of  the  abscess  except  the  strumous  or  cachectic 
state. 

Anatomical  Characters. — The  seat  of  the  abscess  is  not  the  same  in 
all  cases.  The  swelling  can  ordinarily  be  seen  on  examining  the  fauces,  but 
occasionally  it  is  so  low  as  to  be  really  perioesophageal,  and  therefore  invis- 
ible. The  size  of  the  abscess  varies :  sometimes  it  is  large,  pressing  inward 
the  wall  of  the  pharynx  even  against  the  velum  palati  and  into  the  posterior 
nares,  if  the  abscess  have  a  high  location,  or  if  lower  against  the  larynx,  so 
as  to  embarrass  respiration.  Sometimes  the  abscess  is  so  large  or  has  such 
lateral  extension  that  there  is  external  swelling  along  the  side  of  the  neck. 
In  a  few  cases  on  record  the  pus,  instead  of  being  discharged  into  the  pharynx, 
made  its  way  down  the  neck  between  the  muscles  and  the  connective  tissue 
to  the  pleural  cavity,  which  it  entered,  producing  fatal  pleuritis. 

The  walls  of  the  abscess  have  been  found  in  a  different  state  in  different 
cases.  Sometimes  the  sac  at  the  projecting  point  is  so  thin  that  it  seems  as 
if  there  might  have  been  a  spontaneous  cure  could  life  have  been  preserved 
a  few  hours  longer.  In  other  cases  the  sac  is  so  thick  and  firm  that  its  rup- 
ture for  many  days  would  be  impossible. 

Symptoms. — The  precursory  symptoms  differ  in  different  cases  according 
to  the  nature  of  the  cause,  whether  it  be  phlegmonous  pharyngitis  or  simply 
adenitis  or  vertebral  caries.  If  the  abscess  proceed  from  caries,  it  is  preceded 
by  deep-seated  pain,  greatly  increased  by  movements  of  the  head,  and  prob- 
ably preceded  also  by  induration  along  the  sides  of  the  vertebrae. 

The  patient  with  this  disease  is  restless,  his  mouth  hot  and  dry,  tongue 
furred,  deglutition  more  or  less  difiicult.  Sometimes  after  suppuration  has 
occurred  there  are  alternations  of  rigors  and  fever.  The  symptoms  indicate 
approximately  the  seat  of  the  inflammation,  but  on  examination  we  do  not 
find  that  degree  of  redness  of  the  mucous  surface  which  we  had  been  led  to 
expect.  The  tissues  which  are  chiefly  involved  in  the  inflammation,  being 
submucous,  are  hidden  from  view.  We  observe  redness  of  the  pharynx,  but 
it  is  disproportionate  to  the  intensity  of  the  symptoms.  Some  patients  fre- 
quently experience  a  chilly  sensation  through  the  entire  period  of  the  abscess, 
though  greater  at  one  time  than  at  another,  and  occasionally  convulsions 
occur,  especially  in  young  infants.  In  ordinary  cases  embarrassment  of  res- 
piration begins  early,  and  is  the  cause  of  the  chief  danger.  It  becomes  more 
and  more  marked  as  the  abscess  increases.  It  is  noticed  both  during  inspi- 
ration and  expiration.  The  dysphagia  also  increases,  sometimes  to  such  a 
degree  that  drinks  are  taken  with  difficulty  and  solid  food  refused.  The 
respiratory  symptoms  bear  considerable  resemblance  to  those  in  protracted 
laryngitis,  for  which  this  disease  has  been  mistaken.  While  the  respiration 
becomes  impeded  or  whistling,  the  voice  is  also  feeble  or  indistinct  from  the 
pressure  of  the  tumor. 

But  the  symptoms  described  above  are  not  all  present  in  every  case. 
They  vary  according  to  the  size  and  location  of  the  abscess,  whether  it  be 
high  or  low,  posterior  or  lateral.  I  have  met  the  disease  in  a  child  old  enough 
to  make  known  the  subjective  symptoms,  in  whom  there  was  little  or  no  dys- 
phagia ;  and  others  report  similar  cases.  When  the  tumor  has  attained  such 
a  size  that  it  produces  well-marked  symptoms  and  jeopardizes  the  life  of  the 
patient,  it  or  a  part  of  it  can  ordinarily  be  seen  on  depressing  the  tongue, 

^  Prov.  Med.  and  Surg.  Jour.,  1842. 


S  YMPTOMS—1)  URA  TION.  761 

but  usually  its  location  and  condition  can  be  bettor  ascertained  by  explora- 
tion with  the  finger.  The  dyspnoea  increases  as  the  abscess  enlarges,  and 
after  a  time,  unless  it  burst  spontaneously  or  be  opened  by  the  surgeon, 
imperfect  oxygenation  of  the  blood  results.  In  some  patients  paroxysms 
of  dyspnoea  occur,  so  as  to  threaten  immediate  suffocation  ;  coughing  or 
attempts  to  swallow  induce  these  paroxysms,  and  the  patient  is  forced  to 
remain  in  an  erect  or  semi-erect  posture  ;  the  tongue  is  protruded,  the  head 
thrown  back,  the  pulse  is  frequent  and  rapid,  the  limbs  become  livid  and  cool, 
and  finally  death  results  from  dyspnoea.  Occasionally,  when  death  seems 
inevitable,  the  abscess  breaks  during  the  struggles  of  the  child  and  the 
patient  is  restored  to  health.  In  rare  cases  the  result  is  different.  The 
trachea  and  bronchial  tubes  are  deluged  by  the  purulent  discharge  and  imme- 
diate suffocation  occurs.  The  following  was  an  example:  In  May,  1871,  a 
boy  two  years  and  five  months  old,  who  had  the  symptoms  of  an  abscess  for 
three  months,  was  brought  to  the  class  at  Bellevue.  The  head  was  carried 
on  one  side,  its  rotation  caused  pain,  and  a  laryngeal  rale  accompanied  respi- 
ration. The  upper  part  of  the  tumor  could  be  detected  by  the  finger,  but  on 
account  of  its  low  location  it  was  impossible  to  open  it  with  the  bistoury. 
The  temperature  was  103°,  pulse  156.  The  case  remained  under  observa- 
tion, but  in  a  few  days  the  dyspnoea  suddenly  became  so  urgent  that  death 
was  imminent,  when  the  attending  physician  of  the  class,  Dr.  Swezey,  broke 
the  abscess  with  his  finger  and  pus  was  ejected  on  the  floor ;  death,  however, 
occurred  almost  immediately. 

A  correct  appreciation  of  the  symptoms  and  nature  of  peripharyngeal 
abscess  will  be  best  obtained  by  relating  a  case.  I  select  the  following  from 
the  Trans,  of  the  Loud.  Pathol.  Soc,  Oct.  20,  1846:  A  female  infant  died  at 
the  age  of  seven  months,  having  had  difl&cult  breathing  three  weeks  and 
extreme  dyspnoea  during  the  last  days  of  life.  The  dyspnoea  was  constant, 
and  was  aggravated  by  mental  excitement,  by  movements  of  the  body,  and 
by  exposure  to  cold,  During  the  paroxysms  a  peculiar  croupy  sound  accom- 
panied inspiration.  There  was  no  dysphagia  through  the  entire  sickness, 
and  death  occurred  from  apnoea.  The  sac  of  the  abscess  was  of  the  size 
of  a  pigeon's  egg,  and  was  situated  between  the  upper  cervical  vertebrae  and 
the  back  of  the  pharynx.  The  abscess  was  flattened  in  front,  so  as  not  to 
cause  any  decided  prominence  of  the  wall  of  the  pharynx.  From  the  sac  a 
second  small  cyst  extended  forward,  forming  a  nipple-like  swelling  in  the 
pharynx  which  completely  closed  the  orifice  of  the  glottis.  Its  aperture  of 
communication  with  the  body  of  the  abscess  admitted  the  point  of  the  little 
finger,  and  the  whole  swelling  was  freely  movable  and  perfectly  translucent 
at  its  extremities  and  sides.  The  abscess  might  have  been  easily  punctured, 
with  probably  the  preservation  of  life. 

The  DURATION  of  this  malady  is  very  different,  according  to  the  inflam- 
mation, the  rapidity  with  which  the  abscess  enlarges,  and  the  direction 
which  it  points.  A  lateral  or  downward  extension  is  not  so  immediately 
dangerous  to  life  as  the  anterior. 

The  time  when  the  abscess  begins  to  form  cannot  be  precisely  ascertained, 
and  most  writers  in  determining  its  duration  compute  from  the  first  appear- 
ance of  symptoms  which  are  referable  to  the  pharynx.  Dr.  J.  Byrne* 
relates  a  fatal  case  in  which  the  disease  had  apparently  continued  only  about 
one  week.  The  patient  was  an  infant  one  year  old,  and  its  death  was  from 
apnoea.  The  abscess  was  large,  extending  from  the  base  of  the  skull  to  the 
thorax  and  pressing  both  on  the  larynx  and  trachea.  M.  Besserer^  gives  tho 
history  of  an  infant  four  months  old  who  died  in  the  same  way  after  thir- 
teen days.     An   infant  nine  months  old,  whose   case  was  published   by  Dr. 

'  Amer.  Jour,  of  Med.  ScL,  1838.  ^  Archiv.  gen.  de.  Med.,  1840. 


762  PERIPHARYNGEAL  ABSCESS. 

W.  C.  Worthington/  lived  nine  days.  The  abscess  occurred  from  exposure 
to  cold;  the  patient  was  treated  for  croup  and  died  from  suffocation.  The 
anterior  wall  of  the  abscess  was  very  thin.  In  two  cases  treated  by  me  the 
symptoms  indicated  a  continuance  of  the  disease  from  two  to  four  weeks, 
and  in  a  third  case  four  months.  A  fourth  case  is  interesting  on  account 
of  the  short  duration  of  the  severe  symptoms.     The  following  is  the  record 

of  it :    M.  E ,  aged   seven   months,  female,  nursing,  inmate  of  the  New 

York  Foundling  Asylum,  was  observed  to  have  difficult  breathing  for  the 
first  time  on  March  28, 1875.  Since  about  March  8th  some  swelling  had  been 
noticed  along  the  side  of  the  neck,  but  it  gave  rise  to  no  marked  symptoms, 
and  she  had  not  seemed  ill  till  the  obstruction  in  the  respiration  commenced. 
At  my  visit  on  the  evening  of  the  28th  the  infant  was  pointed  out  to  me  as 
in  a  dying  condition.  She  was  lying  in  a  state  of  stupor,  pallid  and  gasping 
for  breath,  with  a  temperature  of  103°,  and  very  feeble  pulse,  numbering 
about  200  per  minute.  On  carrying  the  finger  into  the  throat  an  abscess 
could  be  readily  detected,  situated  in  the  walls  of  the  pharynx  on  the  left 
side  posteriorly.  This  was  easily  opened  by  a  curved  bistoury,  around 
which  adhesive  plaster  was  wound  to  within  half  an  inch  of  the  point.  The 
breathing  immediately  began  to  improve.  On  the  following  day  the  infant 
was  playing  in  the  mother's  lap,  with  a  pulse  of  140,  but  a  normal  tempera- 
ture. With  the  use  of  cod-liver  oil  and  the  syrup  of  the  iodide  of  iron  its 
health  was  soon  fully  restored.  In  a  fifth  case  the  abscess  was  ruptured  by 
the  finger,  and  in  a  sixth  it  was  opened  by  the  lancet.  All  these  patients 
recovered. 

When  the  abscess  grows  slowly  and  presses  lightly  on  the  air-passages 
the  case  may  continue  for  months.  Such  a  one  was  observed  by  the  late 
Professor  Willard  Parker  (AUin).  This  infant  was  one  year  old  ;  it  suffered 
from  pharyngeal  symptoms  nine  months,  was  treated  for  tonsillitis,  and 
death  occurred  as  usual  from  apnoea.  The  abscess  was  two  inches  long,  and 
there  was  no  disease  of  the  vertebrae.  The  same  surgeon  saved  the  life 
of  another  patient  four  years  old,  in  whom  the  disease  was  protracted,  by 
puncturing  the  abscess ;  and  the  late  Professor  Post  also  treated  successfully 
a  case  which  had  continued  three  months  (Allin). 

Diagnosis. — The  diagnosis  of  retropharyngeal  abscess  is  ordinarily  easy, 
provided  that  the  physician  examine  carefully  and  bear  in  mind  the  occasional 
occurrence  of  such  an  abscess.  In  a  large  proportion,  however,  of  the 
recorded  fatal  cases  the  true  nature  of  the  disease  was  not  recognized  during 
life.  Especially  is  the  diagnosis  difficult  when  the  cerebro-spinal  system  is 
early  implicated  and  symptoms  arise  which  divert  attention  from  the  throat 
to  the  brain. 

The  maladies  for  which  peripharyngeal  abscess  is  most  frequently  mis- 
-taken  are  laryngitis  and  simple  but  severe  pharyngitis.  From  laryngitis,  for 
which  it  has  been  most  frequently  mistaken,  it  may  be  distinguished  by  the 
dysphagia  and  by  the  character  of  the  initial  symptoms.  In  laryngitis  there 
is  usually  the  peculiar  cough  from  the  first  or  very  early,  while  in  abscess 
there  is  an  initial  period  of  several  days,  or  even  weeks,  before  respiration  is 
materially  affected.  This  is  the  period  of  inflammation  which  precedes  sup- 
puration. 

In  abscess  pressure  of  the  larynx  backward  is  badly  tolerated,  greatly 
increasing  the  dyspnoea,  while  in  pharyngitis  and  croup  this  effect  is  not  so 
marked.  In  abscess  the  horizontal  position  aggravates  the  dyspnoea,  but  not 
in  pharyngitis  and  croup.  The  character  of  the  voice  also  aids  in  diagnosti- 
cating an  abscess  from  laryngitis,  since  in  the  former  it  is  usually  nasal,  and 
in   the   latter  hoarse   and  whispering.     But  the  decisive  test  is  afforded  by 

^  Prov.  Med.  and  Surg.  Jour.,  1842. 


OESOPHAGITIS.  70.'3 

inspection  and  digital  exploration.  The  tumor  is  seen — or,  if  situated 
too  low  to  be  seen,  is  felt — upon  the  walls  of  the  pharynx. 

If  the  symptoms  of  abscess  are  masked  by  those  arising  from  the  cere- 
bro-spinal  system,  as  by  convulsions,  the  priority  of  tlie  pharyngeal  symp- 
toms aids  in  determining  the  true  disease. 

In  a  case  of  suspected  abscess  the  physician  should  not  only  carefully 
inspect  the  fauces,  but  should  also  employ  digital  examination.  The  finger 
will   often  detect  fluctuation   before  the  abscess  is  apparent  to  the  eye. 

Prognosis. — With  proper  treatment  the  result  is  usually  favorable,  but 
if  the  disease  be  not  recognized  many  die.  In  Dr.  Allin's  cases,  of  those 
under  the  age  of  twelve  years,  9  died,  while  10  recovered  by  the  opening 
of  the  abscess  by  the  lancet,  trocar,  or  finger,  and  1  by  its  spontaneous 
rupture. 

If  the  abscess  be  due  to  disease  of  the  spinal  column,  death  may  occur 
immediately  after  the  sac  is  opened,  the  caries  of  the  intervertebral  carti- 
lages producing,  according  to  Dr.  Allin,  dislocation  of  the  vertebrae.  Death 
may  also  occur,  though  rarely,  from  pleuritis,  in  consequence  of  the  bursting 
of  the  abscess  into  the  pleural  cavity.  Even  in  caries,  if  the  sac  be  properly 
opened  and  if  need  be  reopened,  and  the  head  supported  by  suitable  appara- 
tus, recovery  is  possible,  as  in  a  case  treated  by  Prof.  Post. 

Treatment. — The  proper  treatment  of  peripharyngeal  abscess  is  simple, 
consisting  in  breaking  or  puncturing  the  sac  by  the  finger,  the  lancet,  bis- 
toury, or  pharyngotome.  Each  method  has  been  successfully  employed.  In 
the  majority  of  cases  the  proper  way  to  open  the  abscess  is  by  the  ordinary 
curved  scalpel  or  bistoury,  which  should  be  covered  by  a  strip  of  adhesive 
plaster  to  within  half  an  inch  of  the  point.  If  the  abscess  be  postpharyn- 
geal it  should  be  opened  in  the  median  line.  A  single  incision  suffices  to 
evacuate  the  pus.  If  the  abscess  point  or  be  elastic,  there  is  little  danger  of 
wounding  any  important  vessel  or  producing  dangerous  hemorrhage  if  the 
operation  be  properly  performed.  It  may  be  necessary  to  open  the  abscess 
more  than  once,  as  in  a  case  reported  by  Dr.  Post  and  another  which  I  saw 
with  Dr.  Livingston  of  this  city.  In  certain  cases,  when  the  knife  cannot  be 
readily  employed,  the  abscess  may  be  opened  by  pressure  with  the  finger-nail 
or  the  edge  of  a  teaspoon. 

Patients  with  this  disease  ordinarily  require  constitutional  treatment, 
especially  the  use  of  tonics,  ferruginous  and  vegetable.  The  citrate  of  iron 
and  quinine,  the  citrate  of  iron  and  ammonium,  and  in  strumous  cases  the 
syrup  of  the  iodide  of  iron  with  cod-liver  oil,  are  eligible  preparations. 
Nutritious  diet  and  often  alcoholic  stimulants  are  required. 

CBSOPHAGITIS. 

Disease  of  the  oesophagus  in  infancy  and  childhood  is  comparatively  rare, 
inflammation  being  the  most  frequent  affiection  of  this  portion  of  the  diges- 
tive tube  in  these  periods,  and,  indeed,  the  only  one  which  claims  attention. 
It  is  most  common  in  infants  under  the  age  of  three  or  four  months  who  are 
deprived  of  the  breast-milk  and  are  given  a  diet  which  is  with  difficulty 
digested,  and  perhaps  taken  too  hot  or  too  cold.  It  is  therefore  most  com- 
mon in  foundling  hospitals.  I  have  frequently  observed  it  in  the  Infants' 
Hospital  and  the  Nursery  and  Child's  Hospital  of  this  city,  chiefly  at  the 
autopsies  of  bottle-fed  infants  under  the  age  of  six  months,  whose  symptoms 
had  indicated  disease  or  derangement  of  the  digestive  function.  Many  of 
them  had  diarrhoea  and  died  in  a  state  of  emaciation.  CEsophagitis  in  these 
cases  was  associated  with  simple  or  gangrenous  stomatitis,  thrush,  or  with  gas- 
tritis or  entero-colitis.     Sometimes  all  these  inflammations  coexisted.     In  a 


764  (JESOPHA  G ITIS. 

few  cases  the  confervoid  growth  of  thrush  had  extended  from  the  mouth  to 
the  oesophagus.  It  occurred  in  small  hemispherical  masses  scarcely  as  large 
as  a  pin's  head.  Swallowing  corrosive  or  strongly  irritating  substances,  as 
the  acids  or  alkalies,  is  an  occasional  cause  of  oesophagitis,  the  irritant  at  the 
same  time  producing  stomatitis  and  gastritis. 

x\natomical  Characters. — The  inflamed  surface  sometimes  presents  a 
uniformly  injected  appearance.  Usually,  however,  there  is  greater  intensity 
of  the  inflammation  in  streaks  or  patches  than  over  the  surface  generally. 
I  have  frequently  observed  at  autopsies  a  greater  degree  of  inflammation  in 
the  lower  than  upper  half  of  the  oesophagus,  even  when  the  infant  had  sto- 
matitis at  the  time  of  death. 

QliSophagitis  occurring  from  faulty  regimen  or  antihygienic  conditions  is 
not  accompanied  by  as  much  thickening  of  the  walls  of  the  tube  as  often 
occurs  in  some  other  portions  of  the  digestive  canal;  as,  for  example,  in  the 
colon.  Diphtheritic  inflammation  of  the  oesophagus  is  accompanied  by  so 
great  infiltration  of  the  mucous  membrane  and  underlying  connective  tissue 
that  I  have  seen  the  oesophageal  walls  three  or  four  times  the  normal 
thickness. 

Occasionally  ulcerations  of  the  oesophageal  mucous  membrane  are  observed 
in  the  lower  part  of  the  tube,  and  Billard  describes  the  ulcerative  form  of 
oesophagitis.  At  the  first  autopsies  at  which  I  observed  these  ulcers  I  sup- 
posed that  they  were  pathological  and  indicated  a  severe  grade  of  inflamma- 
tion ;  but  a  more  extended  observation  has  convinced  me  that  they  are  usu- 
ally post-mortem,  and  are  not  at  all  dependent  on  inflammation  of  the  oesoph- 
agus. The  solvent  power  of  the  'gastric  juice  not  only  causes  ulceration 
in  the  stomach,  but,  entering  the  oesophagus,  may  and  not  infrequently  does 
produce  a  solvent  action  on  the  mucous  tissue  there  in  the  cadaver.  At  the 
meeting  of  the  London  Pathological  Society,  March  4, 1852,  Dr.  Graily  Hewitt 
presented  a  specimen  in  which  the  gastric  juice  had  not  only  eaten  entirely 
through  the  coats  of  the  oesophagus  an  inch  above  the  stomach,  but  had  even 
attacked  the  left  lung.  Over  the  age  of  six  months  inflammation  of  the 
oesophagus  is  rare. 

The  symptoms  of  oesophagitis  in  young  and  emaciated  infants,  in  whom 
it  ordinarily  occurs,  are  not  well  pronounced.  Pain  in  deglutition  or  tender- 
ness on  pressure  over  the  oesophagus,  if  present  in  these  infants,  is  ordinarily 
not  appreciable,  nor  have  they  seemed  to  me  to  vomit  oftener  than  other 
infants  of  this  class  who  suifered  from  indigestion  and  gastro-enteritis  with- 
out oesophagitis.  It  is  therefore  difficult  to  diagnosticate  oesophagitis  in  them. 
It  is,  according  to  my  observation,  oftener  present  than  absent  in  spoon-fed 
infants  of  three  months  or  under  who  have  persistent  stomatitis  and  entero- 
colitis. 

Treatment. — In  the  oesophagitis  of  foundlings  and  ill-nourished  infants, 
which  arises,  as  has  been  stated,  from  faulty  regimen,  no  treatment  is  required 
apart  from  that  designed  to  relieve  the  stomatitis  or  entero-colitis  with  which 
it  occurs.  Attention  must  be  directed  mainly  to  the  diet  and  hygienic  man- 
agement. The  remedial  measures  proper  for  such  patients  are  more  fully 
detailed  in  our  remarks  on  entero-colitis.  (Esophagitis  produced  by  swallow- 
ing corrosive  or  highly  irritating  substances  requires  the  same  treatment  as 
in  the  adult — to  wit,  poultices,  demulcent  drinks,  etc. 


INDIGESTION.  765 


CHAPTER    V. 

INDIGESTION,   CONGESTION  OK  STOMACH,   GASTRITIS,   FOLLICULAR 
GASTRITIS,   DIPHTHERITIC  GASTRITIS,   GASTRO-MALACIA. 

Indigestion. 

Indigestion  is  more  common  during  infancy  than  in  any  other  period  of 
life.  While  the  digestive  organs  in  the  adult  readily  assimilate  a  great 
variety  of  food,  it  is  necessary  for  the  well-being  of  the  infant  that  its  diet 
be  simple  and  carefully  prepared.  Departure  from  this  rule  leads  to  indiges- 
tion and  ulterior  diseases. 

After  the  age  of  two  years  a  mixed  diet  is  readily  assimilated,  the  digestive 
function  is  less  frequently  disordered,  and  indigestion  presents  few  peculiarities 
to  distinguish  it  from  that  of  the  adult. 

Indigestion  in  some  children  is  habitual ;  in  others  the  digestive  process  is 
ordinarily  well  performed,  but  from  some  temporary  derangement  of  system 
or  error  of  diet  an  acute  attack  of  indigestion  occurs.  Hence,  two  forms  of 
this  ailment  may  be  described ;  first,  acute,  referring  to  temporary  attacks ; 
secondly,  chronic,  referring  to  the  habitual  state. 

Causes. — The  causes  of  indigestion  are  twofold :  first,  the  condition  of 
the  digestive  function  independently  of  the  aliment;  secondly,  the  unwhole- 
some or  improper  character  of  the  ingesta.  Anything  which  lowers  the  vital 
powers  may  be  a  predisposing  cause  of  indigestion  by  impairing  the  function 
of  the  organs  which  assimilate  the  food.  Impure  air  and  personal  uncleanli- 
ness,  protracted  hot  weather,  and  previous  disease  are  among  the  common 
predisposing  causes.  The  strong  country  child  can  thrive  upon  a  diet  which, 
given  to  the  more  feeble  child  of  the  city,  would  produce  deleterious  results. 
During  the  summer  months  it  often  happens  that  an  infant  in  the  city  can- 
not digest  properly  any  food  given  to  it  except  the  mother's  milk ;  and  from 
this  results  much  of  the  infantile  sickness  and  mortality  which  make  this 
.season  of  the  year  much  dreaded  by  parents.  There  is  a  natural  difference 
in  children  as  regards  liability  to  disordered  digestion.  Some  do  well  upon  a 
diet  which,  given  to  others  similarly  situated,  occasions  vomiting,  gastralgia, 
and  flatulence. 

In  the  majority  of  cases  of  indigestion,  however,  the  fault  does  not  exist 
in  the  child.  It  is  fed  too  often  or  irregularly  or  upon  a  diet  that  is  unwhole- 
some or  indigestible.  It  is  well  known  that  the  milk  of  the  mother  or  the 
wet-nurse  is  liable  to  changes  which  render  it  for  the  time  unsuitable  for  the 
infant.  Her  food  may  be  of  such  a  quality,  or  her  mind  so  excited,  or  some 
function  of  her  system  so  disordered,  as  to  effect  a  temporary  change  in  the 
constitution  of  her  milk.  The  occurrence  of  the  catamenia  or  of  gestation 
in  mothers  who  are  suckling  not  infrequently  produces  this  unfavorable 
result. 

Indigestion  is  most  common  in  those  infants  who,  deprived  of  the 
mother's  milk,  are  entrusted  to  wet-nurses  or  fed  from  the  bottle.  The 
milk  of  the  wet-nurse,  from  not  agreeing  with  the  age  of  the  infant,  from 
irregularity  in  her  mode  of  life,  from  the  acescent  nature  of  her  food,  or  from 
other  causes  which  are  not  appreciable,  may  disagree  with  the  infant  and  be 
imperfectly  digested. 

The  most  common  cause  of  indigestion  in  the  infant  is  artificial  feeding. 


766         INDIGESTION,    CONGESTION  OF  THE  STOMACH,   ETC. 

This,  in  the  cities,  is  productive  of  a  great  amount  of  gastric  and  intestinal 
derangement  and  disease.  The  younger  the  infant  the  less  frequently  does  it 
thrive  if  brought  up  by  hand. 

Whatever  care  may  be  bestowed  in  the  preparation  of  its  food,  whether 
cow's  or  goat's  milk  or  farinaceous  substances  be  used,  there  is  seldom  that 
healthy  nutrition. which  is  observed  in  infants  who  receive  the  breast-milk. 
The  "  swill  milk  "  in  common  use  among  the  poor  families  of  this  city  is 
totally  unfit  for  the  feeding  of  infants,  and  is  apt  to  cause  flatulence,  acidity, 
and  indigestion.  Acute  indigestion  occurs  in  children  of  any  age  from  food 
unsuitable  in  quality  or  quantity,  which  produces  gastralgia  and  other  symp- 
toms to  be  detailed  hereafter.  Those  who  suffer  habitually  from  malassimila- 
tion  are  especially  liable  to  such  acute  attacks. 

In  the  period  of  childhood  chronic  indigestion  is  much  less  frequent  than 
in  infancy,  but  children  are  perhaps  more  subject  than  infants  to  the  acute 
form.  This  is  induced  by  ingesta  taken  in  too  large  quantity  or  of  a  kind 
which  is  with  difficulty  digested.  Cherries,  currants,  raisins,  and  the  paren- 
chyma of  oranges  and  lemons,  dried  fruits,  and  confectionery,  which  are  so 
often  heedlessly  given  to  children,  are  common  causes  of  acute  attacks  of 
indigestion.  These  substances,  being  but  partially  digested  or  not  at  all,  and 
sometimes  accumulating  for  days  in  the  stomach  or  intestines,  may  lead  to  a 
very  serious  and  dangerous  condition. 

Symptoms. — Before  describing  the  symptoms  of  indigestion  I  wish  to- 
direct  attention  to  one  form  of  vomiting  in  young  infants  which  is  usually 
attributed  to  indigestion  by  the  young  practitioner,  but  which  really  has  no 
pathological  significance.  I  refer  to  vomiting  or  regurgitation  of  milk  in 
hearty  and  well-nourished  infants,  resulting  from  too  frequent  nursing  or 
over-nursing.  It  occurs  without  previous  nausea  and  with  little  effort.  The 
relatively  small  size  of  the  stomach  in  young  infants,  its  position  more  verti- 
cal than  in  older  children,  and  the  little  development  of  the  fundus,  which  is 
the  proper  receptacle  of  the  milk,  favor  this  regurgitation.  The  milk  that  is 
ejected  is  unchanged  if  it  be  returned  immediately  after  the  nursing,  but  if 
some  moments  have  elapsed  the  casein  is  more  or  less  coagulated.  Little 
harm  is  done  by  this  loss  of  nutriment  if  the  infant  appear  well  and  thriving. 
It  is,  indeed,  salutary,  for  if  the  food  that  is  in  excess  of  what  is  wanted,  and 
in  excess  of  what  can  be  digested,  be  retained,  it  undergoes  fermentation,, 
and,  becoming  an  irritant,  causes  indigestion  and  diarrhoea.  The  remedy 
consists  in  less  frequent  or  less  prolonged  nursing,  and  allowing  the  infant  tO' 
lie  quietly  in  the  crib  after  each  nursing. 

But  vomiting  is  a  symptom  that  should  always  arrest  attention  and  its 
cause  be  ascertained.  If  the  child  cease  to  grow  and  lose  its  vivacity,  the 
vomiting  has  pathological  significance.  Frequent  vomiting,  without  other 
marked  symptoms  referable  to  the  digestive  apparatus,  and  with  evident  loss 
of  flesh  and  strength,  is  in  most  cases  a  symptom  of  gastric  indigestion  or 
of  incipient  meningitis.  The  presence  of  mucus  in  the  ejected  matter,, 
eructation  of  gas,  and  the  apparent  absence  of  headache  and  of  other  menin- 
geal symptoms  apart  from  the  vomiting,  aid  in  establishing  the  diagnosis  of 
gastric  indigestion. 

With  these  preliminary  remarks  we  will  proceed  to  consider  the  symptoms,, 
first  of  habitual,  and  next  of  acute  temporary,  indigestion. 

The  nursing  infant,  if  the  milk  continually  disagree  with  it,  is  fretful. 
It  has  a  discontented  aspect ;  it  seldom  smiles,  and  is  not  amused  by  playthings 
or  is  only  amused  for  a  short  time.  Its  features  are  pallid  and  bear  the  appear- 
ance of  faulty  nutrition.  Its  body  and  limbs  are  more  or  less  wasted  or  are 
soft  and  flabby.  Vomiting  is  frequently  present,  and  sometimes  a  large  mass 
or  masses  of  casein  are  ejected  which  have  evidently  lain  a  considerable  time 


INDIGESTION.  767 

in  the  .stomacli.  The  bowels  may  be  constipated  or  loose  and  the  evacuations 
are  unhealthy.  This  state  of  the  infant,  continuing,  prevents  the  necessary 
rest  of"  the  mother,  and  may  affect  unfavorably  her  health,  so  as  to  reduce  the 
quantity  of  her  milk,  or  render  it  still  more  unwholesome. 

In  habitual  indigestion  of  young  children  fermentation  (jf  the  food  occurs 
to  a  great  extent,  instead  of  normal  digestion,  and  the  fermentation  results 
in  the  production  of  acids-.  Whatever  irritates  the  j^astro-intestinal  surface 
causes  an  increased  secretion  of  mucus,  and  it  is  believed  that  the  mucus, 
since  it  is  alkaline,  prevents  to  a  great  extent  the  digestive  action  of  the 
pepsin,  which  recjuires  an  acid  medium,  so  that  lactic,  butyric,  and  the  fatty 
acids  result.  This  acid  fermentation,  beginning  in  the  stomach,  extends  to  the 
intestines  as  the  food  is  carried  downward.  Hence  the  acid  breath,  sour- 
smelling  ejecta,  fetid  stools,  flatulence,  and  colicky  pains,  indicating  both 
gastric  and  intestinal  dyspepsia,  so  common  in  young,  improperly-fed  infants. 

Habitual  indigestion  is,  as  might  be  expected,  more  common  and  severe 
in  artificially  fed  infants  than  in  those  at  the  breast,  and  it  is  more  likely  to 
result  in  gastro-intestinal  catarrh.  In  rural  localities,  where  children  are 
much  of  the  time  in  the  open  air,  have  good  constitutions,  active  digestion, 
and  fresh  food,  dyspepsia  is  comparatively  rare,  but  in  large  cities,  in  which 
the  conditions  of  life  are  so  different,  its  occurrence  is  common.  Gross  care- 
lessness in  the  feeding,  and  ignorance  on  the  part  of  mothers  of  the  dietetic 
re(|uireraents  of  young  children  contribute  greatly  to  its  frequency. 

Attacks  of  acvte  itufigestion  not  infrequently  occur  from  careless  and 
improper  feeding  in  children  who  are  habitually  dyspeptic,  as  well  as  in  those 
whose  digestive  function  is  usually  well  performed.  In  these  acute  attacks 
young  children,  especially  infants,  often  suffer  much  from  colicky  pains, 
gastralgia,  or  enteralgia.  Their  countenance  indicates  suffering  ;  they  utter 
sharp  cries  ;  their  thighs  are  flexed  over  the  abdomen  and  moved  from  side  to 
side.  Warm  spirituous  lotions,  friction  or  gentle  pressure  upon  the  abdomen, 
give  some  relief,  especially  if  they  be  attended  by  the  expulsion  of  flatus. 
Vomiting  or  an  evacuation  of  the  bowels  commonly  removes  the  offending 
substance,  and  the  pain  subsides. 

Attacks  of  acute  indigestion  come  on  suddenly,  and  occasionally  are  so 
severe  that  they  produce  dangerous  symptoms,  as  eclampsia.  Apart  from 
pain  or  a  sensation  of  weight  or  fulness  in  the  abdomen,  symptoms  of  a  reflex 
character  fre(|uently  occur,  such  as  headache,  drowsiness  or  languor,  sudden 
twitching  of  the  limbs  premonitory  of  convulsions,  and  even  severe  or  repeated 
convulsions.  One  of  the  most  severe  attacks  of  eclampsia  which  I  have  seen 
occurred  in  a  boy  of  eight  or  ten  years,  induced  by  swallowing  the  pulp  of 
oranges  which  he  had  been  in  the  habit  of  eating,  and  which  had  accumulated 
in  the  stomach  and  intestines.  The  expulsion  of  the  offending  substance 
gave  immediate  relief.  In  some  children  with  acute  indigestion  the  pulse  is 
notably  accelerated,  the  face  flushed,  the  surface  hot,  and  the  temperature 
elevated  two  or  three  degrees  above  normal. 

As  the  child  advances  in  years  and  becomes  stronger  its  digestive  func- 
tion is  more  active,  a  greater  variety  of  food  can  be  assimilated,  and  indi- 
gestion, whether  temporary  or  habitual,  is  less  frequent  than  in  the  first  years 
of  life. 

Prognosis. — Indigestion  in  the  adult,  when  not  due  to  organic  disease, 
involves  little  danger  to  life,  but  in  infancy  its  consequences  are  often  serious. 
Habitual  indigestion  in  the  infant,  whether  due  to  the  bad  quality  of  the 
breast-milk  or  to  artificial  feeding,  is  liable  to  cause  inflammation  of  the  buccal, 
oesophageal,  gastric,  or  intestinal  mucous  caembrane,  and  in  some  patients  of 
two  or  more  of  these  divisions  of  the  intestinal  tract.  Thus,  especially  in 
the  warm  months,  the  acid  products  of  indigestion  often  cause  a  dangerous 


768         INDIGESTION,   CONGESTION  OF  THE  STOMACH,  ETC. 

catarrhal  inflammation,  accompanied  by  vomiting  and  frequent  stools.  Many 
cases  of  atrophy  in  infants,  characterized  by  arrested  growth  and  gradual  loss 
of  flesh  and  strength,  till  perhaps  the  features  have  a  sunken  and  senile 
appearance  from  the  waste  and  the  skin  lies  in  wrinkles,  originate  in  habitual 
indigestion.  Henoch  points  out  the  frequency  of  gastro-malacia  in  infants 
who  have  sufi"ered  from  severe  dyspepsia  accompanied  by  the  abundant  pro- 
duction of  acids.  The  softening  of  the  stomach  is  believed  to  be  largely,  if 
not  entirely,  cadaveric,  the  result  of  post-mortem  digestion  from  the  presence 
of  pepsin  and  the  acids  of  fermentation.  The  gastric  mucous  membrane  can 
be  readily  scraped  away  by  the  nail,  and  it  presents  a  gelatiniform  appearance. 
Sometimes  even  the  stomach  is  perforated  and  the  adjacent  organs  are  acted 
on  by  the  corrosive  liquids. 

If  the  dyspepsia  have  not  continued  so  long  as  to  cause  inflammatory 
complications,  prompt  recovery  is  probable  by  the  use  of  suitable  food  and 
corrective  medicines.  If  such  complications  be  present,  recovery  can  only 
be  gradual. 

Diagnosis. — Habitual  indigestion  does  not  usually  continue  long  without 
the  occurrence  of  more  or  less  gastro-intestinal  catarrh.  The  poor  nutrition 
and  appetite,  the  unhealthy,  flatulent  stools  containing  mucus,  the  vomiting 
and  occasional  colicky  pains,  are  symptoms  which  plainly  indicate  a  dyspeptic 
origin.  Attacks  of  acute  indigestion  are  also  easily  diagnosticated,  in  most 
instances  by  the  sudden  occurrence  of  the  symptoms,  such  as  vomiting,  pain 
in  the  abdomen,  or  a  sensation  of  fulness,  eructation  of  gas,  etc.,  and  the 
speedy  subsidence  of  symptoms  when  the  cause  is  removed.  But  sometimes, 
especially  in  children  over  the  age  of  two  or  three  years,  the  symptoms  may 
so  closely  resemble  those  of  other  acute  diseases  that  a  careful  examination 
is  required  in  order  to  make  a  clear  and  correct  discrimination.  Thus  I  have 
related  above  the  history  of  a  case  in  which  the  high  temperature  and  expira- 
tory moan  closely  resembled  those  of  pneumonia,  but  the  symptoms  quickly 
abated  on  the  expulsion  of  a  considerable  quantity  of  orange-pulp.  An 
attack  of  acute  indigestion,  attended  by  vomiting,  rapid  pulse,  elevated 
temperature,  with  perhaps  some  erythema,  may  be  mistaken  for  the  com- 
mencement of  one  of  the  febrile  diseases  to  which  children  are  so  liable. 
If  on  examination  of  the  fauces  no  redness  of  the  throat  be  observed,  scarlet 
fever  and  diphtheria  can  be  excluded.  By  a  free  evacuation  of  the  bowels 
the  symptoms  abate  and  the  attack  ends,  so  that  if  there  were  any  doubt  in 
the  diagnosis  it  is  soon  dispelled. 

When  eclampsia  results  from  an  attack  of  acute  indigestion,  the  physi- 
cian is  often  compelled  to  act  promptly  without  a  clear  diagnosis,  but  the 
result  of  treatment  soon  renders  the  nature  of  the  attack  apparent. 

Treatment. — The  first  indication  in  treatment  is  obviously  the  removal 
of  the  cause.  In  acute  indigestion,  when  there  is  reason  to  believe  that  there 
is  some  off"ending  substance  in  the  stomach  or  intestines,  if  the  symptoms 
occur  soon  after  the  substance  is  taken  an  emetic  may  be  administered,  and 
ipecacuanha,  in  syrup  or  powder,  is  a  safe  and  usually  efficient  remedy.  If 
several  hours  have  elapsed  a  purgative  should  be  given,  as  castor  oil,  either 
alone  or  in  combination  with  syrup  of  rhubarb,  or  an  enema  of  glycerin  and 
water  may  be  employed. 

If  the  symptoms  be  urgent,  especially  if  convulsions  be  threatened,  we 
should  not  wait  for  the  slow  action  of  a  purgative,  but  should  resort  at  once 
to  an  enema  to  open  the  bowels.  Sometimes  the  pain  in  acute  indigestion 
is  such  as  to  require  immediate  treatment.  I  have  found  in  such  cases  five- 
to  twenty-drop  doses,  according  to  the  age,  of  aniseed  cordial,  made  as 
directed  in  the  National  Formulary,  a  useful  remedy.  In  the  infant  there 
is  often  an  excess  of  acid  in  the  stomach  and  intestines,  which  is  best  treated 


INDIGESTION.  769 

by  alkaline  remedies,  as  lime-water  in  combination  with  the  opiate.     The  fol- 
lowing mixture  will  be  found  useful  in  such  cases : 

K.  Tinct.  opii  deodorat.,  or  liq.  opii  coniposit.  (Simibhs),  gtt.  xij  ; 

Magnes.  calcinat.,  gr.  xij-xxiv; 

Sacch.  alb.,  7,}  ; 

Aq.  anisi,  .^iss.     Misce. 

Dose:  The  bottle  being  first  sliaken,  one  teaspooiifid  every  two  lioiirs  to  a  child  a  year 
old  until  relief  of  pain.  If  there  be  nnicli  pain,  it  is  well  to  add  a  little  ehloro- 
form  or  Hoflinan's  anodyne  to  tlie  mixture. 

Or  the  following  mi.xture  : 

li.  Tinct.  o[)ii  deodorat.,  or  liq.  opii  composit.,  gtt.  xij; 

Eisnuith.  subcarbonat.,  ^^iss  ; 

Syr.  simplic,  ^ss; 

Aq.  cinnamomi,  5J.     Misce. 

Shake  bottle  thoroughly  and  give  one  teaspoonful  to  a  child  of  one  year. 

If  in  the  acute  indigestion  of  infants  diarrhoea  occur,  the  camphorated 
tincture  of  opium,  in  combination  with  chalk  mixture,  may  be  given,  fifteen 
drops  of  the  one  to  a  teaspoonful  of  the  other,  or  the  above  mixture  of 
laudanum  and  bismuth  may  be  employed.  Infants  whose  diet  consists 
largely  of  cow's  or  goat's  milk  digest  with  most  difficulty  the  casein,  which 
often  passes  the  bowels  in  an  imperfectly  digested  state,  or  it  collects  in  a 
large  and  firm  mass  in  the  stomach,  causing  gastralgia  and  rendering  the 
child  fretful  till  it  is  vomited.  I  have  elsewhere  recommended,  as  important 
to  prevent  these  attacks  of  acute  dyspepsia,  the  use  of  the  upper  third  of 
the  milk,  which  contains  less  than  the  average  casein.  The  addition  of  a 
little  farinaceous  food,  as  barley-water,  to  the  nursing-bottle  will  sometimes 
produce  the  same  effect  by  mechanically  separating  the  particles  of  milk. 
Peptonized  milk,  as  recommended  in  our  remarks  on  the  hygienic  treatment 
of  Intestinal  Catarrh,  will  also  be  found  useful  in  certain  cases,  and  also  the 
employment  of  a  good  preparation  of  pepsin  at  each  feeding. 

In  chronic  indigestion  the  means  of  relief  are  different.  They  are  two- 
fold :  first,  as  regards  change  of  diet ;  secondly,  measures  to  improve  the 
digestive  function.  Spoon-fed  infants,  suffering  from  habitual  indigestion, 
require  the  utmost  care  as  regards  the  character  of  their  food,  its  preparation, 
and  the  times  of  feeding.  Often  it  is  best,  if  practicable,  to  procure  a  wet- 
nurse,  and  sometimes  removal  to  a  more  salubrious  locality  is  followed  at 
once  by  improvement  in  the  digestive  function.  If  the  infant  be  already 
wet-nursed,  the  milk  should  be  examined  microscopically  and  otherwise,  and 
inquiry  should  be  instituted  in  reference  to  the  health  and  diet  of  the  wet- 
nurse.  Sometimes  a  change  of  wet-nurse  is  advisable.  (For  facts  and  con- 
siderations bearing  on  this  point  the  reader  is  referred  to  the  chapters  relating 
to  regimen.) 

Children  with  chronic  indigestion  are  occasionally  much  benefited  by  the 
moderate  and  judicious  use  of  alcoholic  stimulants.  These  should  be  given 
sparingly  with  their  food,  and  should  be  discontinued  as  soon  as  the  digestive 
function  is  fully  restored.  M.  Donne  and  some  other  French  writers  recom- 
mended the  habitual  use  of  wine  for  infants  even  in  a  state  of  health,  but 
there  are  reasons,  moral  as  well  as  physical,  why  alcoholic  stimulants  should 
only  be  used  as  medicines  and  not  in  a  state  of  health. 

If  the  case  be  one  of  simple  or  uncomplicated  indigestion,  pepsin  or 
lactopeptin  of  the  shops  and  tonics  may  be  employed.  In  many  instances, 
however,  especially  in  infancy,  gastro-intestinal  inflammation  has  supervened, 
49 


770         INDIGESTION,   CONGESTION  OF  THE  STOMACH,   ETC. 

and  in  such  cases  those  remedies  should  be  employed  which  exert  a  favor- 
able— or  at  least  not  an  unfavorable — effect  on  the  inflamed  surface  over 
which  they  pass. 

In  habitual  indigestion  remedies  are  obviously  required  which  increase 
the  quantity  of  the  digestive  ferments.  The  following  will  be  found  a  use- 
ful prescription  in  cases  of  indigestion  in  which  gastro-intestinal  catarrh  has 
supervened : 

R. 


Acidi  hydrochlorici  dilut., 
Pepsini  puri,  in  lamellis, 
Bismuth,  subnitrat., 

gtt.  xvj-xxxij ; 

3y ; 

Syr.  simplic, 
Aquse  destillat., 

^ss; 

^iij.     Misce. 

Shake  bottle,  and  give  one  teaspoonful  before  each  feeding. 

The  lactopeptin  of  the  shops  is  also  useful,  and  when  diarrhoea  accom- 
panies the  indigestion  the  following  may  be  prescribed : 

R.  Bismuth,  subnitrat.,  ^iij  ; 

Lactopeptin,  ^ij ; 

Pepsini  puri,  in  lamellis,  gj. 

Give  as  much  as  goes  on  a  five-cent-piece  to  a  child  of  ten  months  before  each  feeding. 

If  the  stools  continue  frothy  and  offensive  on  account  of  the  fermenta- 
tion the  following  will  be  found  beneficial : 

R.  Creasoti  or  acidi  carbolici,         gtt.  ij  ; 
Syr.  simplic,  ,^ss ; 

Aquse  destillat.,  .^iss.     Misce. 

Dose :  One  teaspoonful  every  two  hours  to  a  child  of  one  year. 

In  children  over  the  age  of  three  or  four  years  the  vegetable  tonics  are 
often  useful,  as  quinine  in  half-grain  or  one-grain  doses.  Iron  may  also  be 
given,  especially  the  milder  preparations,  as  the  citrate,  in  anaemic  cases. 

Among  the  useful  vegetable  stomachics  and  tonics  may  also  be  men- 
tioned the  compound  tincture  of  cinchona,  compound  tincture  of  gentian^ 
infusion  of  columbo,  fluid  extract  of  columbo,  and  fluid  extract  of  cinchona. 

If  chronic  indigestion  be  complicated  with  gastro-intestinal  inflammation, 
subacute  or  chronic,  for  this  is  the  form  which  is  usually  present,  there  are 
still  certain  tonics  which  may  be  advantageously  administered.  Columbo 
and  the  compound  tincture  of  cinchona  are  often  useful  in  these  cases,  and 
of  the  chalybeates  wine  of  iron  or  the  citrate  of  iron  and  ammonium  or  the 
liquor  ferri  nitratis  may  be  safely  administered.  In  most  cases,  however, 
change  in  the  diet  properly  made  will  be  found  more  useful  than  tonic  and 
corrective  medicines. 

Infants  affected  with  diarrhoea  from  indigestion  often  improve  under  the 
use  of  powders  consisting  of  equal  parts  of  subnitrate  of  bismuth  and  lacto- 
peptin. An  infant  of  three  months  can  take  three  grains  of  each  every  three 
hours  or  before  each  feeding,  or  it  may  take  three  or  four  grains  of  the  sub- 
nitrate  of  bismuth  with  half  a  grain  of  pure  pepsin  in  scales. 

Dyspepsia  often  rapidly  disappears  by  hygienic  measures  without  the  use 
of  medicines,  as  by  removal  from  the  city  to  the  country,  outdoor  exercise, 
or,  if  the  patient  be  an  infant,  by  being  carried  into  the  open  air  daily.  In 
infants  also  marked  improvement  is  often  observed  on  the  approach  of  the 
cool  and  bracing  weather  of  autumn  and  winter. 


GASTRITIS.  771 


Congestion  of  the  Stomach. 

Passive  congestion  of  the  stomach  is  described  anionj^  the  diseases  of  this 
organ  by  Billard,  but  it  is  a  patliological  state  of  little  importance  in  itself. 
It  occurs  in  new-born  infants,  asphyxiated  at  birth  and  with  difficulty  resusci- 
tated. In  these  cases  there  is  generally  intense  capillary  congestion  through- 
out the  system.  The  mucous  membrane  of  the  stomach  is  injected,  but  not 
more  than  that  of  the  mouth  or  intestines.  If  circulation  and  respiration  be 
fully  established,  this  injection  of  the  capillaries  subsides.  No  treatment 
is  required,  except  measures  to  promote  the  circulatory  and  respiratory  func- 
tions. In  cyanosis  and  atelectasis  there  is  often  general  congestion  of  the 
capillaries  of  the  systemic  circulatory  system  on  account  of  the  obstruc- 
tion to  the  flow  of  blood  through  the  heart  in  the  one  disease  and  through 
the  lungs  in  the  other.  There  is  in  these  cases  passive  congestion  of  the 
stomach,  but  not  more  than  of  other  organs. 

Gastritis. 

Inflammation  of  the  stomach,  except  when  produced  by  the  direct  con- 
tact of  some  irritant,  is  rare  in  infancy  and  childhood,  independently  of  dis- 
ease in  some  other  portion  of  the  intestinal  tract.  Cases  have,  however,  been 
reported  in  which  it  was  not  known  that  any  irritating  ingesta  had  been  taken, 
and  in  which  a  careful  examination  revealed  a  healthy  or  nearly  healthy  state 
of  other  portions  of  the  digestive  tube.  The  subjects  were  for  the  most  part 
young  infants.     The  following  is  an  example  related  by  Billard : 

An  infant,  four  days  old,  remarkable  for  the  color  of  his  face  and  firm- 
ness of  flesh,  refused  the  breast  and  vomited  yellow,  acid  matter.  On  the 
following  day  the  vomiting  had  increased,  the  legs  were  oedematous,  face  pal- 
lid and  pinched,  respiration  difficult,  skin  cold,  pulse  slow  and  irregular,  and 
pressure  on  the  epigastric  region  produced  cries  indicative  of  pain. 

Third  day  :  general  sinking  ;  face  thin  and  expressive  of  great  pain  ;  stools 
natural. 

Fourth  and  fifth  days :  condition  the  same.  Death  occurred  on  the  sixth 
day,  and  the  autopsy  was  made  on  the  day  following. 

With  the  exception  of  slight  pneumonia  no  disease  was  discovered  in 
any  part  of  the  system  besides  the  stomach.  The  mucous  membrane  of  this 
organ  was  intensely  vascular  near  the  cardiac  orifice  and  along  the  lesser 
curvature.  This  part  was  also  tumefied,  and  could  be  easily  raised  with  the 
finger-nail.  The  remainder  of  the  gastric  surface  was  hypertemic,  but  to  a 
less  extent. 

This  case  is  interesting  as  showing  what  may  happen,  though  rarely.  A 
nursing  infant  is  seized  with  gastritis  without  apparently  having  taken  any 
irritating  ingesta  and  without  other  disease  of  the  digestive  apparatus.  It 
is  probable,  however,  that  in  cases  like  the  above  the  cause,  if  ascertained, 
would  be  found  in  the  ingesta ;  perhaps  drinks  too  hot,  perhaps  elements  of 
colostrum  or  pathological  elements  in  the  milk,  which  might  produce  gastritis 
in  young  infants,  in  whom  the  mucous  membrane  is  delicate  and  sensitive. 

Gastritis  is  not  uncommon  in  infancy  in  connection  with  inflammation  of 
the  intestines.  The  latter  inflammation  is  sometimes  apparently  subordinate 
to  the  former,  and  if  such  patients  die  the  fatal  result  is  due  mainly  to  the  gas- 
tric disease.  The  reverse  is,  however,  the  rule.  The  gastritis  is  ordinarily 
subordinate   to  the   intestinal    catarrh. 

Cause. — Gastritis,  as  I  have  observed  it  in  infants,  has  been  in  most  cases 
due  in  great  part  to  the  continued  use  of  improper  food — of  food  not  suitable 
to  the  age  of  the  child,  and   which  was   therefore  with  difficulty  digested. 


772         INDIGESTION,   CONGESTION  OF  THE  STOMACH,  ETC. 

Milk,  acid  or  otherwise  unwholesome,  farinaceous  substances,  stale  or  of  an 
inferior  quality  and  not  properly  prepared,  drinks  too  hot  or  too  cold,  may  be 
specified  among  the  causes.  Therefore  this  disease  is  most  common  in  bottle- 
fed  infants,  and  is  comparatively  rare  in  those  who  receive  abundant  and 
wholesome  breast-milk.  Antihygienic  agencies,  apart  from  the  diet,  no  doubt 
exert  some  influence  in  the  production  of  gastritis,  as  they  do  of  stomatitis. 
Uncleanliness  and  residence  in  damp  and  dark  apartments  or  in  an  atmosphere 
loaded  with  noxious  gases  produce  a  condition  of  system  which  strongly  pre- 
disposes to  these  inflammations,  if,  indeed,  they  may  not  be  enumerated 
among  the  direct  causes. 

Rilliet  and  Barthez  have  called  attention  to  the  fact  that  certain  medicinal 
substances  given  to  children  occasionally  cause  gastritis.  They  have  observed 
this  efiect  from  the  use  of  tartar  emetic,  kermes  mineral,  and  croton  oil. 
Gastritis  occurring  in  this  way  may  or  may  not  be  associated  with  inflamma- 
tion in  contiguous  portions  of  the  digestive  tube.  Elsewhere  I  have  related 
a  case  in  which  gastro-enteritis  occurred  in  a  child  nine  years  old  after  having 
taken  a  considerable  quantity  of  kerosene  oil  for  spasmodic  croup. 

Inflammation  of  the  stomach  is  thought  by  some  to  accompany  measles 
and  scarlet  fever  during  the  eruptive  period,  but  this  opinion  is  probably 
incorrect.  If  it  occur,  it  corresponds  with  the  stomatitis  and  dermatitis  of 
these  diseases,  and  disappears  as  they  subside.  It  is  mild  and  accompanied 
by  few  symptoms.  I  have,  as  stated  in  the  remarks  on  Scarlet  Fever,  exam- 
ined in  certain  instances  the  stomachs  of  those  who  have  died  during  the 
eruptive  period  of  these  diseases,  and  found  them  free  from  any  appreciable 
inflammatory  lesion. 

Age. — From  the  records  of  about  seventy  cases  of  inflammatory  disease 
of  the  digestive  mucous  membrane  which  I  have  preserved  it  appeal's  that 
gastritis  is  not  common  over  the  age  of  six  months.  On  the  other  hand,  it 
is  common  in  infants  under  the  age  of  three  months  who  are  deprived  of 
breast-milk.  I  have  met  it  chiefly  in  foundlings  fed  with  the  bottle,  and  hav- 
ing at  the  same  time  entei'o-colitis,  and  often  also  stomatitis  and  oesophagitis. 
In  these  cases  there  is  sometimes  continuous  or  almost  continuous  injection 
and  thickening  of  the  mucous  membrane,  from  the  lip  to  near  the  pyloric 
orifice  of  the  stomach,  and  even  beyond  this  orifice  in  the  intestines. 
The  following  is  an  example  of  gastritis  as  it  frequently  occurs  in  foundling 
institutions : 

Case. — R.  W ,  female,  two  weeks  old,  was  admitted  into  the  New  York 

Infant  Asylum,  August  24,  1865,  anaemic  and  somew^iat  emaciated.  She  was  in 
part  wet-nursed  and  in  part  bottle-fed.  The  emaciation  increased,  and  nearly 
the  entire  buccal  cavity  became  covered  with  the  confervoid  growth  of  thrush. 
On  September  4th  diarrhoea  commenced.  Borax  was  used  for  the  mouth  and 
alkalies  and  astringents  to  check  the  diarrhoea,  but  without  material  improve- 
ment. 

The  following  was  the  record  for  September  7th  :  "  Cries  almost  constantly, 
with  feeble  or  whining  voice ;  still  has  thrush  ;  nurses  and  does  not  vomit ; 
stools  five  or  six  daily,  and  green ;  pulse  136,  feeble."  Death  occurred  Septem- 
ber 8th. 

Autopsy,  Septeviber  9th. — Mouth  and  fauces  not  examined ;  mucous  membrane 
of  oesophagus  vascular  in  its  whole  extent,  with  slight  thickening,  but  without 
ulceration ;  mucous  membrane  of  stomach  injected  like  that  of  the  oesophagus, 
and  somewhat  thickened,  except  in  its  pyloric  extremity,  where  the  appearance 
was  natural  or  nearly  so ;  the  color  in  the  central  part  of  the  inflamed  gastric 
membrane  was  deep  red ;  no  thrush  was  noticed,  except  on  the  buccal  surface 
during  life  ;  along  the  great  curvature  of  the  stomach  were  white  flakes  resem- 
bling those  of  thrush,  but  which  were  found  by  the  microscoi^e  to  consist  mainly 
of  oil-globules  and  epithelial  cells,  without  the  cryptogamic  formation ;  mucous 
membrane  of  small  intestines   healthy  in  their  whole  extent,  except  slightly 


GASTRITIS.  773 

increased  vasculurity  in  :i  few  places  in  tho  ileum;  mucous  membrane  of  colon 
much  injected  throujrliout,  except  near  the  ileo-Ciecal  valve,  where  the  vascularity 
was  slight;  in  the  transverse  and  descending  colon  the  redness  was  pretty  uni- 
form, and  the  membrane  was  thickened,  but  not  ulcerated;  solitary  glands  and 
Peyer's  ])atclies  moderately  elevated. 

The  observations  of  Valleix  show  how  frequently  gastritis  is  associated 
with  severe  attacks  of  thrush.  In  2;}  of  his  cases  of  the  latter  disease  in 
which  the  condition  of  the  stomach  was  noted  after  death  this  organ  pre- 
sented inflammatory  lesions  in  17,  and  in  three  others  appearances  which  may 
or  may  not  have  been  due  to  inflammation. 

Symptoms. — A  difficulty  exists  in  isolating  and  defining  the  symptoms  of 
gastritis,  from  the  fact  that  it  commonly  coexists  with  other  inflammations 
of  the  digestive  tube.  Though  we  may  never  be  able  to  diagnosticate  this 
catarrh  as  certainly  as  we  can  croup  or  pneumonia,  still  there  are  symptoms 
which  arise  directly  from  the  gastritis,  and  with  care  we  may  be  able  to  dis- 
tinguish them  from  those  symptoms  which  are  due  to  other  pathological 
states. 

If  gastritis  be  acute,  pain  is  present.  In  the  above  case  from  Billard, 
as  well  as  in  a  case  observed  by  myself  and  related  under  the  head  of  Gel- 
atinous Softening,  there  were  frequent  cries,  and  the  countenance  indicated 
much  suff"ering  until  the  stage  of  collapse.  If  there  be  less  intensity  of 
inflammation  and  the  disease  be  more  protracted,  as  is  ordinarily  the  case,  the 
pain  is  not  so  severe,  and  it  may  be  so  slight  as  not  to  attract  attention. 
Sometimes  there  is  tenderness,  so  that  pressure  upon  the  epigastric  region  is 
badly  tolerated.  Vomiting  is  regarded  as  one  of  the  most  constant  symp- 
toms. The  infant  after  nursing  seems  in  distress  till  the  milk  is  returned,  but 
it  nurses  with  avidity  in  consequence  of  the  thirst  if  it  be  not  too  exhausted 
or  feeble.  The  dejections  may  be  quite  regular  throughout  the  disease,  as  in 
the  case  from  Billard.  There  is  ordinarily,  however,  diarrhoea  from  the 
presence  of  entero-colitis.  The  pulse  is  sometimes  accelerated  and  sometimes 
nearly  natural.  The  emaciation  in  gastritis  is  rapid,  since  not  only  the  milk 
is  in  great  measure  vomited,  but  the  digestive  function,  so  far  as  the  stomach 
is  concerned,  is  seriously  impaired.  The  features  become  wrinkled  and  senile, 
the  eyes  hollow,  the  limbs  attenuated,  and  the  cranial  bones  uneven.  Death 
occurs  from  exhaustion. 

Anatomical  Characters. — Simple  gastritis  may  affect  the  entire  mucous 
surface  of  the  stomach  or  be  limited  to  a  certain  part.  The  part  which  is  most 
likely  to  escape  is  that  toward  the  pyloric  orifice.  This  portion  of  the  organ 
is  sometimes  found  in  nearly  or  quite  the  normal  state,  while  the  cardiac  half 
or  two-thirds  is  inflamed.  The  vascularity  of  the  diseased  surface  is  not  uni- 
form. In  one  place  there  is  simple  arborescence  ;  in  another  intense  continu- 
ous redness;  and  between  these  two  extremes  are  different  grades  of  vascu- 
larity. The  mucous  membrane  is  somewhat  thickened,  softened,  and  the 
secretion  of  mucus  increased.  Extravasation  of  blood  is  not  infrequent 
under  the  mucous  membrane,  usually  in  points,  and  the  mucus  may  be  mixed 
with  more  or  less  blood.  Small  shreds  or  portions  of  coagulated  milk  are 
often  found  with  the  mucus  attached  to  the  gastric  surface.  I  have  observed, 
though  rarely,  small  superficial  ulcers  at  the  point  where  the  inflammation 
had  been  most  intense. 

Dr.  A.  Jacobi  says :  "  Indeed,  the  boundary-line  between  a  simple  dys- 
pepsia and  a  gastric  catarrh  is  perhaps  never  made  out  clearly.  The  epithelium 
of  the  mucous  membrane  does  not  belong  to  it  exclusively,  but  spreads  in  the 
contiguity  of  the  tissues  into  the  muciparous  and  the  peptic  glands.  Thus 
the  inflammatory  condition  of  the  surface  becomes  at  once  a  parenchymatous 
affection,  though  it  be  possible  that  an  uncomplicated  catarrh  and  an  uncom- 


774         INDIGESTION,   CONGESTION  OF  THE  STOMACH,  ETC. 

plicated  inflammation   may  have   an    occasional   existence Unless    a 

gastric  catarrh  or  a  dyspepsia  ....  be  relieved  at  once  the  merely  func- 
tional or  superficial  disorder  becomes  organic  and  deep-seated.  These  changes 
may  refer  either  to  the  tissue  or  the  secretion.  Inflammatory  thickening, 
erosions,  ulcerations,  or  (Moncorvo)  dilatation  of  the  stomach  will  be  observed 
in  a  great  many  instances.     The  secretions  become  abnormal ;  the  normal 

hydrochloric  acid  of  the  gastric  juice  is  almost  invariably  diminished 

Lactic  acid,  however,  is  produced  in  much  larger  quantities  than  the  first 
stage  of  digestion  requires,  and  with  it  acetic,  butyric,  and  the  rest  of  the 
fatty  acids."  ^ 

Diagnosis. — In  protracted  cases,  when  entero-colitis  is  present,  it  is  dif- 
ficult to  make  a  positive  diagnosis.  Our  opinion  must  then  be  little  more 
than  a  plausible  conjecture.  In  the  acute  attacks  we  can  diagnosticate  the 
gastritis  with  more  certainty.  If  a  young  infant  aff"ected  with  sprue  be 
seized  with  pain,  and  vomits  often ;  if  emaciation  be  rapid  and  there  be  no 
diarrhoea,  or  diarrhoea  not  sufiicient  to  account  for  the  prostration ;  if  the 
buccal  mucous  membrane,  dotted  with  the  points  of  thrush,  present  a  dry 
appearance  and  the  deep-red  color  of  severe  stomatitis, — there  can  be  little 
doubt  of  the  presence  of  gastritis.  The  diagnosis  is  rendered  more  certain 
by  signs  of  tenderness  when  pressure  is  made  upon  the  epigastric  region. 

Prognosis. — Like  other  inflammations,  gastritis  is  probably  sometimes 
so  mild  that  it  does  not  materially  increase  the  suffering  or  danger  of  the 
child.  This  mild  form  of  the  disease  under  favorable  circumstances  soon 
subsides.  In  other  cases,  by  the  continuance  or  increase  of  the  cause,  the 
inflammatory  process  becomes  more  severe  and  extensive,  resulting  even  in 
disintegration  of  the  mucous  membrane.  Those  cases  are  especially  severe 
and  likely  to  end  fatally  which  are  protracted  and  accompanied  by  severe 
thrush,  with  a  desiccated  appeai'ance  of  the  buccal  surface  or  with  entero- 
colitis. Pain,  vomiting,  and  rapid  emaciation  in  such  children  indicate  the 
speedy  approach  of  death.  Improvement  in  the  stomatitis  or  entero-colitis 
is  a  favorable  indication,  but  these  inflammations  may  improve  without  cor- 
responding improvement  in   the  gastritis. 

Treatment. — All  foods  or  drinks,  except  those  of  a  bland  and  unirritat- 
ing  nature,  should  be  forbidden.  If  practicable,  the  young  infant  should 
take  no  nutriment  except  the  mother's  milk  or  that  of  a  wet-nurse.  Since 
there  is  an  excess  of  acid  in  inflammation  of  the  mucous  coat  of  the  diges- 
tive tube,  lime-water  may  be  advantageously  given  in  combination  with 
breast-milk.  Opium  is  required  to  relieve  the  pain  and  quiet  the  action 
of  the  stomach.  The  camphorated  tincture  of  opium,  in  doses  of  four  or 
five  drops  to  a  child  a  month  old,  or  the  syrup  of  poppy,  tincture  of  opium, 
or  liquor  opii  compositus  in  proportionate  doses,  may  be  administered.  If 
there  be  thirst  a  little  gum-water  should  be  given  frequently.  If  there  be 
much  emaciation  and  the  vital  powers  are  failing,  it  will  be  necessary  to 
resort  to  the  use  of  stimulants.  Stimulating  enemata  are  preferable  to 
stimulants  given  by  the  mouth.  Much  benefit  may  be  anticipated  from 
local  measures.  Irritation  should  be  produced  upon  the  epigastrium  by 
mustard  or  other  means,  followed  by  fomentations.  It  is  rarely,  perhaps 
never,  proper  to  use  leeches  if  the  patient  be  an  infant.  Death  occurs 
from  exhaustion,  and  it  is  therefore  important  that  the  vital  powers  should 
not  be  reduced.  If  the  child  be  weaned,  the  diet  at  first  should  be  restricted 
to  arrowroot,  rice-water,  barley-water,  or  similar  bland  substances.  In 
advanced  stages  of  gastritis  animal  broths  and  jellies  may  be  required.  To 
relieve  the  thirst,  carbonic-acid  water,  Vichy  water,  or  plain  water  acidulated 
with  a  few  drops  of  hydrochloric  acid  may  be  employed.     If  symptoms  of 

^  Arch,  of  Pediairics,  Aug.,  1889. 


FOLLICULAR   GASTRITIS,   ETC.  775 

indigestion  continue,  it  may  be  best  to  employ  bismuth  and  pepsin  after  the 
gastritis  has  abated. 

Follicular  Gastritis  ,  Diphtheritic  Gastritis. 

The  pathological  character  of  follicxdar  gastritis  is  similar  to  that  of  fol- 
licular stomatitis.  It  is  an  inflammation  affecting  the  gastric  follicles  and 
ending  in  their  ulceration.  It  is  not  a  frequent  disease;  it  occurs  in  young 
infants.  Billard  observed  fifteen  cases.  The  symptoms  in  these  patients 
were  similar  to  those  in  simple  gastritis  of  a  severe  form.  The  emaciation 
and  prostration  were  rapid,  and  death  occurred  early.  We  can  only  diag- 
nosticate the  gastritis  without  determining  its  follicular  character.  How 
many  recover  it  is  impossible  to  ascertain,  but  the  disease  is  likely  to  be 
fatal  on  account  of  the  intensity  of  the  inflammation,  not  only  of  the  fol- 
licles, but  of  the  intervening  mucous  membrane.  The  treatment  is  that  of 
gastritis. 

Diphtlio'itic  gastritis  is  infrequent.  It  occasionally  occurs  during  epi- 
demics of  diphtheria.  Allusion  is  elsewhere  made  to  a  case  treated  in  the 
Nursery  and  Child's  Hospital  of  this  city  in  December,  1859.  The  patient, 
eighteen  months  old,  previously  had  had  protracted  entero-colitis,  and  died 
exhausted  after  a  brief  attack  of  diphtheria.  There  were  lesions  referable 
to  the  entero-colitis.  and  the  body  was  much  emaciated.  The  diphtheritic 
exudation  was  found  covering  the  fauces,  epiglottis,  glottis  to  the  rima  glot- 
tidis,  the  entire  oesophagus,  and  almost  the  entire  stomach.  The  mucous 
surface  underneath  was  injected  ;  that  of  the  oesophagus  and  stomach  espe- 
cially was  very  vascular,  softened  and  thickened,  and  the  submucous  connec- 
tive tissue  was  infiltrated. 

The  pseudo-membrane  taken  from  the  epiglottis  and  examined  under  the 
microscope  presented  an  amorphous  appearance  ;  no  cells  were  noticed  in  it, 
and  fibrillation  was  not  distinct ;  that  from  the  stomach  was  found  to  consist 
almost  entirely  of  cells,  the  plastic  corpuscles  of  some  writers,  the  pyoid  of 
others.  The  digestive  process,  so  far  as  the  stomach  was  concerned,  had 
evidently  been  almost  if  not  entirely  suspended,  and  hence  in  part  the  sudden 
prostration.  Diphtheritic  ga.stritis  probably  does  not  occur  without  general 
infection  of  the  system  with  the  diphtheritic  virus.  The  proper  treatment  is 
the  use  of  lime-water  or  one  of  the  solvents  of  pseudo-membranes  which  do 
not  irritate  the  mucous  membrane,  while  the  constitutional  treatment  proper 
for  diphtheria  is  employed. 

Dilatation  of  Stomach. 

The  stomach  may  undergo  abnormal  dilatation,  according  to  Dr.  A.  Jacobi, 
from  overfeeding  with  bulky,  especially  amylaceous,  food ;  from  diminished 
contractility  in  its  muscular  coat  consequent  on  debility :  from  imperfect 
digestion  and  flatulence  ;  from  catarrhal  gastritis  and  peritoneal  adhesions. 
In  its  treatment  he  recommends  medicines  (as  bismuth)  which  diminish  fer- 
mentation, the  avoidance  of  fats  and  starches,  and  large  quantities  of  fluid 
ingesta.  Milk  may  be  given  in  small  quantities  and  often.  Diarrhoea  due  to 
this  state  of  the  stomach,  Jacobi  says,  may  require  astringents,  as  tannin. 
Raw  beef,  beef  peptones,  and  peptonized  milk  are  useful,  as  is  also  an 
abdominal  binder.  Faradic  and  galvanic  currents  have  been  used  with  some 
advantage,  and  the  tincture  of  nux  vomica  or  strychnia,  gr.  y^  to  y^. 
three  times  daily,  will  increase  the  contractility  of  the  muscular  coat  of  the 
stomach.' 

*  Arch,  of  Pediatrics,  Aug.,  18S9. 


776         INDIGESTION,   CONGESTION  OF  THE  STOMACH,  ETC. 

Gastro-malacia. 

It  is  now  many  years  since  the  attention  of  the  profession  was  directed 
to  disorganization  of  the  coats  of  the  stomach  which  is  sometimes  observed 
at  post-mortem  examinations.  John  Hunter  first  ascertained  that  the  gastric 
juice  begins  to  have  a  solvent  effect  on  the  tissues  of  the  stomach  soon  after 
death.  Though  Hunter  erred  when  he  stated  that  the  coats  of  the  stomach  • 
are  more  or  less  digested  in  all  or  nearly  all  cases,  it  is  certain  that  post- 
mortem digestion  does  take  place  in  many  cadavers,  so  that  in  a  few  hours 
after  death  the  gastric  mucous  membrane  is  destroyed  to  a  greater  or  less 
extent,  and  occasionally  the  stomach  is  perforated  or  is  even  severed  from  its 
connection  with  the  oesophagus.  I  have  seen  several  examples  of  this  post- 
mortem digestion  in  infants. 

Most  cases  of  supposed  pathological  softening  of  the  stomach  reported 
by  the  older  observers  seem  to  have  been  such  as  I  have  described — namely, 
cadaveric.  It  is  now  believed  by  pathologists  that  gastro-malacia  always^ 
occurs  as  a  cadaveric  change,  or,  if  it  be  pathological  in  exceptional  instances, 
it  in  such  cases  takes  place  when  the  individual  is  nearly  or  quite  moribund 
and  the  circulation  of  blood  in  it  has  come  to  the  standstill. 

The  so-called  white  softening  of  the  stomach  has  been  observed  chiefly 
in  the  bodies  of  those  who  during  life  were  anaemic  and  ill-nourished.  The 
mucous  membrane  in  such  cases  has  lost  its  firmness,  and  is  easily  separated. 
from  the  subjacent  tissue.  This  softening  has  no  connection  with  any  inflam- 
matory process.  It  is  the  result  of  the  low  vitality  of  the  patient.  I  believe 
that  in  a  large  proportion  of  infants  whose  systems  have  been  reduced  and 
blood  impoverished  for  a  considerable  time  the  gastro-intestinal  mucous  mem- 
brane will  be  found  after  death  less  firm  and  resisting  than  in  those  who  have 
been  habitually  robust. 

A  vague  opinion  exists  in  the  minds  of  most  physicians  as  to  the  nature, 
and  even  appearance,  of  the  so-called  gelatinous  softening  of  the  stomach. 
and  the  following  observations  will  be  cited  in  order  to  give  a  clearer  idea 
of  it: 

Billard  has  recorded  two  cases  with  his  usual  minuteness,  and  adds  : 
"  What  inference  shall  be  drawn  from  the  preceding  facts  and  considera- 
tions ?  None  other  than  that  the  gelatinous  softening  of  the  stomach  con- 
sists in  a  disorganization  of  the  mucous  membrane  of  this  viscus,  caused  by 
an  acute  or  chronic  phlegmasia ;  that  this  disorganization  is  characterized 
by  an  accumulation  of  serum  in  the  walls  of  this  organ  ;  the  intumescence 
and  gelatinous  consistence  of  the  mucous  membrane  in  a  part  usually  cir- 
cumscribed are  situated  more  frequently  in  the  greater  curvature,  and  about 
which  the  membrane   exhibits  more   or  less  evident  traces  of  an  acute  or 

chronic  phlegmasia The  softening  now  under  consideration  must  not 

be  confounded  with  another  kind  of  softening "  (white),  "  which  does  not 
usually  succeed  an  acute  phlegmasia." 

West,  in  speaking  of  gelatinous  softening,  says :  "  Softening  of  the 
stomach  varies  in  degree  from  a  slight  diminution  in  the  consistence  of  the 
mucous  membrane  to  a  state  of  complete  diffluence  of  all  the  tissues  of  the 

organ When  the    change  is    not  far    advanced  the  exterior   of  the 

stomach  presents  a  perfectly  natural  appearance,  but  on  laying  it  open  a 
colorless  or  slightly  brownish  tenacious  mucus,  like  the  mucilage  of  quince- 
.seed,  is  found  closely  adhering  to  its  interior  over  a  more  or  less  considerable 
space  at  the  great  end  of  this  organ." 

Cruveilhier  says  :  "  This  softening  often  proceeds  from  the  interior  toward 
the  exterior.  There  is  at  the  beginning  simple  separation  of  the  fibres  by  a 
gelatinous  mucus,  and  in   consequence  the  parietes  are  thickened  and  semi- 


GASTRO-MALACIA.  777 

transparent If  the  transformation  be  complete,  the  di.sor<ranized  por- 
tions are  removed  hiyer  after  hiyer,  those  which  remain  becoming  gradually 
thinner.  Tiie  peritoneum  alone  resists  for  some  time,  but  at  length  it  is 
attacked,  worn,  and  gives  way,  and  perforation  of  the  stomach  results.  The 
parts  thus  transformed  are  colorless,  transparent,  apparently  inorganic, 
completely  deprived  of  vessels,  and  exhaling  an  odor  resembling  that  of 
milk." 

Bouchut  remarks  :  "  Softening  of  the  mucous  membrane  of  the  stomach 
in  children  at  the  breast  is  not  a  special  disease  which  it  is  necessary  to 
describe  by  itself.  This  alteration  is  always  connected  with  other  diseases. 
and  especially  with  disease  of  the  large  intestine,  the  knowledge  of  which 
fact  has  been  too  long  neglected.  It  is  the  consequence  of  the  acidity  of  the 
liquids  contained  in  the  digestive  tube  of  young  children — liquids  which  are 
very  acid  in  the  disease  we  have  above  referred  to." 

Rokitansky  says  of  this  form  of  softening :  "  If  we  consider,  in  addition 
to  the  above  remarks,  the  uniform  localization  of  the  disease,  that  in  none  of 
its  stages  it  presents,  either  at  the  point  of  the  softening  or  in  its  vicinity^ 
hyperaemic  injection  or  reddening,  and  that  we  are  still  less  able  to  demon- 
strate upon  the  inner  surface  of  the  stomach  or  in  the  tissue  of  its  coats  the 
products  of  inflammation,  we  are  constrained  to  infer  the  non-inflammatory 
nature  of  the  aff"ection." 

Without  extending  these  extracts  it  is  seen  that  eminent  authorities  not 
only  disagree  in  reference  to  the  cause  of  gelatinous  softening  of  the  stomach, 
but  that  they  also  diff'er  in  their  description  of  its  appearances.  This  diver- 
sity of  opinion  is  most  likely  attributable  to  the  fact  that  the  two  kinds  of 
softening  have  been  confounded.  Rokitansky  and  Bouchut  probably  refer  tO' 
cases  of  white  softening  which  occur  in  atonic  states  of  the  tissues  in  feeble 
infants,  and  therefore  have  concluded  that  softening  of  the  stomach  is  not 
inflammatory.  I  believe,  from  my  observations,  that  the  opinion  of  Billard 
is  correct,  and  that  true  gelatinous  softening  is  sometimes  found  in  stomachs 
that  have  been  inflamed,  but  it  may  be  in  such  cases  cadaveric. 

The  following  case,  which  was  watched  by  myself  with  great  interest 
from  beginning  to  end,  was  an  example  of  softening  following  gastritis : 

Case. — G.  S. ,  male,  robust,  was  born  July  10,  1865.     The  mother  not 

being  able  to  suckle  the  infant,  and  the  danger  of  artificial  feeding  in  the  warm 
months  being  well  understood,  a  wet-nurse  was  procured.  About  the  14th  of 
July,  this  wet-nurse  having  insufficient  milk,  another  was  procured  temporarily, 
who  suckled  the  inflint  till  July  20th,  when  a  third  wet-nurse  was  engaged, 
whose  child,  healthy  and  thriving,  Avas  six  weeks  old.  Previously  to  this  time 
the  infant  appeared  well.  It  had  uniformly  nursed  vigorously  and  seemed 
satisfied. 

On  the  22d  of  July  thrush,  apparently  mild,  was  observed  in  the  mouth,  and 
a  powder,  supposed  to  be  borax,  and  labelled  such,  was  obtained  at  a  drug-store 
to  be  used  as  a  wash  for  the  mouth.  This  powder  was  afterward  ascertained  to 
be  alum.  Five  grains  were  dissolved  in  as  many  teaspoonfuls  of  water,  and  the 
mouth  of  the  child  was  swabbed  occasionally  with  it.  A  piece  of  linen,  folded 
so  as  to  resemble  the  tip  of  a  nursing-bottle,  was  occasionally  dipped  into  the 
solution,  and  the  infant  was  allowed  to  suck  it.  The  use  of  the  alum  was  com- 
menced about  6  P.  M.  In  the  first  part  of  the  evening  the  infant  slept  consider- 
ably, and  of  course  did  not  nurse  often,  but  about  8  p.  i\r.  it  began  to  be  very 
fretful,  and  it  then  nursed  more  frequently.  It  vomited  once  between  8  and  10 
o'clock  p.  M.  In  order  to  quiet  the  infant  the  tip  soaked  in  the  solution  was  often 
applied  to  the  mouth,  but  there  was  scarcely  any  intermission  in  its  crying. 
Through  the  night  it  vomited  again  once  or  twice,  and  about  the  middle  of  the 
night  had  one  free  liquid  stool,  which  was  passed  with  much  tenesmus.  The 
countenance  of  the  infant  was  indicative  of  suffering,  and  its  tliighs  were  repeat- 
edly flexed  over  the  abdomen,  as  if  that  were  the  seat  of  its  distress.     Paregoric 


778         INDIGESTION,   CONGESTION  OF  THE  STOMACH,  ETC. 

in  two-drop  doses  was  several  times  given  through  the  night,  and  flannel  soaked 
with  hot  whiskey  was  applied  to  the  abdomen. 

July  23d :  In  ignorance  of  the  cause  of  the  child's  sickness  another  wet-nurse 
■was  obtained  early  in  the  morning,  and  one-sixth  of  a  drop  of  liq.  opii  compos, 
was  given  every  hour,  with  the  effect  of  inducing  a  little  sleep.  The  tongue  was 
very  red,  desiccated,  and  studded  with  more  numerous  points  of  thrush  than  on 
the  previous  day.  It  now  refused  to  nurse,  apparently  from  soreness  of  the 
tongue.  At  each  attempt  of  the  nurse  to  induce  it  to  take  the  nipple,  it  rubbed 
the  mouth  across  the  breast,  crying  either  from  pain  or  disappointment.  The 
alum  was  not  used  in  the  latter  part  of  the  night  of  the  22d,  but  late  in  the 
morning  of  the  23d  it  was  resumed,  the  mistake  of  the  druggist  not  being  discov- 
ered till  mid-day,  when  it  was  estimated  that  about  five  grains  had  been  used. 
Occasionally  a  little  of  the  solution  was  placed  in  the  mouth  with  a  spoon,  so  as 
to  be  swallowed,  in  the  belief  that  the  thrush  affected  the  oesophagus.  The  infant 
continued  to  suffer  much  during  the  day,  sleeping  at  times  a  few  minutes.  Its 
strength  was  evidently  failing ;  respiration  regular ;  pulse  about  140 ;  its  alvine 
discharges  yellow,  of  natural  consistence  and  frequency. 

Evening  23d  :  Surface  hot ;  it  is  very  restless ;  pulse  150  to  160 ;  tongue  dry, 
intensely  red,  and  dotted  with  points  of  thrush.  Is  treated  with  opiates,  a  little 
lime-water,  and  fomentations. 

24th :  In  the  first  part  of  the  day  nursed  pretty  well ;  in  the  latter  part  could 
be  induced  to  draw  the  breast  only  once  or  twice.  The  symptoms  to-day  were 
the  same  as  yesterday,  with  the  exception  of  greater  emaciation  and  prostration  ; 
•cranial  bones  uneven  and  features  pinched. 

25th  :  Pulse  140  to  148 ;  strength  rapidly  failing,  but  it  cries  at  times  loudly. 
The  milk  of  the  nurse,  placed  in  the  mouth  with  a  spoon,  is  often  held  a  consid- 
erable time  before  it  is  swallowed,  and  deglutition  seems  difficult.  Respiration 
in  the  first  part  of  the  day  and  previously  natural ;  in  the  latter  part  of  the  day 
accelerated  ;  dejections  natural ;  no  vomiting  ;  appearance  of  tongue  more  natural 
than  yesterday. 

26th  :  Died  to-day  in  a  state  of  collapse  at  12.80  P.  M.  The  hands  were  cold 
several  hours  before  death,  and  the  milk  given  it  was  regurgitated. 

Autopsy,  Tiuenty-two  Hours  after  Death. — Much  emaciation ;  no  rigor  mortis ; 
cranial  bones  uneven ;  the  upper  part  of  the  pharynx  injected  to  the  extent  of 
about  half  an  inch  ;  from  this  point  to  the  stomach  membrane  healthy  ;  mucous 
membrane  covering  the  cardiac  two-thirds  of  the  stomach  disintegrated,  almost 
•diffluent,  and  in  places  detached  from  the  subjacent  tissues ;  mucous  coat  of  the 
pyloric  third  of  the  organ  nearly  healthy  ;  along  the  edge  of  the  softened  portion 
the  mucous  membrane  was  vascular  to  the  extent  of  a  few  lines  ;  the  muscular 
and  serous  coats  of  the  stomach  underneath  the  softened  portion  were  easily 
torn ;  the  mucous  membrane  of  the  small  intestine  presented  in  places  that 
■degree  of  vascularity  known  as  arborescence ;  there  was  no  destruction  or  soften- 
ing of  its  mucous  membrane ;  the  colon  was  healthy ;  the  stomach  was  nearly 
«mpty  ;  the  contents  of  the  small  and  large  intestines  were  natural  in  color  and 
consistence ;  the  other  viscera  were  healthy ;  in  the  left  pleural  cavity  was  about 
one  ounce  of  transparent  serum  and  a  less  quantity  in  the  right  cavity. 

The  weather  at  the  time  was  warm,  but  the  infant  was  placed  on  ice,  and 
a  pan  containing  ice  was  kept  upon  the  abdomen.  It  evidently  died  of 
gastritis,  the  accompanying  inflammation  being  subordinate,  and  in  fact  insig- 
nificant. At  first  it  was  a  question  with  me  whether  the  alum  might  not 
have  caused  the  gastritis,  so  that  the  case  should  be  properly  placed  in  the 
category  of  deaths  from  swallowing  corrosive  substances.  In  order  to  deter- 
mine this  point,  I  administered  alum  daily  to  two  kittens,  commencing  when 
they  were  seven  days  old.  The  quantity  given  to  each  was  ten  grains  daily 
in  two  doses  for  three  consecutive  days,  and  on  the  two  following  days  five 
grains.  The  only  uniform  result  noticed  was  an  increased  fiow  of  saliva, 
which  washed  some  of  the  alum  from  their  mouths,  and  occasionally  slight 
vomiting.  There  was  not  even  any  apparent  inflammation  of  the  buccal 
membrane  from  the  alum. 

Post-mortem  appearances,  as  in  the  above  case,  and  similar  ones  recorded 


G ASTRO-INTESTINAL  BACTERIA.  779 

by  Viilleix  and  others,  in  wliicli  gelatinous  softening  coexisted  with  evident 
lesions  of  gastritis,  render  it  highly  probable,  if  indeed  they  do  not  demon- 
strate, that  the  softening  is  one  of  the  sequels  of  the  inflammation  at  the 
point  where  it  occurs ;  but  whether  it  begins  in  the  moribund  state  or  is 
entirely  cadaveric  is   uncertain. 

In  Valleix's  twenty-four  cases  of  what  he  terms  fatal  muguet,  softening  of 
the  mucous  membrane  of  the  stomach  was  one  of  the  most  common  lesions, 
and  at  the  same  time,  which  is  the  point  of  interest,  there  were  signs  which 
showed  conclusively  the  presence  of  gastric  inflammation.  The  common 
coexistence  of  the  lesions  of  gastric  inflammation,  such  as  redness  and 
thickening,  with  gelatinous  softening  of  the  stomach,  is  a  fact  that  arrests 
attention,  and  strengthens  the  belief  that  gastro-malacia  is  one  of  the  sequelae 
of  gastritis. 

I  am  not  prepared  to  accept  nor  reject  the  theory  of  Billard  that  the 
immediate  cause  of  the  softening  is  the  afflux  of  serum,  nor  that  of 
Bouchut   that  it  is   an   excess   of  acid. 

It  has  been  said  that  M.  Baron  was  able  to  diagnosticate  gelatinous  soft- 
ening. The  symptoms  are  those  of  the  severe  forms  of  gastritis.  The  vom- 
iting, great  pain,  restlessness,  sudden  and  progressive  emaciation,  and  finally 
•collapse  preceding  the  fatal  result,  without  sufiicient  diarrhoea  to  cause  the 
rapid  sinking,  are  the  symptoms  on  which  the  diagnosis  was  based.  These 
symptoms  indicated  a  gastritis,  but  physicians  of  the  present  time  would 
hardly  consider  them   sufl&cient  to  justify  the  diagnosis  of  gastro-malacia. 


CHAPTER  VI. 

G ASTRO-INTESTINAL  BACTERIA. 

Recent  investigations  have  demonstrated  that  these  organisms  sustain 
an  important  causal  relation  to  the  indigestion,  malassimilation,  and  diar- 
rheal diseases  of  infancy.  They  are  minute  unicellular  bodies,  and  are 
classified  as  follows  :  first,  the  micrococci,  or  globular  bacteria  ;  secondly,  the 
bacilli,  or  rod-shaped  bacteria ;    and  thirdly,  the  spirilla  or  spiral  bacteria. 

The  pathogenic  character  of  these  bodies  has  been  to  a  considerable 
extent  elucidated  by  the  microscopic  examinations  and  experiments  of  seve- 
ral European  scientists,  prominent  among  whom  is  Escherich,  and  by  the 
investigations  of  Booker  and  Vaughan  in  America. 

Bacteria  are  not  present  in  the  stomach  and  intestines  in  the  foetus,  nor 
in  the  meconium  at  birth.  They  are  conveyed  to  the  digestive  tract  of  the 
newly-born  through  the  air  and  saliva  and  the  liquid  ingesta,  and  it  is 
believed  that  they  sometimes  obtain  entrance  through  the  anus,  for  they 
have  been  found  in  the  meconium  three  to  seven  hours  after  birth  (Escher- 
ich). AVhen  the  meconium  is  expelled  the  bacteria  which  it  contains  disap- 
pear, and  other  species  subsequently  take  their  place  in  the  milk-feces. 
The  feces  of  healthy  nurslings  contain  a  larger  number  of  bacteria,  of  which 
the  bacterium  lactis  aerogenes  and  bacterium  coli  commune  are  uniformly 
present.  According  to  Booker,  in  the  healthy  suckling  the  stomach  contains 
few  bacteria,  chiefly  bacilli ;  the  duodenum  also  contains  but  few ;  but  they 
increase  in  number  on  tracing  the  intestine  downward.  On  reaching  the 
lower  end  of  the  upper  third  of  the  small  intestine,  we  find  a  considerable 
number  of  bacteria,  including  diplococci,  bacteria  lactis  aerogenes,  and  colon 


780  G ASTRO-INTESTINAL  BACTERIA. 

bacteria.  The  bacteria  lactis  aerogenes  undergo  no  farther  increase  in  the 
lower  part  of  the  small  intestines  and  in  the  colon,  but  the  colon  bacteria 
(bacterium  coli  commune)  undergo  a  great  increase  in  number  in  the  lower 
part  of  the  ilevxm  and  in  the  colon.  They  exist  in  large  numbers  in  the  entire 
length  of  the  colon,  and  of  larger  size  than  in  the  small  intestine.  The  bac- 
terium lactis  aerogenes  occurs  in  the  form  of  "  short,  thick  rods,  with  rounded 
ends."  Injected  into  the  blood  of  guinea-pigs  and  rabbits,  it  causes  death, 
preceded  by  the  phenomena  of  intestinal  catarrh.  The  bacterium  coli  com- 
mune is  believed  to  be  always  present  in  feces,  whatever  the  diet.  It  is  also 
rod-shaped  and  it  varies  in  size  and  length,  the  largest  and  longest  specimens 
attaining  the  length  of  five  micro-millimetres.  According  to  Booker,  both 
these  microbes  promote  fermentation  in  the  intestines.  Many  other  forms 
of  bacteria  have  been  discovered  in  the  milk-feces  of  infants,  in  addition  to 
the  two  which  we  have  described.  Bscherich  discovered  twelve  varieties, 
micrococci  and  bacilli. 

To  the  physician  the  gastro-intestinal  bacteria  are  mainly  interesting  on 
account  of  the  supposed  causal  relation  which  they  sustain  to  certain  abnor- 
mal conditions  of  the  digestive  tract,  especially  to  the  diarrhoeal  affections. 
It  is  important  in  investigating  this  subject  to  ascertain  what  bacteria  are 
present  in  normal  feces,  and  whether  they  exert  pathogenic  action  under 
certain  circumstances.  This  has  been,  in  a  measure,  ascertained,  as  we  have 
seen,  but  another  interesting  and  important  inquiry  relates  to  new  forms 
of  bacteria  that  appear  in  the  feces  in  diseased  conditions  of  the  stomach 
and  intestines,  and  the  causal  relation  which  they  bear  to  these  conditions. 
New  forms  of  bacteria  may  appear  in  the  feces  in  gastro-intestinal  disease 
without  sustaining  a  causal  relation  to  it  or  influencing  it.  Again,  although 
not  causing  the  disease,  they  may  influence  its  course  and  duration,  or  they 
may  cause  gastro-intestinal  disease  by  lodging  in  the  food,  especially  in  milk, 
and  producing  by  their  agency  poisonous  chemical  substances  in  it  before  it 
is  employed  in  the  nursery.  The  well-known  poisoning  by  the  tyrotoxicon 
in  the  hotels  at  Long  Branch,  this  poison  being  produced  in  milk  proba- 
bly by  microbic  action  six  or  eight  hours  after  the  milking,  was  an  instance 
of  this  kind.  Again,  a  species  of  bacteria  not  occurring  in  the  stools  in 
health,  but  appearing  in  disease,  as  in  indigestion,  inanition,  or  diarrhoea, 
may  be  the  chief  factor  in  causing  this  morbid  state. 

According  to  Booker,  none  of  the  gastro-intestinal  secretions  has  an 
injurious  eff"ect  on  bacteria,  except  the  gastric  juice,  but  certain  bacteria  are 
antagonistic  to  others,  so  that  their  presence  prevents  the  full  development 
of  the  latter.  Bacteria,  which  in  the  normal  state  of  the  gastro-intestinal 
tract  do  not  find  a  soil  suitable  for  their  development  in  the  stomach  or 
intestines,  obtain  the  conditions  favorable  for  their  growth  and  propagation 
in  diseased  states,  as  when  indigestion  or  catarrh  is  present. 

The  pathogenic  action  of  bacteria  in  the  digestive  tract  can  be  most  suc- 
cessfully investigated  by  experimenting  with  them  when  they  have  been 
isolated  from  other  substances  by  repeated  cultivations.  Hayem  and  Le- 
sage  have  isolated  a  bacillus  which  they  have  discovered  in  green  stools  of 
infants,  and  which  they  believe  produces  by  its  disturbing  action  the  green 
color  and  abnormal  state  of  the  stools.  The  green  color  in  the  feces  of 
infantile  diarrhoea  they  believe  to  be  sometimes  due  to  an  excess  of  the  bile- 
pigment,  but  in  other  instances  is  produced  by  the  action  of  a  bacillus,  which 
occurs  especially  in  the  upper  two-thirds  of  the  small  intestine,  where  it 
attains  the  length  of  two  to  three  micro-millimetres.  Injected  into  the 
blood  of  sucking  animals,  this  bacillus  appeared  in  the  duodenum  ten  or 
twelve  hours  subsequently,  and,  increasing  in  number,  caused  green  colora- 
tion of  the  intestinal   contents.     The   same   result  was   produced  when  thiS' 


SIMPLE  DIARRHCEA.  781 

microbe  was  administered  in  the  inge.sta.  In  its  dry  state  it  floats  in  the  air, 
so  that  when  an  infant  having  green  stools  produced  by  its  action  enters  a 
ward,  others  are  liable  to  be  attacked  with  the  green  diarrha-a  if  its  soiled 
diapers  are  allowed  to  dry   in   the  room. 

Baginsky  has  investigated  the  stools  in  the  acid  diarrhoea  of  infants,  and 
has  isolated  two  forms  of  bacteria  which  liquefy  gelatin.  One  of  these  pro- 
duces green  coloring  matter,  and  is  probably  the  same  as  that  described  above  ; 
the  other  was  constantly  present  in  the  acid  diarrhceal  feces,  was  poisonous 
to  animals,  and  it  is  probably  impotent  in  the  pathogenic  role.  Baginsky 
believes  from  his  observations  that  the  bacterium  lactis  aerogenes  present  in 
the  normal  stools  of  the  suckling  is  under  favorable  circumstances  antagonis- 
tic to  the  development  of  pathogenic  organisms. 

Dr.  Booker  has  isolated  forty  bacteria  from  the  stools  of  30  infants,  all 
seriously  sick  with  diarrhceal  diseases,  11  having  cholera  infantum,  14  catar- 
rhal enteritis,  and  5  dysentery.  The  largest  number  of  the.se  organisms 
occurred  in  cases  of  cholera  infantum,  and  the  next  largest  number  in  cases 
of  catarrhal  entero-eolitis.  According  to  Booker,  the  bacteria  of  the  normal 
milk-feces  still  appear  in  the  diarrhceal  stools.  The  bacterium  coli  commune 
was  found  by  him  in  all  the  diarrhceal  cases,  but  its  number  appeared  to 
diminish  according  to  the  severity  of  the  attack.  On  the  other  hand,  the  bac- 
terium lactis  aerogenes  occurred  in  larger  number  in  the  diarrhceal  stools  than 
in  healthy  milk-fece.s.  Booker  discovered  bacteria  of  the  proteus  group  in 
7  of  the  1 1  cases  of  cholera  infantum  ;  which  is  a  matter  of  significance,  inas- 
much as  Eschcrich  did  not  find  any  bacterium  of  this  group  in  normal  milk- 
feces. 

In  a  very  interesting  and  instructive  paper  read  before  the  American 
Pediatric  Society  in  June,  1890,  Dr.  Victor  C.  Vaughan  detailed  his  experi- 
ments, which  showed  that  "  three  micro-organisms,  differing  sufficiently  to  be 
recognized  as  of  different  species,  produce  poisons,  all  of  which  induce  vom- 
iting and  purging,  and  when  used  in  sufficient  quantity,  death  "  in  cats  and 
dogs  experimented  on.  Dr.  Vaughan  concludes  his  paper  with  the  following 
aphorisms :  "  1st.  There  are  many  germs,  any  one  of  which,  when  introduced 
into  the  intestine  of  the  infant  under  certain  favorable  circumstances,  may 
produce  diarrhoea.  2.  Many  of  these  germs  are  probably  truly  saprophytic. 
3.  The  only  digestive  secretion  which  is  known  to  have  any  decided  germici- 
dal effect  is  the  gastric  juice.  Therefore,  if  this  secretion  be  impaired,  there 
is  at  least  the  possibility  that  the  living  germ  will  pass  on  to  the  intestine, 
will  there  multiply,  and  will,  if  it  be  capable  of  so  doing,  elaborate  a  chem- 
ical poison,  which  may  be  absorbed.  4.  Any  germ  which  is  capable  of  grow- 
ing and  producing  an  absorbable  poison  in  the  intestine  is  a  pathogenic  germ. 
5.  The  proper  classification  of  germs  in  regard  to  their  relation  to  disease 
cannot  be  made  from  their  morphology  alone,  but  must  depend  largely  upon 
the  products  of  their  growth." 


CHAPTER    VII. 

SIMPLE   DIARRHCEA. 

DlARRH(EA  is  frequent  during  the  whole  period  of  infancy.  French 
writers  describe  several  varieties,  according  to  the  character  of  the  evac- 
uations, as  acescent,  mucous,  and  serous.     M.  Rostan  even  describes  four- 


782  SIMPLE  DIARRHOEA. 

teen  distinct  kinds.  But  the  tendency  of  medical  science  in  modern  times 
is  to  simplify  the  nomenclature  of  diseases — to  describe  under  a  single  name 
those  affections  which  are  essentially  the  same,  though  differing  somewhat 
in  their  features.  Now,  all  the  forms  of  diarrhoea  in  the  infant  may  be 
so  grouped  as  to  reduce  the  number  to  not  more  than  three  or  four.  In 
this  way  repetition  and  prolixity  are  avoided,  as  well  as  an  unnecessary 
refinement. 

The  most  common  form  of  diarrhoea  is  that  enunciated  in  our  heading. 
But  often  a  diarrhoea  which  is  non-inflammatory  at  first  becomes  a  catarrh. 
Thus  the  simple  diarrhoea  of  infancy  may  become  an  entero-colitis  from  the 
continued  use  of  improper  diet. 

Causes. — These  are  various.  Conditions  or  agencies  which  have  no 
appreciable  effect  in  the  adult  often  increase  the  number  of  evacuations 
in  young  children.  Food  which  imperfectly  digests,  and  some  of  which 
perhaps  ferments,  stimulates  the  intestinal  follicles  to  excessive  secretion,, 
and  increases  the  peristaltic  movements  by  its  irritating  action,  thus  causing 
diarrhoea.  Too  frequent  and  abundant  feeding  is  another  cause,  especially  in 
young  infants,  some  of  whom  may  vomit  the  suplus  food  and  remain  well,^ 
but  others  do  not.  Food  which  cannot  be  assimilated  becomes  an  irritant  in 
consequence  of  fermentative  change,  and  produces  frequent  and  unhealthy 
evacuations.  In  the  light  of  our  present  knowledge  we  assign  to  the  agency 
of  intestinal  bacteria  an  important  causal  relation  to  those  forms  of  diar- 
rhoea which  are  attended  by  fermenting,  imperfectly-digested,  and  unhealthy 
stools. 

The  mother's  milk  or  the  milk  of  the  wet-nurse  may  disagree,  either 
from  some  temporary  derangement  of  her  system  or  continued  ill-health,  or 
from  causes  which  are  not  understood.  Diarrhoea  in  the  nursling  is  the 
result. 

Fright  or  strong  mental  impressions  will  also  in  some  children  increase 
the  number  of  evacuations.  This  cause  being  transient,  the  diarrhoea  soon 
subsides. 

Another  cause  is  exposure  to  cold.  Children  who  are  insufficiently 
clothed  in  the  winter  season,  who  are  taken  from  a  heated  room  into  a 
cool  one  without  sufficient  protection,  or  who  lie  uncovered  at  night,  are 
very  subject  to  diarrhoeal  attacks  from  the  impression  of  cold  on  the 
system. 

The  cause  of  simple  diarrhoea  may  exist  in  the  child  itself.  In  some 
children  the  evolution  of  the  teeth  is  attended  by  a  relaxed  state  of  the 
bowels,  which  ceases  when  the  gum  is  pierced.  Worms  in  the  intestines 
may  also  operate  as  a  cause.  Diarrhoea  is  occasionally  salutary  within  cer- 
tain limits,  and  of  course  it  is  not  strictly  correct  to  call  it  a  disease  when  it 
is  a  means  of  relief.  If  occurring  from  excessive  or  irritating  ingesta,  it  is 
obviously  conservative. 

Symptoms. — Diarrhoea  may  come  on  suddenly ;  at  other  times  there  are 
precursory  symptoms  continuing  for  some  days.  Whether  or  not  there  be 
antecedent  symptoms  depends  chiefly  on  the  cause.  If  this  be  exposure  to 
cold  or  the  use  of  improper  aliment,  it  commonly  occurs  immediately. 

Among  the  prodromic  symptoms  sometimes  present  are  restlessness,  dis- 
turbed sleep,  transient  abdominal  pains,  nausea  or  vomiting,  and  other  symp- 
toms of  indigestion.  The  stools  in  simple  diarrhoea  differ  much  in  color  and 
consistence  in  different  cases,  and  perhaps  at  different  periods  in  the  same 
case.  In  infants  they  are  often  green.  This  color,  which  is  a  source  of 
anxiety  to  the  inexperienced,  and  especially  to  the  parents,  is  often  produced 
by  trivial  causes.  Slight  indigestion  will  produce  it,  and  so  will  excess  of 
food,  even  when  bland  and  unirritating.     In  our  remarks  on  the  gastro-intes- 


ANATOMICAL   CHARACTERS.  783: 

tinal  bacteria  we  have  stated  that  a  microbe  has  the  power  to  produce  the 
green  color.  The  stools  in  infantile  diarrhoea  often  contain  particles  of  coag- 
ulated casein,  but  in  children  advanced  beyond  the  period  of  first  dentition 
they  do  not  differ  materially  in  appearance  from  the  evacuations  of  the  adult. 
They  are  usually  passed  easily,  but  if  they  be  acid  or  in  any  way  irritating 
there  may  be  more  or  less  tenesmus,  especially  in  infants.  Sometimes  before 
the  evacuations  there  is  a  sensation  of  fulness  in  the  abdomen.  In  that  form 
of  diarrhoea  which  has  been  designated  acescent  not  only  are  the  stools  acid^ 
but  matters  vomited  have  an  acid  odor  and  give  an  acid  reaction. 

During  the  quiet  hours  of  sleep,  when  no  foods  and  drinks  are  taken,  the- 
diarrhoea  diminishes.  If  the  complaint  be  slight,  there  is  little  thirst ;  but 
if  the  stools  be  frequent  and  thin,  especially  if  they  approach  the  watery 
character,  the  patient  is  thirsty.  The  appetite  varies,  the  tongue  is  moist 
and  covered  with  a  light  fur,  and  there  is  often  more  or  less  meteorism, 
but  no  abdominal  tenderness. 

The  features  in  this  disease  are  pallid.  In  a  few  days,  if  the  evacuation.<y 
continue,  there  is  evident  loss  of  weight  and  flesh.  The  rotundity  of  the 
limbs  is  gradually  lost  and  the  tissues  become  soft  and  flabby.  But  in  most 
cases  when  the  malady  has  reached  this  stage  its  original  character  is  lost^ 
and  it  has  become  inflammatory. 

Certain  epiphenomena,  as  Barrier  terms  them,  occur  at  times  in  non- 
inflammatory as  well  as  in  inflammatory  diarrhoea ;  as,  for  example,  a  sym- 
pathetic cough  or,  which  is  more  serious,  cerebral  complications.  Convul- 
sions or  stupor,  indicating  the  supervention  of  spurious  hydrocephalus,  may 
occur  in  either  form  of  diarrhoea.  This  disease  is  described  elsewhere.  More 
or  less  fever  may  occur  in  simple  diarrhoea,  but  it  is  not  constant  and  the 
pulse  may  or  may  not  be  accelerated. 

Anatomical  Characters. — It  is  obvious  from  the  nature  of  simple 
diarrhoea  that  it  is  attended  by  little  or  no  structural  changes  perceptible  tO' 
the  anatomist.  In  cases  supposed  to  be  simple  or  non-inflammatory,  which 
have  ended  fatally  either  from  the  diarrhoea  or  an  intercurrent  disease,  the  most 
marked  leisons  observed  have  been  more  or  less  tumefaction  of  the  intestinal 
glands,  with  perhaps  diminished  firmness  and  resistance  of  the  mucous  mem- 
brane. Cases  like  the  following,  which  have  usually  been  regarded  as  non- 
inflammatory, are  not  infrequent,  but  it  seems  to  me  probable  that  in  at  least 
a  certain  proportion  of  such  cases  the  intestinal  follicular  apparatus  has  passed 
beyond  the  physiological  state  of  an  exaggerated  functional  activity,  and  that 
the  disease  should  be  designated  a  catarrh  or  inflammation.  Inasmuch  a& 
non-inflammatory  diarrhoea,  if  protracted,  is  very  liable  to  become  inflamma- 
tory, it  is  often  difficult  to  determine  whether  the  malady  has  undergone  this- 
change,  even  with  the  aid  of  post-mortem  inspection. 

On  the  7th  of  July,  1865,  a  foundling  one  month  old  died  at  the  Infant 
Asylum.  It  was  much  emaciated,  with  eyes  sunken  and  features  pinched, 
at  the  time  of  its  death.  It  was  wet-nursed  to  the  close  of  its  life,  but  the 
nurse's  milk  was  insufficient.  It  did  not  vomit,  did  not  have  any  marked 
acceleration  of  pulse  (128  per  minute),  and  its  evacuations  were  about  four 
daily,  and  thin.  The  stomach  and  intestines  were  pale  throughout.  The 
solitary  glands,  particularly  those  in  the  colon,  and  the  patches  of  Peyer. 
were  tumefied  so  as  to  be  visible  and  somewhat  raised  above  the  surround- 
ing surface.  But  no  lesions  being  observed  which  are  characteristic  of 
inflammation,  the  disease  was  regarded  as  non-inflammatory. 

Niemeyer,  with  others,  describes  even  the  mildest  forms  of  diarrhoea  under 
the  term  catarrhal  inflammation,  and  he  appears  to  consider  the  transient 
effects  of  a  purgative  as  an  incipient  catarrh.  But  it  seems  to  me  prefer- 
able, in  the  present  state  of  pathological  knowledge,  to  regard  all  those  diar- 


784  SIMPLE  DIABBHCEA. 

rhoeas  whicli  immediately  abate  with  the  removal  of  the  cause,  and  which  are 
attended  by  no  marked  anatomical  change,  as  non-inflammatory  or  simple. 
They  are  characterized  by  increased  secretion  of  the  intestinal  follicles  and 
increased  peristalsis. 

Prognosis. — In  a  large  proportion  of  cases  simple  diarrhcea  is  not  dan- 
gerous. With  the  adoption  of  suitable  measures  to  remove  the  cause  and 
the  use  of  medicines  to  control  the  discharges  the  patient  recovers.  The 
remark  already  made  may  be  repeated  here,  that  occasionally  diarrhoea  is 
salutary  within  certain  limits,  as  when  there  is  a  foreign  substance  in  the 
intestines  either  irritating  mechanically  or  by  its  chemical  properties,  and 
which  the  diarrhoea  serves  to  remove. 

The  danger  arises  from  complications,  as  spurious  hydrocephalus,  or  from 
the  emaciation  and  exhaustion,  or  from  its  eventuating  in  inflammation. 

If  the  rotundity  of  the  figure  and  firmness  of  the  tissues  be  preserved, 
showing  that  alimentation  is  still  sufiicient,  and  no  complication  arise,  the  diar- 
rhoea is  not  as  a  rule  dangerous.  In  infants  that  over-nurse  and  do  not  vomit 
the  surplus  milk,  the  evacuations  are  sometimes  green  and  frequent,  and  yet 
fulness  of  figure  is  preserved  and  the  development  of  the  body  proceeds  as 
usual.  On  the  other  hand,  diarrhoea  attended  by  emaciation  or  softness  or 
fiabbiness  of  the  flesh  involves  danger  and  requires  immediate  treatment. 

Treatment. — It  is  necessary,  in  order  to  treat  diarrhoea  in  infancy  and 
childhood  successfully,  to  ascertain  the  cause,  and,  as  far  as  possible,  to 
remove  it.  It  is  not  till  the  cause  ceases  to  operate  that  we  can  expect  a 
satisfactory  result  from  medication.  The  disease  may  be  temporai'ily  relieved 
by  medicine,  but  it  usually  returns  at  once  when  treatment  is  omitted,  unless 
the  patient  be  removed  from  the  influence  of  the  agencies  which  produce  it. 
These  remarks  are  especially  applicable  to  the  diarrhoea  of  infants.  With 
them  very  generally,  when  aff"ected  with  this  complaint,  there  is  some  fault 
as  regards  the  quantity  or  quality  of  food.  Attention  to  this  matter  will 
show  the  need  of  a  change  of  wet-nurse,  or,  if  the  infant  be  spoon-fed,  a 
change  in  the  character  of  its  food  or  in  the  mode  of  preparation,  or  even  in 
the  quantity  given.  Sometimes  by  change  in  the  diet  and  the  adoption  of 
hygienic  measures  the  complaint  ceases,  so  as  to  require  no  medication. 
Sometimes  the  temporary  abstinence  from  milk-food,  and  the  employment 
of  barley  gruel  in  its  place  or  the  use  of  barley  gruel  and  peptonized  milk, 
suffice  to  cure  the  diarrhoea.  If  medicines  be  needed  and  the  symptoms  are 
not  urgent,  it  is  occasionally  advantageous  to  commence  treatment  by  the  use 
of  one  of  the  milder  purgatives  in  a  small  dose.  In  the  ivfant,  in  whom  the 
dejections  are  so  generally  acid,  an  alkaline  laxative  or  a  laxative  conjoined 
with  an  alkali  often  has  a  good  effect  as  preliminary  treatment.  Half  a  tea- 
spoonful  to  one  teaspoonful  of  castor  oil  or  a  proportionate  dose  of  calcined 
magnesia  removes  any  acid  or  irritating  substance  from  the  intestines,  and  is 
followed  by  a  diminution  in  the  number  of  stools.  The  improvement,  how- 
ever, without  subsequent  treatment  is  usually  only  for  a  day  or  two.  In  this 
<;ity  a  purgative  dose  of  castor  oil  is  often  given  as  a  domestic  remedy  in 
infantile  diarrhoea,  the  beneficial  effect  from  it  having  popularized  its  use  for 
this  purpose.  Trousseau  usually  gave  Eochelle  salts,  but  this  medicine  is 
too  severe  and  dangerous  for  the  treatment  of  infantile  diarrhoea,  especially 
in  v/arm  months. 

If  there  have  been  previous  constipation  and  the  diarrhoea  have  just  com- 
menced, a  purgative  is  obviously  indicated.  West  says :  "  Provided  there 
be  neither  much  pain  nor  much  tenesmus,  and  the  evacuations,  though 
watery,  are  fecal  and  contain  little  mucus  and  no  blood,  very  small  doses  of 
the  sulphate  of  magnesia  and  tincture  of  rhubarb  have  seemed  to  me  more 
useful  than  any  other  remedy  : 


INTESTINAL  CATARRH  OF  INFANCY.  785 

R.  Magnesias  sulphatis,  3,j  ; 

Tinct.  rhei,  ,5j  ; 

Syr.  zingiberis,  3J  ; 

Aqiia'  carui,  gix.     Misce. 

3j  ter  (lie  for  children  one  year  old. 

I  seldom  fail  to  observe  from  it  a  speedy  diminution  in  the  frequency  of 
the  action  of  the  bowels,  and  a  return  of  the  natural  character  of  the 
evacuations." 

Since  many  cases  of  simple  diarrhoea  are  due  to  the  use  of  food  which 
does  not  readily  digest,  but  undergoes  in  part  fermentation,  the  food  should 
be  carefully  selected  and  prepared  according  to  the  directions  given  in  the 
chapters  relating  to  artificial  feeding.  In  cases  of  fermentation,  due  often 
to  microbic  agency,  the  digestion  is  very  imperfect,  and  the  diarrhoea  which 
results  is  often  best  treated,  so  far  as  medicines  are  concerned,  by  the  use  of 
pepsin  and  bismuth  subnitrate,  as  ten  or  fifteen  grains  of  pepsinum  sac- 
charate  and  bismuth  subnitrate,  given  at  each  feeding,  with  perhaps  an  equal 
quantity  of  bismuth  in  mistura  creta  midway  between  the  feedings. 

In  the  simple  diarrhoea  of  infants  the  compound  powder  of  chalk  and 
opium  is  sometimes  an  excellent  medicine,  containing  as  it  does  an  astringent 
with  the  opiate  and  alkali.  It  may  be  given  in  doses  of  three  grains  to  a 
child  one  year  old  every  three  hours  midway  between  the  feedings.  The 
following  is  a  convenient  formula  for  administering  substantially  the  same 
medicines  in  the  liquid  form  : 

R.  Tinct.  opii  deodorat.,  gtt.  xvj  ; 

Bismuth,  subnitrat.,  gij ; 

Syr.  simplic,  Jss; 

Mistur.  cretfe,  ^iss.     Misce. 

Shake  well,  and  give  one  teaspoonful  every  three  hours  between  the  feedings. 

I  often  employ  this  prescription  or  one  similar  to  it  at  my  first  visit.  If 
the  patient  be  not  relieved  by  the  opiate,  alkali,  and  bismuth,  and  by  proper 
regimen,  in  all  probability  inflammation  of  the  intestinal  mucous  membrane 
is  present.  In  patients  over  the  age  of  two  or  three  years  simple  diarrhoea 
approaches  in  character  that  of  the  adult,  and  the  treatment  appropriate  for 
the  adult  is  proper  in  these  cases,  allowance  being  made  for  the  difference  in 
age.  In  infants,  in  whom  this  disease,  if  protracted,  very  soon  becomes  an 
undoubted  entero-colitis,  attended  if  it  be  protracted  by  emaciation  and  weak 
heart,  alcoholic  stimulants  are  often  required  at  an  early  period  on  account 
of  the  prostration  and  feeble  power  of  endurance. 


CHAPTER    VIII. 

INTESTINAL  CATARRH   OF  INFANCY   (ENTERO-COLITIS). 

It  is  customary  with  writers  to  treat  of  inflammation  of  the  small  and 
large  intestines  in  infancy  as  a  single  disease,  for  the  following  reasons : 
First,  the  symptoms  of  colitis  at  this  period  of  life  do  not  ordinarily  differ, 
in  any  marked  degree,  from  those  of  enteritis.  The  tormina,  tenesmus,  and 
abdominal  tenderness  which  characterize  colitis  in  childhood  and  adult  life 
are  ordinarily  lacking  or  are  not  appreciable  by  the  observer,  and  the  muco- 
sanguineous  evacuations  are  oftener  absent  than  present.     On  account  of  this 

50 


786  INTESTINAL   CATARRH  OF  INFANCY. 

absence  of  symptoms  Bouchut  says :  "  Dysentery  is  a  very  rare  disease 
among  young  children.  Its  existence  might  even  be  denied  if  it  had  not 
been  observed  at  the  period  of  some  severe  epidemics  of  dysentery."  If 
Bouchut  refers  by  the  term  dysentery  to  the  ordinary  phenomena  of  that 
disease,  his  remark  is  correct ;  but  as  regards  the  lesions  it  is  erroneous,  for 
colitis  is  a  common  infantile  malady.  Billard,  after  analyzing  eighty  cases 
of  intestinal  inflammation  in  infants,  says  :  "  From  this  calculation  it  is 
evidently  very  difficult  to  make  a  correct  diagnosis  of  inflammation  of  the 
intestinal  tube  in  sucking  infants,  yet  it  would  seem  as  if  the  proper  signs 
of  enteritis  or  ileitis  were  the  rapid  tympanitis  of  the  abdomen,  the  diar- 
rhoea, accompanied  with  vomiting ;  while  in  colitis,  diarrhoea  alone,  without 
tympanitis,  is  the  most  frequent."  And  again :  "  In  consequence  of  the 
impossibility  we  have  found  to  exist  of  tracing  with  exactitude  the  series  of 
symptoms  proper  to  inflammation  of  the  different  portions  of  the  digestive 
tube,  we  shall  content  ourselves  with  presenting  an  analytical  sketch  of  the 
causes,  symptoms,  and  ordinary  course  of  inflammation  of  the  mucous  mem- 
brane of  the  intestines  in  general." 

The  frequent  absence  of  any  pathognomonic  symptom  or  sign  by  which 
to  determine  the  exact  seat  of  intestinal  inflammation  in  the  infant  is  admitted 
by  recent  observers  as  well  as  Billard. 

The  second  reason  why  intestinal  inflammation  in  the  infant  is  described 
as  a  single  disease  is,  that  enteritis  and  colitis  in  the  majority  of  cases  coexist. 
This  will  be  seen  when  we  come  to  speak  of  the  anatomical  characters. 

In  rural  districts  infantile  diarrhoea  is  not  so  prevalent  and  fatal  as  in 
cities.  In  the  farming  sections  it  does  not  materially  increase  the  death-rate, 
and  it  is  therefore  not  so  important  a  malady  as  in  cities.  In  cities  it  largely 
increases  the  aggregate  of  deaths.  Especially  fatal  is  that  form  of  it  which 
is  known  as  the  summer  epidemic,  as  is  seen  by  the  mortuary  records  of 
any  large  city.  Thus,  in  New  York  City  during  1882  the  deaths  from  diar- 
rhoea reported  to  the  Health  Board,  tabulated  in  months,  were  as  follows : 

Jan.  Feb.  Mar.  Apr.  May.  June.  July.  Aug.  Sept.  Oct.  Nov.  Dec. 
Under  five  years  .  .34  32  50  50  72  231  1533  817  362  195  68  35 
Over  five  years  ...  14       15       14       20       15         19       131     149       84      55     31      24 

It  is  seen  that  in  1882  in  New  York  City  the  deaths  from  diarrhoea  under 
the  age  of  five  years  were  greatly  in  excess  of  the  number  during  the  whole 
period  of  life  subsequently  to  that  age. 

The  following  statistics  show  how  great  a  destruction  of  life  this  malady 
causes  even  under  the  surveillance  of  an  energetic  Health  Board ;  and  before 
this  Board  was  established  it  was  much  greater,  as  I  had  abundant  opportuni- 
ties to  observe.  The  last  annual  report  of  the  New  York  Board  of  Health 
was  made  in  1875,  since  which  time  weekly  bulletins  have  been  issued.  The 
deaths  from  diarrhoea  at  all  ages  in  the  last  three  years  in  which  annual 
reports  were  issued  were  as  follows : 

1873.  1874.  1875. 

January 94  43  46 

February 84  34  52 

March  .' 93  40  58 

April 114  47  45 

May 95  61  89 

June 220  144  157 

July 1514  1205  1387 

August 967  1007  1012 

September 424  587  608 

October 213  255  185 

November 87  105  57 

December 53  56  50 


l-JTIOLOUY.  787 

In  its  annual  report  for  1S70  the  Board  states:  "The  mortality  from  the 
diarrh(jeal  affections  amounted  to  2789,  or  83  per  cent,  of  the  total  deaths  ; 
and  of  these  deaths,  95  per  cent,  occurred  in  children  less  than  five  years 
old,  92  per  cent,  in  children  less  than  two  years  old,  and  07  per  cent,  in  those 
less  than  a  year  old."  Every  year  the  reports  of  the  Flealth  Board  furnish 
similar  statistics,  but  enough  have  been  given  to  show  how  great  a  sacrifice 
of  life  infantile  diarrhoea  produces  annually  in  this  city. 

What  we  observe  in  New  York  in  reference  to  this  disease  is  true  also,  to 
a  greater  or  less  extent,  in  other  cities  of  this  country  and  Europe,  so  far  as 
we  have  reports.  Not  in  every  city  is  there  the  same  proportionate  mortality 
from  this  cause  as  in  New  York,  but  the  frequency  of  infantile  diarrhoea  and 
the  mortality  which  attends  it  render  it  an  important  disease  in,  I  believe, 
most  cities  of  both  continents.  In  country  towns,  whether  in  villages  or 
farm-houses,  this  disease  is  comparatively  unimportant,  inasmuch  as  few  cases 
occur  in  them,  and  the  few  that  do  occur  are  of  mild  type,  and  consequently 
much  less  fatal  than  in  cities. 

The  comparative  immunity  of  rural  districts  has  an  important  relation,  as 
we  will  see,  to  the  hygienic  management  of  these  cases. 

Etiology. — The  intestinal  catarrh  of  infants  is  occasionally  produced  by 
taking  cold.  Infants  insufficiently  protected  by  clothing  and  exposed  to 
sudden  changes  of  temperature  or  to  currents  of  air  in  the  apartments 
where  they  reside,  or  heedlessly  exposed  outdoor  by  careless  nurses,  some- 
times become  afiected  with  diarrhoea,  even  of  a  fatal  character.  They  con- 
tract an  intestinal  inflammation  from  taking  cold,  just  as  other  infants  may 
contract  coryza  or  bronchitis  from  the  same  cause. 

But  the  most  common  causes  of  infantile  diarrhoea  are,  first,  the  use  of 
food  which  is  unsuitable  for  infantile  digestion,  and  which  therefore  acts  as 
an  irritant ;  and,  secondly,  residence  in  a  foul  atmosphere,  to  which  we  will 
soon  call  attention,  and  which  largely  increases  the  percentage  of  deaths  in 
our  cities  during  the  hot  months.  Diarrhoea  due  to  taking  cold  occurs  in  all 
localities  and  climates,  but  it  is  obviously  most  common  in  times  of  change- 
able weather.  That  due  to  the  use  of  unsuitable  food  and  foul  air  occurs  for 
the  most  part  in  cities,  and  much  more  frequently  in  the  summer  season  than 
in  the  cool  months,  as  the  above  statistics  show.  Infantile  intestinal  catarrh, 
however  produced,  presents  nearly  the  same  anatomical  characters,  so  that, 
whatever  its  etiology,  it  is  proper  to  describe  it  as  one  disease ;  but  that  form 
of  it  which  requires  most  elucidation,  and  the  causes  of  which  we  will  con- 
sider in  the  following  pages,  is  that  produced  by  impure  air  and  improper 
diet. 

The  prevalence  and  severity  of  infantile  diarrhoea  in  cities  correspond 
closely  with  the  degree  of  atmospheric  heat,  as  may  be  inferred  from  the 
foregoing  statistics.  In  New  York  this  disease  begins  in  the  month  of  May 
— earlier  in  some  years  than  in  others — in  a  few  scattered  cases,  commonly 
of  a  mild  type.  Cases  become  more  and  more  numerous  and  severe  as  the 
weather  grows  warmer,  until  July  and  August,  when  the  diarrhoea  attains  its 
maximum  prevalence  and  severity.  In  these  two  months  it  is  by  far  the  most 
frequent  and  fatal  of  all  the  diseases  in  the  cities.  In  the  middle  of  Sep- 
tember new  patients  begin  to  be  less  common,  and  in  the  latter  part  of  this 
month  and  subsequently  new  cases  do  not  occur,  unless  under  unusual  cir- 
cumstances which  favor  the  development  of  this  malady.  In  New  York  a  con- 
siderable number  of  deaths  of  infants  occur  from  diarrhoea  in  October.  October 
is  not  a  hot  month  in  our  latitude — its  average  temperature  is  lower  than  that 
of  May — and  yet  the  mortality  from  this  disease  is  considerably  larger  in  the 
former  than  in  the  latter  month.  This  fact,  which  seems  to  show  that  the 
prevalence   of  the  summer  diarrlnca  does  not  correspond  with  the  degree  of 


788  INTESTINAL   CATARRH  OF  INFANCY. 

atmospheric  heat,  is  readily  explained.  The  mortality  in  October,  and  indeed 
in  the  latter  part  of  September,  is  not  that  of  new  cases,  but  is  mainly  of 
infants,  as  I  have  observed  every  year,  who  contract  the  disease  in  July  or 
August  or  earlier,  and  linger  in  a  state  of  emaciation  and  increasing  weak- 
ness till  they  finally  succumb,  some  even  in  cool  weather. 

The  fact  is  therefore  undisputed,  and  is  universally  admitted,  that  the 
summer  season,  stated  in  a  general  way,  is  the  cause  of  this  annually  recur- 
ring diarrhoeal  epidemic.  That  atmospheric  heat  does  not  in  itself  cause 
the  diarrhoea  is  evident  from  the  fact  that  in  rural  districts  there  is  the  same 
intensity  of  heat  as  in  cities,  and  yet  the  summer  complaint  does  not  occur. 
The  cause  must  be  looked  for  in  the  state  of  the  atmosphere  engendered  by 
heat  where  unsanitary  conditions  exist,  as  in  large  cities.  Moreover,  obser- 
vations show  that  the  noxious  effluvia  with  which  the  air  becomes  polluted 
under  such  circumstances  constitute  or  contain  the  morbific  agent.  Thus,  in 
one  of  the  institutions  of  this  city  a  few  years  since,  on  May  10th,  which 
happened  to  be  an  unusually  warm  day  for  this  month,  an  offensive  odor  was 
noticed  in  the  wards,  which  was  traced  to  a  large  manure  heap  that  was  being 
upturned  in  an  adjacent  garden.  On  this  day  four  young  children  were 
severely  attacked  by  diarrhoea,  and  one  died.  Many  other  examples  might 
be  cited  showing  how  the  foul  air  of  the  city  during  the  hot  months,  when 
animal  and  vegetable  decomposition  is  most  active,  causes  diarrhoea.  Several 
years  since,  while  serving  as  sanitary  inspector  for  the  Citizens'  Association  in 
one  of  the  city  districts,  my  attention  was  particularly  called  to  one  of  the  streets, 
in  which  a  house-to-house  visitation  disclosed  the  fact  that  nearly  every 
infant  between  two  avenues  had  diarrhoea,  and  usually  in  a  severe  form,  not 
a  few  dying.  The  street  was  compactly  built  with  wooden  tenement-houses 
on  each  side,  and  contained  a  dense  population,  mainly  foreigners,  poor, 
ignorant,  and  filthy  in  their  habits.  It  had  no  sewer,  and  the  refuse  of  the 
kitchens  and  bed-chambers  was  thrown  into  the  street,  where  it  accumulated 
in  heaps.  Water  trickled  down  over  the  sidewalks  from  the  houses  into  the 
gutters  or  was  thrown  out  as  slops,  so  that  it  kept  up  a  constant  moisture  of 
the  refuse  matter  which  covered  the  street,  and  promoted  the  decay  of  the 
animal  and  vegetable  substances  which  it  contained.  The  air  in  the  domiciles 
and  street  under  such  conditions  of  impurity  was  necessarily  foul  in  the 
extreme,  and  stifling  during  the  hot  days  and  nights  of  July  and  August ; 
and  it  was  evidently  the  important  factor  in  producing  the  numerous  and 
severe  diarrhoeal  cases  which  were  in  these  domiciles. 

In  another  locality,  occupied  by  tripe-dealers  and  a  low  class  of  butchers 
who  carried  on  fat-  and  bone-boiling  at  night,  the  air  was  so  foul  after  dark 
that  the  peculiar  impurity  which  tainted  it  could  be  distinctly  noticed  in  the 
mouth  for  a  considerable  time  after  a  night  visit.  In  the  street  where  these 
nuisances  existed  and  in  adjacent  streets  the  summer  diarrhoea  was  very 
prevalent  and  destructive  to  human  life.  Murchison  states  that  20  out  of  25 
boys  were  aff"ected  with  purging  and  vomiting  from  inhaling  the  effluvia  from 
the  contents  of  an  old  drain  near  their  school-room.  Physicians  are  familiar 
with  a  similar  fact  showing  this  purgative  effect  of  impure  air — that  the 
atmosphere  of  a  dissecting-room  often  causes  diarrhoea  in  those  otherwise 
healthy. 

The  impurities  in  the  air  of  a  large  city  are  very  numerous.  Among  those 
of  a  gaseous  nature  are  sulphurous  acid,  sulphuric  acid,  sulphuretted  hydro- 
gen ;  various  gases  of  the  carbon  group,  as  carbonic  acid,  carburetted  hydrogen, 
and  carbonic  oxide  ;  gases  of  the  nitrogen  group,  as  the  acetate,  sulphide, 
and  carbonate  of  ammonium,  nitrous  and  nitric  acids ;  and  at  times  com- 
pounds of  phosphorus  and  chlorine  (Parkes).  A  theory  deserving  conlider- 
ation  is  that  certain  gaseous  impurities  found  in  the  air  form  purgative  com- 


ETIOLOGY.  789 

binations.  1).  F.  Lincoln,  in  his  interesting  paper  on  the  atmosphere  in  the 
Cyclopedia  (if  Medicine,  writes  in  regard  to  sulphuretted  hydrogen  :  "  When 
in  the  air,  freely  exposed  to  the  contact  of  oxygen,  it  becomes  sulphuric  acid. 
Sulphide  of  ammonium  in  the  same  circumstances  becomes  a  sulphate, 
which,  encountering  common  salt  (chloride  of  sodium),  produces  sulphate  of 
sodium  and  chloride  of  ammonium.  The  sulphates  form  a  characteristic 
ingredient  of  the  air  in  manufacturing  districts."  The  sulphates,  w^e  know, 
are  for  the  most  part  purgatives,  but  whether  they  or  other  chemical  agents 
exist  in  the  respired  air  in  sufficient  quantity  to  disturb  the  action  of  the 
intestines,  even  where  atmospheric  impurities  are  most  abundant,  is  problem- 
atical and  uncertain. 

Again,  the  solid  impurities  in  the  air  of  a  large  city  are  very  numerous, 
as  any  one  may  observe  by  viewing  a  sunbeam  in  a  darkened  room  which  is 
made  visible  by  the  numerous  particles  floating  in  it.  These  particles  consist 
largely  of  organic  matter,  which  sometimes  has  been  carried  a  long  distance 
by  the  wind.  The  remarkable  statement  has  been  made  that  in  the  air  of 
Berlin  organic  forms  have  been  found  of  African  production.  Ehrenberg 
discovered  fragments  of  insects  of  various  kinds — rhizopods,  tardigrades, 
polygastrics,  etc. — which,  existing  in  considerable  quantity  and  inhaled  in 
hot  weather  when  decomposition  and  fermentation  are  most  active,  may  be 
deleterious  to  the  system.  Monads,  bacteria,  vibriones,  amorphous  dust  con- 
taining spores  which  retain  their  vitality  for  months,  are  among  the  substances 
found  in  the  air  of  cities.  The  well-known  hazy  appearance  of  the  atmosphere 
resting  over  a  large  city  like  New  York  when  viewed  from  a  distance  is  due 
to  the  gaseous  and  solid  impurities  with  which  the  air  is  so  abundantly  sup- 
plied—  impurities  which  assume  importance  in  pathological  studies,  since 
minute  organisms  are  now  believed  to  cause  so  many  diseases  the  etiology  of 
which  has  heretofore  been  obscure.  There  can  be  no  reasonable  doubt,  from 
recent  investigations,  that  the  deleterious  agents  which  cause  the  form  of 
diarrhoea  which  we  are  considering  are  to  a  great  extent  bactei'ia,  which  find  a 
soil  most  favorable  for  their  propagation  where  the  air  as  well  as  ingesta  con- 
tains impurities.  In  foul  air,  as  in  the  summer  season,  in  the  crowded  parts 
of  the  city,  and  especially  where  decomposing  animal  and  vegetable  matter 
exists,  the  number  of  micro-organisms  is  vastly  greater,  as  different  observers 
have  remarked,  than  in  salubrious  localities.  Foul  air  and  unwholesome  food 
— food  that  has  begun  to  undergo  decomposition  or  that  digests  with  difficulty, 
so  that  part  of  it  ferments — afford  the  conditions  which  are  eminently  favor- 
able for  the  development  of  pathogenic  as  well  as  non-pathogenic  germs.  We 
have  seen  that  Booker  and  Vaughan  have  found  bacteria  in  diarrhoeal  stools 
which  when  isolated  by  cultivation  either  kill  or  cause  intestinal  catarrh  in 
animals  experimented  on,  or  the  ptomaines  produced  by  the  bacteria  have 
this  eflfect.  The  evidence,  therefore,  is  strong  that  bacteria  are  the  chief 
causal  agents  of  those  forms  of  diarrhcea  which  originate  from  foul  air  and 
unwholesome  and  indigestible  food. 

In  those  portions  of  our  cities  which  are  occupied  by  the  poor  more  than 
anywhere  else  those  conditions  prevail  which  render  the  atmosphere  foul  and 
unwholesome.  One  accustomed  to  the  pure  air  of  the  country  would  scarcely 
believe  how  stifling  and  poisonous  the  atmosphere  becomes  during  the  hot 
summer  days  and  close  summer  nights  in  and  around  the  domiciles  in  the 
poor  quarters  of  the  city.  Among  the  causes  of  this  foul  air  may  be  men- 
tioned too  dense  a  population,  the  occupancy  of  small  rooms  by  large  families, 
rigid  economy  and  ceaseless  endeavor  to  make  ends  meet,  so  that  in  the 
absorbing  interest  sanitary  requirements  are  sadly  neglected.  Adults  of  such 
families,  and  children  of  both  sexes  as  soon  as  they  are  old  enough,  engage 
in  laborious  and  often  filthy  occupations.     Many  of  them  seldom  bathe,  and 


790  INTESTINAL   CATARRH  OF  INFANCY. 

they  often  wear  for  days  the  same  under-garments,  foul  with  perspiration  and 
dirt.  The  intemperate,  vicious,  and  indolent,  who  always  abound  in  the  quar- 
ters of  the  city  poor,  are  notoriously  filthy  in  their  habits  and  add  to  the  insa- 
lubrity by  their  presence.  Children  old  enough  to  be  in  the  streets  and  adults 
away  at  their  occupations  escape  to  a  great  extent  the  evil  effects  of  impure 
air,  but  the  infantile  population  always  suffer  severely. 

Every  physician  who  has  witnessed  the  summer  diarrhoea  of  infants  is 
aware  of  the  fact  that  the  mode  of  feeding  has  much  to  do  with  its  occur- 
rence. A  large  proportion  of  those  who  each  summer  fall  victims  to  it 
would  doubtless  escape  if  the  feeding  were  exactly  proper.  In  New  York 
City  facts  like  the  following  are  of  common  occurrence  in  the  practice  of  all 
physicians :  Infants  under  the  age  of  eight  months,  if  bottle-fed,  nearly 
always  contract  diarrhoea,  and  usually  of  an  obstinate  character,  during  the 
summer  months.  The  younger  the  infant,  the  less  able  is  it  to  digest  any 
other  food  than  breast-milk,  and  tHe  more  liable  is  it  therefore  to  suffer  from 
diarrhoea  if  bottle-fed.  In  the  institutions"  nearly  every  bottle-fed  infant 
under  the  age  of  four  or  even  six  months  dies  in  the  hot  months  with  symp- 
toms of  indigestion  and  intestinal  catarrh,  while  the  wet-nursed  of  the  same 
ages  remain  well.  Sudden  weaning,  the  sudden  substitution  of  cow's  milk 
or  an  artificially  prepared  food  in  place  of  breast-milk  in  hot  weather,  almost 
always  produces  diarrhoea,  often  of  a  severe  and  fatal  nature.  Feeding  an 
infant  in  the  hot  months  with  indigestible  and  improper  food,  as  fruits  with 
seeds  or  the  ordinary  table  food  prepared  in  such  a  way  that  it  overtaxes  the 
digestive  function  of  the  infant,  causes  diarrhoea,  and  not  infrequently  that 
severe  form  of  it  which  will  be  described  under  the  term  cholera  infantum. 
Many  obstinate  cases  of  the  summer  complaint  begin  to  improve  under 
change  of  diet,  as  by  the  substitution  of  one  kind  of  milk  for  another 
or  the  return  of  the  infant  to  the  breast  after  it  has  been  temporarily 
withdrawn  from  it.  It  is  a  common  remark  in  the  families  of  the  city  poor 
that  the  second  summer  is  the  period  of  greatest  danger  to  infants.  This 
increased  liability  of  infants  to  contract  diarrhoea  in  the  second  summer 
is  due  to  the  fact  that  most  infants  in  their  second  year  are  table-fed,  while 
in  the  first  year  they  are  wet-nursed.  Such  facts,  with  which  all  physicians 
are  familiar,  show  how  important  the  diet  is  as  a  factor  in  causing  the  sum- 
mer complaint. 

Occasionally,  from  continued  ill-health,  the  milk  of  the  mother  or  wet- 
nurse  does  not  agree  with  the  nursling.  Examined  with  the  microscope, 
it  is  found  to  contain  colostrum.  Under  such  circumstances  if  a  healthy 
wet-nurse  be  employed  the  diarrhoea  ceases.  It  is  very  important  that  any 
woman  furnishing  breast-milk  to  an  infant  should  lead  a  quiet  and  regular 
life,  with  regular  meals  and  sleep.  R.  B.  Gilbert^  relates  striking  cases  in 
which  venereal  excesses  on  the  part  of  wet-nurses  were  immediately  followed 
by  fatal  diarrhoea  in  the  infants  whom  they  suckled. 

One  not  a  resident  would  scarcely  be  able  to  appreciate  the  difficulty 
which  is  experienced  in  a  large  city  in  obtaining  proper  diet  for  young  chil- 
dren, especially  those  of  such  an  age  that  they  require  milk  as  the  basis  of 
their  food.  Milk  from  cows  stabled  in  the  city  or  having  a  limited  pastur- 
age near  the  city,  and  fed  upon  a  mixture  of  hay  with  garden  and  distillery 
products,  the  latter  often  largely  predominating,  is  unsuitable.  It  is  defici- 
ent in  nutritive  properties,  prone  to  fermentation,  and  from  microscopical  and 
chemical  examinations  which  have  been  made  it  appears  that  it  often  con- 
tains deleterious  ingredients.  If  milk  be  obtained  from  distant  farms,  where 
pasturage  is  fresh  and  abundant — and  in  New  York  City  this  is  the  usual 
source  of  the  supply — considerable  time  elapses  before  it  is  served  to  cus- 

^  Louisville  Med.  Journal,  Aug.  19,  1882, 


ETIOLOGY.  791 

tomers,  so  that,  particulurly  in  the  liot  months  of  July  and  August,  it  fre- 
quently has  begun  to  undergo  lactic-acid  fermentation  when  the  infants 
receive  it.  That  dispensed  to  families  in  the  morning  is  the  milking  of  the 
previous  morning  and  evening.  The  use  of  this  milk  in  midsummer  by 
infants  under  the  age  of  ten  months  frequently  gives  rise  to  more  or  less 
diarrhoea. 

The  ill-success  of  feeding  with  c(nv's  n)ilk  has  led  to  the  preparation  of 
various  kinds  of  food  which  the  shops  contain,  but  no  dietetic  preparation  has 
yet  appeared  which  agrees  so  well  with  the  digestive  function  of  the  infant  as 
breast-milk,  and  is  at  the  same  time  sufficiently  nutritive. 

In  New  York  City  inqiroper  diet,  unaided  by  the  conditions  which  hot 
weather  produces,  is  a  common  cause  of  diarrhoea  in  young  infants,  for  at  all 
seasons  Ave  meet  with  this  diarrhoea  in  infants  who  are  bottle-fed ;  but  when 
the  atmospheric  conditions  of  hot  weather  and  the  use  of  food  unsuitable  for 
the  age  of  the  infant  are  both  present  and  operative,  this  diarrhoea  so  increases 
in  frequency  and  severity  that  it  is  proper  to  designate  it  the  summer  epidemic 
of  the  cities.  Several  years  since,  before  the  New  York  Foundling  Asylum 
was  established,  the  foundlings  of  New  York,  more  than  a  thousand  annually, 
were  taken  to  the  almshouse  on  Blackwell's  Island  and  consigned  to  the  care 
of  pauper-women,  who  were  mostly  old,  infirm,  and  filthy  in  their  habits  and 
apparel.  Their  beds,  in  which  the  foundlings  were  also  placed  alongside  of 
them,  were  seldom  clean,  not  properly  aired  and  washed,  and  under  the  beds 
were  various  garments  and  utensils  which  these  pauper-women  had  brought 
with  them  as  their  sole  property  from  their  miserable  abodes  in  the  city. 
With  such  surroundings  the  air  which  these  infants  breathed  day  and  night 
manifestly  contained  poisonous  emanations,  while  their  diet  was  equally 
improper,  for  it  was  prepared  by  these  women  from  such  milk  and  farinaceous 
food  as  were  furnished  the  almshouse.  When  assigned  to  duty  in  the  alms- 
house, this  service  being  at  that  time  a  branch  of  Charity  Hospital,  I  was 
informed  that  all  the  foundlings  died  before  the  age  of  two  months  ;  one  only 
was  pointed  out  as  a  curiosity  which  had  been  an  exception  to  the  rule.  The 
disease  of  which  they  perished  was  diarrhoea,  and  this  malady  in  the  summer 
months  was  especially  severe  and  rapidly  fatal.  The  unpleasant  experiences 
in  this  institution  furnished  additional  evidence,  were  any  wanting,  that  foul 
air  and  improper  diet  ai'e  the  two  important  factors  in  causing  the  summer 
diarrhoea  of  infants.  Since  that  beneficial  charity,  the  New  York  Foundling 
Asylum,  in  East  Sixty-eighth  street,  came  into  existence,  providing  pure  air 
and,  for  a  considerable  proportion  of  the  foundlings,  breast-milk,  many  of 
these   waifs  have  been  rescued  from  death. 

Affe. — Age  is  a  predisposing  cause  of  diarrhaea,  since  most  cases  occur 
under  the  age  of  three  years.  A  large  majority  of  the  summer  diarrhoeas  of 
the  cities  occur  under  the  age  of  two  years.  The  following  table  embraces 
all  the  cases  that  came  to  one  of  the  city  dispensaries  during  my  service 
between  the   months  of  May  and  October,  inclusive : 

Age.  Cases. 

5  months  or  under 58 

5  months  to  12  months      212 

12  months  to  18  months .  174 

18  months  to  24  months 93 

24  months  to  36  months .36 

Total 573 

Dentition. — Statistics  show  that  by  far  the  largest  number  of  cases  occur 
during  the  period  of  first  dentition  ;  hence  the  prevalent  opinion  among  fam- 
ilies that  dentition  causes  the  diarrhoea.     It  is  the  common  belief  among  the 


792  INTESTINAL   CATARRH  OF  INFANCY. 

poor  of  New  York  that  diarrhoea  occurring  during  dentition  is  conservative, 
and  should  not  be  checked.  They  believe  that  an  infant  cutting  its  teeth  suf- 
fers less,  and  may  be  saved  from  serious  illness,  if  it  have  frequent  stools. 
Every  summer  I  see  infants  reduced  to  a  state  of  imminent  danger  through 
the  continuance  of  diarrhoea  during  several  weeks,  nothing  having  been  done 
to  check  it  in  consequence  of  this  absurd  belief.  The  progressive  loss  of  flesh 
and  strength  and  wasting  of  the  features  do  not  excite  alarm,  under  the  blind- 
ing influence  of  this  theory,  till  the  diarrhoea  has  continued  so  long  and 
become  so  severe  that  it  is  with  difficulty  controlled,  and  the  patient  is  in  a 
state  of  real  danger  when  the  physician  is  first  summoned.  The  following 
statistics,  which  comprise  cases  occurring  during  my  service  in  one  of  the  city 
dispensaries,  show  the  preponderance  of  cases  during  the  age  when  dental 
evolution  is  occurring : 

Cases. 

No  teeth  and  no  marked  turgescence  of  gums -47 

Cutting  incisors  . 106 

Cutting  anterior  molai-s 41 

Cutting  canines 40 

Cutting  last  molars 20 

All  the  teeth  cut 28 

Total •   .    .    . 282 

It  so  happens  that  the  period  of  dental  evolution  corresponds  with  that  of 
the  most  rapid  development  and  the  greatest  functional  activity  of  the  gastric 
and  intestinal  follicles,  and  the  predisposition  which  exists  to  diarrhoeal  mala- 
dies at  this  age  must  be  attributed  to  this  cause  rather  than  to  dentition. 

Symptoms. — The  intestinal  catarrh  of  infancy  commonly  begins  gradually 
with  languor,  fretfulness,  and  slight  rise  of  temperature.  The  diarrhoea  at 
first  usually  attracts  little  attention  from  its  mildness.  The  stools,  while  they 
are  thinner  than  natural,  vary  in  appearance,  being  yellow,  brown,  or  green. 
Infants  with  milk  diet  usually  pass  green  and  acid  stools  containing  particles 
of  indigested  casein.  The  tongue  in  the  commencement  of  the  attack  is  moist 
and  covered  with  a  slight  fvir.  At  a  more  advanced  stage  it  may  be  moist, 
but  is  often  dry,  and  in  dangerous  forms  of  the  malady,  accompanied  by  pros- 
tration, the  buccal  surface  is  red  and  the  gums  more  or  less  swollen  and  some- 
times ulcerated.  Vomiting  is  common.  It  may  commence  simultaneously 
with  the  diarrhoea,  especially  when  food  that  is  unusually  indigestible  and 
irritating  to  the  stomach  has  been  given,  but  more  frequently  this  symptom 
does  not  appear  until  the  diarrhoea  has  continued  a  few  days.  I  preserved 
memoranda  of  the  date  when  vomiting  began  in  the  cases  treated  in  two  con- 
secutive years,  and  found  that  ordinarily  it  was  toward  the  close  of  the  first 
week.  When  it  is  an  early  and  prominent  symptom  it  appears  to  be  due  to 
the  presence  in  the  stomach  of  imperfectly  digested  or  fermented  and  acid 
food,  which,  when  ejected,  gives  a  decidedly  acid  reaction  with  appropriate 
tests.  It  contains  coagulated  casein  and  undigested  particles  of  whatever 
food  has  been  given.  In  many  patients  the  progressive  loss  of  flesh  and 
strength  is  largely  due  to  the  indigestion  and  vomiting,  by  which  the  food, 
which  is   so  much  required  for  proper  nourishment,  is  lost. 

Emesis  occurring  at  a  late  stage  of  infantile  diarrhoea  is  often  due  to 
commencing  spurious  hydrocephalus,  which  is  not  an  infrequent  complica- 
tion, as  we  will  see,  of  protracted  cases.  Perhaps  when  a  late  symptom  it 
may  sometimes  have  an  ursemic  origin,  for  the  urine  is  usually  quite  scanty 
in  advanced  cases.  It  seems  probable,  however,  that  deleterious  effects 
from  non-elimination  of  urea  are  to  a  considerable  extent  prevented  by  the 
diarrhoea. 

The  fecal  evacuations  may  remain   nearly  uniform  in  appearance  during 


SYMPTOMS.  793 

the  disease,  but  in  many  patients  they  vary  in  color  and  consistence  at  differ- 
ent periods.  In  the  same  ease  they  may  be  brown  and  offensive  at  one  time, 
green  at  another,  and  aj^ain  they  may  contain  masses  of  a  putty-like  appear- 
ance, the  partly-digested  casein  or  altered  epithelial  cells.  The  stools  some- 
times consist  largely  of  mucus,  with  or  without  occasional  streaks  of  blood, 
indicating  the  predominance  of  inflammation  in  the  colon.  This  is  the 
mucous  diarrhoea  of  Barrior.  The  stools  are  sometimes  yellow  when  passed, 
but  become  green  on  exposure  to  the  air  from  chemical  reaction  due  to 
admixture  with  the  urine,  or  to  the  agency  of  the  microbe  mentioned  above 
that  produces  green  coloring  matter. 

The  character  of  the  alvine  discharges  is  interesting.  In  addition  to 
undigested  casein  I  have  found  epithelial  cells,  single  or  in  clusters  (some- 
times regularly  arranged  as  if  detached  in  mass  from  the  villi),  fibres  of 
meat,  crystalline  formations,  mucus,  and  occasionally  blood,  as  stated  above. 
In  one  instance  I  observed  an  appearance  resembling  three  or  four  crypts  of 
Lieberkiihn  united,  probably  thrown  off"  by  ulceration.  If  the  stools  are 
green,  colored  masses  of  various  sizes,  but  mostly  small,  are  also  seen  under 
the  microscope. 

The  pulse  is  accelerated  according  to  the  severity  of  the  attack.  The 
heat  of  the  surface  is  at  first  generally  increased,  though  but  slightly  in 
ordinary  cases ;  but  when  the  vital  powers  begin  to  fail  from  the  continuance 
of  the  diarrhoea,  the  warmth  of  the  surface  diminishes.  In  advanced  cases 
approaching  a  fatal  termination  the  face  and  extremities  are  pallid  and 
cool,  and  the  pulse  gradually  becomes  more  frequent  and  feeble.  The  skin 
is  usually  dry,  and,  as  already  stated,  the  urinary  secretion  diminished.  In 
severe  cases  attended  by  frequent  alvine  discharges  the  infant  does  not  pass 
urine  oftener  than  once  or  twice  daily.  The  imperfect  action  of  the  skin 
and  kidneys  is  noteworthy. 

Protracted  cases  of  diarrhoea  are  frequently  complicated  by  two  cutaneous 
eruptions — erythema  extending  over  the  perineum  and  frequently  as  far  as 
the  thighs  and  lower  part  of  the  abdomen,  due  to  the  acid  and  irritating  cha- 
racter of  the  stools  ;  and  boils  upon  the  forehead  and  scalp.  The  latter  some- 
times extend  to  the  pericranium,  and  in  case  of  recovery  leave  permanent 
cicatrices.  This  furuncular  affection  of  the  scalp  has  seemed  to  me  useful 
in  consequence  of  the  external  irritation  which  it  causes,  since  it  occurs 
at  a  time  when,  on  account  of  the  feeble  heart's  action  and  languid  circula- 
tion, passive  congestion  of  the  vessels  of  the  brain  and  meninges  is  liable 
to  be  present. 

Patients  who  are  weak  and  wasted  in  consequence  of  protracted  diar- 
rhoea, remaining  almost  constantly  in  the  recumbent  position,  often  have  an 
occasional  dry  cough  which  continues  till  the  close  of  life.  It  is  due  to 
hypostatic  congestion  in  the  lungs,  usually  limited  to  the  posterior  and  infe- 
rior portions  of  the  lobes,  extending  but  a  little  way  into  the  lungs.  It  is 
the  result  of  prolonged  recumbency  with  feeble  heart's  action  and  feeble 
pulmonary  circulation.  Infants  reduced  by  chronic  diseases,  lying  day  after 
day  in  their  cribs,  with  little  movement  of  their  bodies,  are  very  liable  to 
this  passive  congestion  of  depending  portions  of  their  lungs,  toward  which 
the  blood  gravitates,  and  into  which  but  little  air  enters  in  consequence  of 
their  distance  and  position  and  the  feeble  respirations.  The  hyperaemia 
which  results  is  of  a  passive  character,  a  venous  congestion,  and  the  aff"ected 
lobules  have  a  dusky-red  color.  This  congestion,  continuing,  soon  results  in 
pneumonia  of  the  catarrhal  form,  subacute  and  of  a  low  grade,  for  pulmo- 
nary lobules  in  which  the  blood  remains  stagnant  soon  exhibit  augmented 
cell-proliferation,  perhaps  from  the  irritating  effiects  of  the  elements  of  the 
blood  now  withdrawn  from  the  circulation. 


794  INTESTINAL   CATARRH  OF  INFANCY. 

I  have  made  or  procured  a  considerable  number  of  microscopic  examina- 
tions in  these  cases  of  hypostatic  pneumonia,  and  the  solidification  of  the 
pulmonary  lobules  has  been  found  to  be  due  to  the  exaggerated  development 
of  the  epithelial  cells  in  the  alveoli,  together  with  venous  congestion.  The 
affected  lobules,  whether  in  a  stage  of  hypostatic  congestion  or  the  more 
advanced  stage  of  hypostatic  pneumonia,  when  examined  at  the  autopsy 
were  somewhat  softer  than  in  health,  of  dark  color,  and  many  of  the  lob- 
ules could  be  inflated  by  strong  force  of  the  breath ;  but  in  protracted  cases 
the  alveoli  in  central  parts  of  the  inflamed  area  resisted  insufflation.  The 
lung  in  hypostatic  pneumonia,  even  when  it  is  inflated,  still  feels  firmer 
between  the  fingers  than  the  normal  lung. 

Hypostatic  pneumonia  is  so  common  in  hospitals  for  infants  that  some 
physicians  whose  observations  have  been  chiefly  in  such  institutions  have 
almost  ignored  other  forms  of  pulmonary  inflammation.  Billard  many  years 
ago  wrote :  " .  .  .  .  The  pneumonia  of  young  children  is  evidently  the 
result  of  stagnation  of  blood  in  their  lungs.  Under  these  circumstances  the 
blood  may  be  regarded  as  a  kind  of  foreign  body."  Of  all  the  chronic  and 
exhausting  diseases  of  infancy,  no  one  has,  according  to  my  observations, 
been  so  frequently  complicated  by  hypostatic  pneumonia  as  the  disease  which 
we  are  considering,  although  it  does  not  usually  give  rise  to  any  more  prominent 
symptom  than  an  occasional  cough.  Limited  to  a  small  and  almost  immov- 
able part  of  the  lung,  it  does  not  ordinarily  accelerate  respiration  or  render 
it  painful,  and  the  cough  is  also  apparently  painless. 

When  the  progressive  loss  of  flesh  and  strength  has  continued  several 
weeks  and  the  patient  is  much  exhausted,  another  complication  is  liable  to 
occur,  known  as  spurious  hydrocephalus  or  the  hydrocephaloid  disease,  the 
anatomical  characters  of  which  will  be  described  in  the  proper  place.  The 
commencement  of  spurious  hydrocephalus  is  announced  by  gradually  increas- 
ing drowsiness,  perhaps  preceded  by  a  period  of  fretfulness.  Vomiting  and 
rolling  the  head  are  occasional  early  symptoms  of  this  complication.  As  the 
drowsiness  increases  the  pupils  become  less  sensitive  to  light  than  in  their 
normal  state,  and  are  usually  contracted.  When  the  drowsiness  becomes 
profound  and  constant  the  pupils  remain  contracted  as  in  sound  sleep  or  in 
opium  narcotism.  The  functional  activity  of  the  organs  is  now  also  dimin- 
ished, the  vomiting  ceases,  the  stools  become  less  frequent,  the  buccal  surface 
dry,  and  the  urine  scanty,  while  the  pulse  is  frequent  and  feeble.  Spurious 
hydrocephalus  either  continues  till  death  or  by  stimulation  the  patient  may 
emerge  from  it.     When  profound  the  usual  result  is  death. 

Although  infantile  diarrhoea  in  its  commencement  may  be  promptly 
arrested  by  proper  hygienic  and  medicinal  treatment,  if  it  continue  a  few 
weeks  the  anatomical  changes  which  occur  are  such  that  recovery,  if  it  take 
place,  is  necessarily  slow  and  gradual.  Improvement  is  shown  by  better 
digestion,  fewer  stools  and  of  better  appearance,  less  frequent  vomiting,  a 
more  cheerful  countenance,  and  the  absence  of  symptoms  which  indicate  a 
complication.  Many  recover  after  days  of  anxious  watching  and  perhaps 
after  many  fluctuations. 

Death  may  occur  early  from  a  sudden  aggravation  of  symptoms  and  rapid 
sinking,  or  the  attack  may  be  so  violent  from  the  first  that  the  infant  quickly 
succumbs  ;  but  more  frequently  death  takes  place  after  a  prolonged  sickness. 
Little  by  little  the  patient  loses  flesh  and  strength  till  a  state  of  marked 
emaciation  is  reached.  The  eyes  and  cheeks  are  sunken,  the  bony  projections 
of  the  face,  trunk,  and  limbs  become  prominent,  and  the  skin  lies  in  wrinkles 
from  the  wasting.  The  altered  expression  of  the  face  makes  the  patient 
look  older  than  the  actual  age.  The  joints  in  contrast  with  the  wasted 
extremities  seem  enlarged  and  the  fingers  and   toes  elongated.     The  stools 


ANATOMICAL   CHARACTERS.  795 

diminish  in  frequency  from  diminished  peristaltic  and  vermicular  action,  and 
vomiting,  if  previously  present,  now  ceases.  A  feeble,  quick,  and  scarcely 
appreciable  pulse,  slow  respiration,  and  diminished  inflation  of  the  lungs, 
sightless  and  contracted  pupils,  over  which  the  eyelids  no  longer  close, 
announce  the  near  approach  of  death.  The  drowsiness  increases  and  the 
limbs  become  cool,  while  perhaps  the  head  is  hot.  The  infant  no  longer  has 
the  ability  to  nurse,  or  if  bottle-fed  the  food  placed  in  the  mouth  flows  back 
or  is  swallowed  with  apparent  indifference.  So  low  is  its  vitality  that  it  lies 
pallid  and  almost  motionless  for  hours  or  even  days  before  death,  and  death 
occurs  so  quietly  that  the  moment  of  its  occurrence  is  scarcely  appreciable. 

Anatomical  Characters. — Since  the  prominent  and  essential  symptoms 
of  the  disease  which  we  are  considering  pertain  to  the  digestive  apparatus, 
it  is  evident  that  the  lesions  which  attend  and  characterize  it  are  to  be  found 
in  this  part  of  the  system.  Lesions  elsewhere,  so  far  as  they  are  appreciable 
to  us,  are  secondary  and  not  essential.  I  have  witnessed  a  large  number  of 
autopsies  of  infants  who  have  perished  from  diarrhoea,  chiefly  in  institutions, 
and  they  have  been  sufficiently  marked  and  uniform  to  enable  us  to  desig- 
nate it  an  entero-colitis.  Several  years  since  I  preserved  records  of  the 
autopsical  appearances  in  the  intestinal  catarrh  of  infants,  most  of  them  being 
cases  of  summer  diarrhoea.  The  number  aggregated  eighty-two.  Since  then 
I  have  witnessed  many  autopsies  in  institutions  in  cases  of  this  disease,  and 
the  lesions  observed  were  similar  to  those  in  the  eighty-two  cases. 

The  question  may  properly  be  asked.  Can  inflammatory  hyperaemia  of  the 
intestinal  mucous  membrane  be  distinguished  from  simple  congestion  if  there 
be  no  ulceration  and  no  appreciable  thickening  of  the  intestine  ?  It  is  pos- 
sible that  occasionally  I  have  recorded  as  inflammatory  what  was  simply  a 
congestive  lesion,  but  I  do  not  think  I  have  incorporated  a  sufficient  number 
of  such  cases  to  vitiate  the  statistics.  In  a  large  proportion  of  the  cases 
there  was  evident  thickening  of  the  intestinal  mucous  membrane  or  other 
unequivocal  evidence  of  inflammation.  The  following  is  an  analysis  of  the 
82  cases  :  The  duodenum  and  jejunum  presented  the  appearance  of  inflam- 
matory hyperaemia  in  12  cases..  The  hypergemia  was  usually  in  patches  of 
variable  extent  or  of  that  form  described  by  the  term  arborescent.  In  51 
cases  the  duodenal  and  jejunal  mucous  membrane  was  pale  and  without  any 
other  appearance  characteristic  of  catarrh  or  inflammation.  In  the  remain- 
ing 19  cases  the  appearance  of  the  duodenum  and  jejunum  was  not  recorded, 
so  that  it  was  probably  normal.  On  the  other  hand,  in  the  ileum  inflam- 
matory lesions  were  present  as  a  rule.  In  49  cases  I  found  the  surface  of 
the  ileum  distinctly  hyperaemic,  and  in  that  portion  of  it  nearest  the  ileo- 
cecal valve,  including  the  valve  itself,  the  inflammation  had  evidently  been 
the  most  intense,  since  in  this  portion  the  hyperasmia  and  thickening  of  the 
mucous  membrane  were  most  marked.  In  16  cases  the  surface  of  the  ileum 
appeared  nearly  or  quite  normal ;  in  14  hyperaemia  in  the  small  intestines  in 
patches,  streaks,  or  arborescence  was  recorded,  but  the  records  do  not  state 
in  which  division  of  the  intestines  they  were   observed. 

Billard,  with  other  observers,  has  noticed  the  frequency  and  intensity  of 
the  inflammatory  lesions  in  entero-colitis  in  the  terminal  portion  of  the  small 
intestines,  and  thickening  in  many  cases  of  the  ileo-caecal  valve,  and  he 
asks  whether  the  vomiting  which  is  so  common  and  often  obstinate  in  this 
disease  may  not  be  sometimes  due  to  obstruction  to  the  passage  of  fecal 
matter  at  the  valve  in  consequence  of  its  hyperaemia  and  swelling,  but  he  has 
not  observed  any  retained  fecal  matter  above  it,  such  as  we  find  in  any  part 
of  the  colon,  or  any  other  appearance  which  indicated  sufficient  obstruction 
to  cause  symptoms.  But  it  seems  not  improbable  that  the  reason  why  the 
inflammatory  lesions  are    more    pronounced  at  and   immediately  above  the 


796  INTESTINAL   CATARRH  OF  INFANCY. 

valve  than  in  other  parts  of  the  small  intestine  is  that  the  fecal  matter,  so 
commonly  acid  and  irritating  in  this  disease,  is  somewhat  delayed  in  its  pas- 
sage downward  at  this  point. 

Small  superficial  circular  or  oval  ulcers  were  observed  in  the  ileum  in  4 
cases,  in  2  of  which  they  were  found  also  in  the  lower  part  of  the  jejunum. 
In  1  case  the  records  state  that  ulcers  were  in  the  jejunum,  but  do  not  men- 
tion whether  they  were  also  in  the  ileum.  In  1  case,  in  which  there  was 
much  thickening  of  the  ileum  next  to  the  ileo-csecal  valve,  many  small  gran- 
ulations had  sprouted  up  from  the  submucous  connective  tissue,  so  that  the 
mucous  surface  appeared  as  if  studded  with  small  warts. 

Softening  of  the  mucous  membrane  was  also  apparent  in  certain  cases. 
The  firmness  of  its  attachment  to  the  parts  underneath  varied  considerably 
in  difi"erent  specimens.  I  was  able  in  cases  in  which  there  was  considerable 
softening  to  detach  readily  the  mucous  membrane  with  the  nail  or  handle  of 
the  scalpel  within  so  short  a  period  after  death  that  it  was  probable  that  the 
change  of  consistence  was  not  cadaveric.  In  some  cases  the  vessels  of  the 
submucous  tissue  were  injected  and  this  tissue  infiltrated. 

In  all  the  cases  except  one,  lesions  were  present  indicating  inflammation 
of  the  mucous  membrane  of  the  colon.  In  39  hyperaemia,  thickening,  and 
other  signs  of  inflammation  extended  over  nearly  or  quite  the  entire  colon  ; 
in  14  the  colitis  was  confined  to  the  descending  portion  entirely  or  almost 
entirely ;  in  28  cases  the  records  state  that  inflammatory  lesions  were  found 
in  the  colon,  but  their  exact  location  is  not  mentioned.  In  18  of  the  autop- 
sies the  mucous  membrane  of  the  colon  was  found  ulcerated. 

Therefore,  according  to  these  statistics — and  autopsies  which  I  have  wit- 
nessed that  are  not  embraced  in  them  disclosed  similar  lesions — colitis  is 
present,  almost  without  exception,  in  cases  of  summer  diarrhoea,  associated 
with  more  or  less  ileitis.  The  portion  of  the  colon  which  presents  the  most 
marked  inflammatory  lesions  is  that  in  and  immediately  above  the  sigmoid 
flexure — that  portion,  therefore,  in  which  any  fermenting  fecal  matter  has 
reached  its  greatest  degree  of  fermentation,  and  consequently  contains  the 
most  irritating  elements,  and  where,  next  to  the  caput  coli,  it  is  longest 
delayed  in  its  passage  downward. 

The  solitary  glands  of  both  the  large  and  small  intestines  and  Peyer's 
patches  undergo  hyperplasia.  In  cases  of  short  duration  and  in  parts  of 
the  intestine  where  the  inflammatory  action  has  been  mild,  the  solitary  glands 
present  a  vascular  appearance,  like  the  surrounding  membrane,  and  are  slightly 
enlarged.  The  enlargement  is  most  apparent  if  the  intestine  be  viewed  by 
transmitted  light,  when  not  only  are  the  glands  seen  to  be  swollen,  but  their 
central  dark  points  are  distinct.  If  a  higher  grade  of  intestinal  catarrh  or  a 
catarrh  more  protracted  have  occurred,  the  volume  of  these  follicles  is  so 
increased  that  they  rise  above  the  common  level  and  present  a  papillary 
appearance.  Peyer's  patches  are  also  distinct  and  punctate.  The  enlarge- 
ment of  Peyer's  patches,  like  that  of  the  solitary  glands,  is  due  to  hyperpla- 
sia, the  elementary  cells  being  largely  increased  in  number. 

The  small  ulcers  which,  as  we  have  seen  from  the  above  statistics,  are 
present  in  a  certain  proportion  of  cases  in  the  mucous  membrane  of  the 
colon,  and  more  rarely  in  that  of  the  small  intestine  when  the  inflammation 
has  been  protracted  and  of  a  severe  type,  appear  to  occur  in  the  solitary 
glands  and  in  the  mucous  membrane  surrounding  them.  While  some  of 
these  glands  in  a  specimen  are  simply  tumefied,  others  are  slightly  ulcerated, 
and  others  still  nearly  or  quite  destroyed.  The  ulcers  are  usually  from  one 
to  three  lines  in  diameter,  circular  or  oval,  with  edges  slightly  raised  from 
infiltration.  Rarely,  I  have  seen  minute  coagula  of  blood  in  one  or  more 
ulcers,  and  I  have  also  observed  ulcers  which  have  evidently  been  larger  and 


ANATOMICAL  CHARACTERS.  797 

have  partially  healed.  The  ulcers  are  more  frequently  found  in  the  descend- 
ing colon  than  in  other  portions  of  the  intestines.  When  ulcers  are  present 
they  commonly  occur  in  the  descending  colon,  or  if  occurring  elsewhere  they 
are  most  abundant  in  this  situation. 

According  to  my  observations,  these  ulcers  are  found  chiefly  in  infants 
over  the  age  of  six  months — during  the  time,  therefore,  when  there  is  great- 
est functional  activity  and  most  rapid  development  of  the  solitary  glands. 
Peyer's  patches,  though  frecjuently  prominent  and  distinct,  have  not  been 
ulcerated  in  any  of  the  cases  observed  by  me. 

The  appendix  vermiformis  participates  in  the  catarrh  when  it  occurs  in 
the  caput  coli,  its  mucous  membrane  being  hyperaemic  and  thickened.  In 
certain  rare  cases  the  inflammation  is  so  intense  that  a  thin  film  of  fibrin  is 
exuded  in  places  upon  the  surface  of  the  colon.  It  is  liable  to  be  overlooked 
or  washed  away  in  the  examination.  The  rectum  usually  presents  no  inflam- 
matory lesions,  or  but  slight  lesions  in  comparison  with  those  in  the  colon. 
It  remains  of  the  normal  pale  color,  or  is  but  slightly  vascular  in  most 
patients,  even  when  there  is  almost  general  colitis.  Hence  the  infrequency 
of  tenesmus.  If  tenesmus  be  present,  probably  the  rectum  participates  in 
the  inflammation. 

As  might  be  expected  from  the  nature  of  the  disease,  the  secretion  of 
mucus  from  the  intestinal  surface  is  augmented.  It  is  often  seen  forming  a 
layer  upon  the  intestinal  surface,  and  it  appears  in  the  stools  mixed  with  epi- 
thelial cells  and  sometimes  with  blood  and  pus. 

The  mesenteric  glands  in  cases  which  have  run  the  most  protracted  course 
and  ended  fatally  are  found  more  or  less  enlarged  from  hyperplasia.  They 
are  frequently  as  large  as  a  pea  or  larger,  and  of  a  light  color,  the  color  being 
due  not  only  to  the  hyperplasia,  but  in  part  to  the  anaemia.  Occasionally, 
when  patients  have  been  much  reduced  from  the  long  continuance  of  diar- 
rhoea, and  are  in  a  state  of  marked  cachexia  before  death,  we  find  certain  of 
these  glands  caseous. 

The  state  of  the  stomach  is  interesting,  since  indigestion  and  vomiting  are 
so  commonly  present.  I  have  records  of  its  appearance  in  59  cases,  in  42 
of  which  it  seemed  normal,  having  the  usual  pale  color,  and  exhibiting  only 
such  changes  as  occur  in  the  cadaver.  In  the  remaining  17  cases  the  stom- 
ach was  more  or  less  hyperaemic,  and  in  3  of  them  points  of  ulceration  were 
observed  in  the  mucous  membrane. 

All  physicians  familiar  with  this  disease  have  remarked  the  frequency  of 
stomatitis.  In  protracted  and  grave  cases  it  is  a  common  complication.  The 
buccal  surface  in  these  cases  is  more  vascular  than  natural,  and  if  the  vital 
powers  are  much  reduced  superficial  ulcerations  are  not  infrequent,  oftener 
upon  the  gums  than  elsewhere.  The  gums  are  frequently  spongy,  more  or 
less  swollen,  bleeding  readily  when  rubbed  or  pressed.  Thrush  is  a  com- 
mon complication  of  protracted  diarrhoea  in  infants  under  the  age  of  three  or 
four  months,  but  is  infrequent  in  older  infants.  Occurring  in  those  over  the 
age  of  six  or  eight  months,  it  has  an  unfavorable  prognostic  significance,  indi- 
cating a  form  of  diarrhoea  which  commonly  eventuates  in  death. 

The  belief  has  long  been  prevalent  in  the  past  that  the  liver  is  also  in 
fault.  The  green  color  of  the  stools  was  supposed  to  be  due  to  vitiated  bile. 
But  usually  in  the  post-mortem  examinations  which  I  have  made  I  have 
found  that  the  green  coloration  of  the  fecal  matter  did  not  appear  at  the 
point  where  the  bile  enters  the  intestines,  but  at  some  point  below  the  ductus 
communis  choledochus,  in  the  jejunum  or  ileum.  The  green  tinge,  at  first 
slight,  becomes  more  and  more  distinct  on  tracing  it  downward  in  the  intes- 
tine.    The  manner  in  which  it  is  produced  has  been  treated  of  elsewhere. 

I  have  notes  of  the  appearance  and  state  of  the  liver  in  32  fatal  cases. 


798 


INTESTINAL   CATARRH  OF  INFANCY. 


Nothing  could  be  seen  in  these  examinations  which  indicated  any  anatomical 
change  in  this  organ  that  could  be  attributed  to  the  diarrhoeal  malady.  The 
size  and  weight  of  the  liver  varied  considerably  in  infants  of  the  same  age, 
but  probably  there  was  no  greater  difference  than  usually  obtains  among 
glandular  organs  in  a  state  of  health.  The  following  was  the  weight  of  this 
organ  in  20  cases : 


Age.  Weight. 

4  weeks 5    ounces. 

2  months ^       " 


^ 

5 

6J 
9 

^ 

6 

61- 


Age.  Weight. 

10  months 6|  ounces. 

13  "        6 

14  "       9         '•' 

15  "        6         " 

15      "       1^       " 

15  "       9J       " 

16  "       6        " 

19  " 4J      " 

20  "       9i      " 

23      '•'       15        " 


In  none  of  these  cases  did  the  size,  weight,  or  appearance  of  this  organ  seem 
to  be  different  from  that  in  health  or  in  other  diseases,  except  in  one  in  which 
fatty  degeneration  had  occurred,  but  this  was  probably  due  to  tuberculosis,, 
which  was  also  present.  In  most  of  these  cases  the  liver  was  examined 
microscopically,  and  the  only  noteworthy  appearance  observed  was  the 
variable  amount  of  oil-globules  in  the  hepatic  cells.  In  some  specimens  the 
oil-globules  were  in  excess,  in  others  deficient,  and  in  others  still  they  were 
more  abundant  in  one  part  of  the  organ  than  in  another.  Little  importance 
was  attached  to  these  differences  in  the  quantity  of  oily  matter. 

Hypostatic  congestion  of  the  posterior  portions  of  the  lungs,  ending  if  it 
continue  in  a  form  of  subacute  catarrhal  pneumonia  and  giving  rise  to  an 
occasional  painless  cough,  has  been  described  in  the  preceding  pages.  The 
character  of  the  cough  in  connection  with  the  wasting  might  excite  suspicions 
of  the  presence  of  tubercles  in  the  lungs  ;  but  tubercles  are  rare  in  this  dis- 
ease, and  when  present  I  should  suspect  a  strong  hereditary  predisposition. 
They  occurred  in  only  1  of  the  82  cases. 

The  state  of  the  encephalon  in  those  patients  in  whom  spurious  hydro- 
cephalus occurs  is  interesting.  In  protracted  cases  of  diarrhoea  the  brain 
wastes  like  the  body  and  limbs.  In  the  young  infant,  in  whom  the  cranial 
bones  are  still  ununited,  the  occipital  and  sometimes  the  frontal  bones  become 
depressed  and  overlapped  by  the  parietal,  the  depression  being  of  course  pro- 
portionate to  the  diminution  in  size  of  the  encephalon.  The  cranium  becomes 
quite  uneven.  In  other  children,  with  the  cranial  bones  consolidated,  serous 
effusion  occurs  according  to  the  degree  of  waste,  thus  preserving  the  size  of 
the  encephalon.  The  effusion  is  chiefly  external  to  the  brain,  lying  over  the 
convolutions  fi'om  the  base  to  the  vertex.  Its  quantity  varies  from  one  or 
two  drachms  to  an  ounce  or  more.  Along  with  this  serous  effusion,  and  ante- 
dating it,  passive  congestion  of  the  cerebral  veins  and  sinuses  is  also  present. 
This  congestion  is  the  obvious  and  necessary  result  of  the  feebleness  of  the 
heart's  action  and  the  loss  of  brain-substance. 

Diagnosis. — In  the  adult,  abdominal  tenderness  is  an  important  diag- 
nostic symptom  of  intestinal  catarrh,  but  in  the  infant  this  symptom  is  lack- 
ing or  is  not  in  general  appreciable,  so  that  it  does  not  aid  in  diagnosis. 
When  the  diagnosis  of  the  disease  is  established,  the  symptoms  do  not 
usually  indicate  what  part  of  the  intestinal  surface  is  chiefly  involved,  but 
it  may  be  assumed  that  it  is  the  lower  part  of  the  ileum  and  the  colon.  The 
presence  of  mucus  or  of  mucus  tinged  with  blood  in  the  stools  shows  the 
predominance  of  colitis. 


CHOLERA    INFANTUM.  799 

Prognosis. — Although  this  disease  largely  increases  the  death-rate  of 
young  children,  most  cases  can  be  cured  if"  proper  hygienic  and  medicinal 
measures  be  early  applied.  It  is  obvious,  from  what  has  been  stated  in  the 
foregoing  pages,  that  cholera  infantum  is  the  form  of  this  malady  which 
involves  greatest  danger.  Except  in  such  cases  there  is  sufficient  forewarn- 
ing of  a  fatal  result,  for  if  death  occur  it  is  after  a  lingering  sickness,  with 
fluctuations  and  gradual  loss  of  flesh  and  strength.  Patients  often  recover 
from  a  state  of  great  prostration  and  emaciation,  provided  that  no  fatal  com- 
plications arise.  The  eyes  may  be  sunken,  the  .skin  lie  in  folds  from  the 
wasting,  the  strength  may  be  so  exhausted  that  any  other  than  the  recumbent 
position  is  impossible,  and  yet  the  patient  may  recover  by  removal  to  the 
country,  by  change  of  weather,  or  by  the  use  of  better  diet  and  remedies. 
Therefore  an  absolutely  unfavorable  prognosis  should  not  be  made  except  in 
cases  that  are  complicated  or  that  border  on  collapse.  The  most  dangerous 
symptoms,  except  those  which  indicate  commencing  or  actual  collapse,  arise 
from  the  state  of  the  brain.  Rolling  the  head,  squinting,  feeble  action  or 
permanent  contraction  of  the  pupils,  spasmodic  or  irregular  movements  of 
the  limbs,  indicate  the  near  approach  of  death,  as  do  also  coldness  of  face 
and  extremities  and  inability  to  swallow.  It  is  obvious  also,  in  making  the 
prognosis  in  ordinary  cases,  that  we  should  consider  the  age  of  the  patient, 
and  if  the  diai-rhoja  be  that  of  the  summer  season,  the  state  of  the  weather, 
the  time  in  the  summer,  whether  in  the  beginning  or  near  its  close,  and  the 
surroundings,  especially  in  reference  to  the  impurity  of  the  air,  as  well  as 
the  patient's  condition. 

Cholera  Infantum,  or  Oholeriform  Diarrhcea. 

This  is  the  most  severe  form  of  infantile  diarrhoea.  It  receives  the  name 
which  designates  it  from  the  violence  of  its  symptoms,  which  closely  resemble 
those  of  Asiatic  cholera.  It  is,  however,  quite  distinct  from  that  disease. 
It  is  characterized  by  frequent  stools,  vomiting,  great  elevation  of  tempera- 
ture, and  rapid  and  great  emaciation  and  loss  of  strength.  It  commonly 
occurs  under  the  age  of  two  years.  It  sometimes  begins  abruptly,  the  pre- 
vious health  having  been  good ;  in  other  cases  it  is  preceded  by  the  ordinary 
form  of  diarrhoea.  The  stools  have  been  thinner  than  natural  and  somewhat 
more  frequent,  but  not  such  as  to  excite  alarm,  when  suddenly  they  become 
more  frequent  and  watery,  and  the  parents  are  surprised  and  frightened  by 
the  rapid  sinking  and  real  danger  of  the  infant. 

The  first  evacuations,  unless  there  have  been  previous  diarrhoea,  may 
contain  fecal  matter,  but  subsequently  they  are  so  thin  that  they  soak  into 
the  diaper  like  urine,  and  in  some  cases  they  scarcely  produce  more  of  a  stain 
than  does  this  secretion.  Their  odor  is  peculiar — not  fecal,  but  musty  and 
ofi"ensive  ;  occasionally  they  are  almost  odorless.  Commencing  simultaneously 
with  the  watery  evacuations  or  soon  after  is  another  symptom — irritability  of 
the  stomach,  which  increases  greatl}'  the  prostration  and  danger.  Whatever 
drinks  are  swallowed  by  the  infant  are  rejected  immediately  or  after  a  few 
moments,  or  retching  may  occur  without  vomiting.  The  appetite  is  lost  and 
the  thirst  is  intense.  Cold  water  is  taken  with  avidity,  and  if  the  infant 
nurse  it  eagerly  seizes  the  breast  in  order  to  relieve  the  thirst.  The  tongue 
is  moist  at  first,  and  clean  or  covered  with  a  light  fur,  pulse  accelerated,  res- 
piration either  natural  or  somewhat  increased  in  frequency,  and  the  surface 
warm,  but  its  temperature  is  speedily  reduced  in  severe  cases.  The  internal 
temperature  or  that  of  the  blood  is  always  very  high.  In  ordinary  cases  of 
cholera  infantum  the  thermometer  introduced  into  the  rectum  rises  to  or 
above  105°,  and  I  have  seen  it  indicate  107°.     Although  the  infant  may  be 


800  INTESTINAL   CATARRH  OF  INFANCY. 

restless  at  first,  it  does  not  appear  to  have  any  abdominal  pain  or  tenderness. 
The  restlessness  is  apparently  due  to  thirst  or  to  that  unpleasant  sensation 
which  the  sick  feel  when  the  vital  powers  are  rapidly  reduced.  The  urine  is 
scanty  in  proportion  to  the  gravity  of  the  attack,  as  it  ordinarily  is  when  the 
stools  are  frequent  and  watery. 

The  emaciation  and  loss  of  strength  are  more  rapid  than  in  any  other  dis- 
ease which  I  can  recall  to  mind,  unless  in  Asiatic  cholera.  In  a  few  hours 
the  parents  scarcely  recognize  in  the  changed  and  melancholy  aspect  of 
the  infant  any  resemblance  to  the  features  which  it  previously  exhibited. 
The  eyes  are  sunken,  the  eyelids  and  lips  are  permanently  open  from  the 
feeble  contractile  power  of  the  muscles  which  close  them,  while  the  loss  of  the 
fluids  from  the  tissues  and  the  emaciation  are  such  that  the  bony  angles 
become  more  prominent  and  the  skin  in  places  lies  in  folds. 

As  the  disease  approaches  a  fatal  termination,  which  often  occurs  in  two 
or  three  days,  the  infant  remains  quiet,  not  disturbed  even  by  the  flies  which 
alight  upon  its  face.  The  limbs  and  face  become  cool,  the  eyes  bleared, 
pupils  contracted,  and  the  urine  scanty  or  suppressed.  In  some  instances, 
when  the  patient  is  near  death,  the  respiration  becomes  accelerated,  either 
from  the  effect  of  the  disease  upon  the  respiratory  centres  or  from  pulmonary 
congestion  resulting  from  the  feeble  circulation.  As  the  vital  powers  fail  the 
pulse  becomes  progressively  more  feeble,  the  surface  has  a  clammy  coldness, 
the  contracted  pupils  no  longer  respond  to  light,  and  the  stupor  deepens,  from 
which  it  is  impossible  to  arouse  the  infant. 

In  the  more  favorable  cases  cholera  infantum  is  checked  before  the  occur- 
rence of  these  grave  symptoms,  and  often  in  cases  which  are  ultimately  fatal 
there  is  not  such  a  speedy  termination  of  the  malady  as  is  indicated  in  the 
above  description.  The  choleriform  diarrhoea  abates  and  the  case  becomes 
one  of  the  ordinary  summer  complaint. 

Anatomical  Characters. — Rilliet  and  Barthez,  who  of  foreign  writers 
treat  of  cholera  infantum  at  greatest  length,  describe  it  under  the  name  of 
gastro-intestinal  choleriform  catarrh.  "  The  perusal,"  they  remark,  "  of 
anatomico-pathological  descriptions,  and  especially  the  study  of  the  facts, 
show  that  the  gastro-intestinal  tube  in  subjects  who  succumb  to  this  disease 
may  be  in  four  diff"erent  states :  («)  either  the  stomach  is  softened  without 
any  lesion  of  the  digestive  tube ;  (6)  or  the  stomach  is  softened  at  the  same 
time  that  the  mucous  membrane  of  the  intestine,  and  especially  its  follicular 
apparatus,  is  diseased  ;  (c)  or  the  stomach  is  healthy,  while  the  follicular 
apparatus  or  the  mucous  membrane  is  diseased ;  (d)  or,  finally,  the  gastro- 
intestinal tube  is  not  the  seat  of  any  lesion  appreciable  to  our  senses  in  the 
present  state  of  our  knowledge,  or  it  presents  lesions  so  insignificant  that  they 
are  not  sufficient  to  explain  the  gravity  of  the  symptoms. 

"  So  far,  the  disease  resembles  all  the  catarrhs,  but  what  is  special  is  the 
abundance  of  serous  secretion  and  the  disturbance  of  the  great  sympathetic 
nerve. 

"  The  serous  secretion,  which  appears  to  be  produced  by  a  perspiration 
(analogous  to  that  of  the  respiratory  passages  and  of  the  skin)  rather  than 
by  a  follicular  secretion,  shows,  perhaps,  that  the  elimination  of  substances  is 
effected  by  other  organs  than  the  follicles;  pei'haps,  also,  we  ought  to  see  a 
proof  that  the  materials  to  eliminate  are  not  the  same  as  in  simple  catarrh. 
T^pon  all  these  points  we  are  constrained  to  remain  in  doubt.  We  content 
ourselves  with  pointing  out  the  fact." ' 

On  the  1st  of  August,  1861,  I  made  the  autopsy  of  an  infant  sixteen 
months  old  which  died  of  cholera  infantum  with  a  sickness  of  less  than  one 
day.     The  examination  was  made  thirty  hours  after  death.     Nothing  unusual 

'  Maladies  des  Enfants. 


ANATOMICAL  CHARACTERS.  801 

was  observed  in  the  brain,  unless  perliaps  a  little  more  than  the  ordinary 
injection  of  vessels  at  the  vertex.  No  marked  anatomical  change  was 
observed  in  the  stomach  and  intestines,  except  enlargement  of  the  patches  of 
Peyer  as  well  as  of  the  solitary  and  mesenteric  glands.  Mucous  membrane 
pale.  In  this  and  the  following  cases  there  was  apparently  slight  softening 
of  the  intestinal  mucous  membrane,  but  whether  it  was  pathological  or 
cadaveric  was  uncertain,  as.  the  weather  was  very  warm.  The  liver  seemed 
healthy.  Examined  by  the  microscope,  it  was  found  to  contain  about  the 
normal  number  of  oil-globules. 

The  second  case  was  that  of  an  infant  seven  months  old,  wet-nursed,  who 
died  July  26,  1862,  after  a  sickness  also  of  about  one  day.  He  was  pre- 
viously emaciated,  but  without  any  marked  ailment.  The  post-mortem 
examination  was  made  on  the  28th.  The  brain  was  somewhat  softer  than 
natural,  but  otherwise  healthy.  There  was  no  abnormal  vascularity  of  the 
membranes  of  the  brain,  and  no  serous  effusion  within  the  cranium.  The 
mucous  membrane  of  the  intestines  had  nearly  the  normal  color  throughout, 
but  it  seemed  somewhat  thickened  and  softened ;  the  solitary  glands  of  the 
colon  were  prominent.     The  patches  of  Peyer  were  not  distinct. 

In  the  New  York  Prote-stant  Episcopal  Orphan  Asylum  an  infant  twenty 
months  old,  previously  healthy,  was  seized  with  cholera  infantum  on  the  25th 
of  June,  1864.  The  alvine  evacuations,  as  is  usual  with  this  disease,  were 
frequent  and  watery  and  attended  by  obstinate  vomiting.  Death  occurred  in 
slight  spa.sms  in  thirty-six  hours.  The  exciting  cause  was  probably  the  use 
of  a  few  currants  which  were  eaten  in  a  cake  the  day  before,  some  of  which 
ffuit  was  contained  in  the  first  evacuations.  The  brain  was  not  examined. 
The  only  pathological  changes  which  were  observed  in  the  stomach  and  intes- 
tines were  slightly  vascular  patches  in  the  small  intestines  and  an  unusual 
prominence  of  the  solitary  glands  in  the  colon.  The  glands  resembled  small 
beads  imbedded  in  the  mucous  membrane.  The  lungs  in  the  above  cases 
were  healthy,  excepting  hypostatic  congestion. 

Since  the  date  of  these  autopsies  I  have  made  others  in  cases  which 
terminated  fatally  after  a  brief  duration,  and  have  uniformly  found  similar 
lesions — to  wit,  the  gastro-intestinal  surface  either  without  vascularity  or 
scantily  vascular  in  streaks  or  patches,  sometimes  presenting  a  whitish  or  soggy 
appearance  and  somewhat  softened,  while  the  solitary  glands  were  enlarged 
so  as  to  be  prominent  upon  the  surface.  In  cases  which  continue  longer 
evident  inflammatory  lesions  soon  appear  which  are  identical  with  those 
which  have  already  been  described  in  our  remarks  relating  to  the  ordinary 
form  of  diarrhoea. 

During  my  term  of  service  in  the  New  York  Foundling  Asylum  in  the 
summer  of  1884  an  infant  died  after  a  brief  illness  with  all  the  symptoms  of 
cholera  infantum,  and  the  intestines  were  sent  to  William  H.  Welch,  now  of 
Johns  Hopkins  Hospital,  for  microscopic  examination.  His  report  was  as 
follows :  "  I  found  undoubted  evidence  of  acute  inflammation.  There  was 
an  increased  number  of  small  round  cells  (leucocytes)  in  the  mucous  and 
submucous  coats.  This  accumulation  of  new  cells  was  most  abundant  in 
and  around  the  solitary  follicles,  which  were  greatly  swollen.  Clumps  of 
lymphoid  cells  were  found  extending  even  a  little  into  the  muscular  coat. 
The  epithelial  lining  of  the  intestine  was  not  demonstrable,  but  this  is  usu- 
ally the  case  with  post-mortem  specimens  of  human  intestine,  and  justifies 
no  inferences  as  to  pathological  changes.  The  glands  of  Lieberkiihn  were 
rich  in  the  so-called  goblet-cells,  and  some  of  the  glands  were  distended  with 
mucus  and  desquamated  epithelium,  so  as  to  present  sometimes  the  appear- 
ance of  little  cysts.  This  was  observed  especially  in  the  neighborhood  of 
the  solitary  follicles.      The  blood-vessels,  especially  the  veins  of  the  sub- 

61 


802  INTESTINAL   CATARRH  OF  INFANCY, 

mucous  coat,  were  abnormally  distended  with  blood.  I  searched  for  micro- 
organisms, and  found  them  in  abundance  upon  the  free  sui'face  of  the  intes- 
tine, in  mucous  accumulations  there,  and  also  in  the  mouths  of  the  glands 
of  Lieberkiihn.  Both  rod-shaped  and  small  round  bacteria  were  found.  I 
attach  no  especial  importance  to  finding  bacteria  upon  the  surface  of  the 
intestine.  The  general  result  of  the  examination  is  to  confirm  the  view  that 
cholera  infantum  is  characterized  by  an  acute  intestinal  inflammation." 

Nature. — Cholera  infantum  appears  from  its  symptoms  and  lesions  to  be 
the  most  severe  form  of  intestinal  catarrh  to  which  infants  are  liable.  The 
alvine  discharges,  to  which  the  rapid  prostration  is  largely  due,  probably  con- 
sist in  part  of  intestinal  secretions,  and  in  pai't  of  serum  which  has  transuded 
from  the  capillaries  of  the  intestines.  That  the  intestinal  mucous  membrane 
sometimes  presents  a  pale  appearance  at  the  autopsy  of  an  infant  who.  pre- 
viously well,  has  died  of  cholera  infantum  after  a  sickness  of  twenty-four 
or  forty-eight  hours,  is  perhaps  due  to  the  great  amount  of  liquid  secretion 
and  transudation  in  which  the  inflamed  surface  is  bathed.  Moreover,  it  is,  I 
believe,  a  recognized  fact  that  the  hypergemia  of  an  acutely  inflamed  surface 
when  of  short  duration  frequently  disappears  in  the  cadaver,  as  that  of  scar- 
let fever  and  erysipelas.  The  early  hyperplasia  of  the  solitary  and  mesen- 
teric glands,  and  the  hyperaemia  and  thickening  of  the  surface  of  the  ileum 
and  colon  in  those  who  have  survived  a  few  days,  afi"ords  additional  proof 
of  the  inflammatory  character  of  the  malady. 

The  opinion  has  been  expressed  by  certain  observers  that  cholera  infan- 
tum is  identical  with  thermic  fever  or  sunstroke.  There  is  indeed  a  resem- 
blance to  thermic  fever  as  regards  certain  important  symptoms.  In  cholera 
infantum  the  temperature  is  from  105°  to  108°  ;  in  sunstroke  it  is  also  very 
high,  often  running  above  108°.  Great  heat  of  head,  contracted  pupils,  thin 
fecal  evacuations,  embarrassed  respiration,  scanty  urine,  and  cerebral  symp- 
toms are  common  toward  the  close  of  cholera  infantum,  and  they  are  the 
prominent  symptoms  in  sunstroke.  Nevertheless,  I  cannot  accept  the  theory 
which  regards  these  maladies  as  identical,  and  which  removes  cholera  infan- 
tum from  the  list  of  intestinal  diseases.  In  cholera  infantum  the  gastro- 
intestinal symptoms  always  take  the  precedence,  and  are,  except  in  advanced 
cases,  always  more  prominent  than  other  symptoms.  It  does  not  commence 
as  by  a  stroke  like  coitp  de  soleil,  but  it  comes  on  more  gradually,  though 
rapidly,  and  it  often  supervenes  upon  a  diarrhoea  or  some  error  of  diet.  In 
the  commencement  of  cholera  infantum  the  infant  is  usually  not  drowsy^ 
and  is  often  wide  awake  and  restless  from  the  thirst.  Contrast  this  with  the 
alarming  stupor  of  sunstroke.  Sunstroke  only  occurs  during  the  hours  of 
excessive  heat,  but  cholera  infantum  may  occur  at  any  hour  or  in  any  day 
during  the  hot  weather,  provided  that  there  be  sufficient  dietetic  cause. 
Again,  intestinal  inflammation  is  not  common  in  sunstroke,  while  it  is  the 
common,  or,  as  I  believe,  the  essential,  lesion  of  cholera  infantum.  These 
facts  show,  in  my  opinion,  that  the  two  maladies  are  essentially  and  entirely 
distinct.  Nevertheless,  cases  of  apparent  sunstroke  sometimes  occur  in  the 
infant,  and  if  the  bowels  are  at  the  same  time  relaxed  the  disease  may  be 
regarded  as  cholera  infantum,  and  if  fatal  is  usually  reported  as  such  to  the 
health  authorities.  Cases  of  this  kind  I  have  occasionally  observed  or  they 
have  been  reported  to  me,  although  they  are  not  common. 

With  the  exception  of  the  organs  of  digestion  no  uniform  lesions  are 
observed  in  any  of  the  viscera  in  cholera  infantum,  except  such  as  are  due  to 
change  in  the  quantity  and  fluidity  of  the  blood  and  its  circulation.  Writers 
describe  an  anaemic  appearance  of  the  thoracic  and  abdominal  viscera,  and 
occasionally  passive  congestion  of  the  cerebral  vessels.  The  cerebral  symp- 
toms usually  present  toward  tiie  close  of  life  in  unfavorable  cases  of  cholera 


DJA  GNOSIS—  TREA  TMENT.  803 

infantum  arc  often  due  to  s{)uriou.s  hydrocephalus,  which  we  have  described 
above;  but  as  the  urinary  secretion  is  scanty  or  suppressed,  cerebral  symptoms 
may  in  certain  cases  be  due  to  uncniia. 

Diagnosis. — This  form  of  the  summer  diarrhoea  is  diagnosticated  by  the 
symptoms,  and  especially  by  the  frecjuency  and  character  of  the  stools.  The 
stools  have  already  been  described  as  frequent,  often  passed  with  considerable 
force,  deficient  in  fecal  matter,  and  thin,  so  as  to  soak  into  the  diaper  almost 
like  urine.  The  vomiting,  thirst,  rapid  sinking,  and  emaciation  serve  to  dis- 
tinguish cholera  infantum  from  other  diarrhoeal  maladies. 

When  Asiatic  cholera  is  prevalent  the  diiferential  diagnosis  between  the 
two  is  difficult  if  not  impossible. 

Prognosis. — Cholera  infantum  is  one  of  those  diseases  in  regard  to  which 
physicians  often  injure  their  reputation  by  not  giving  sufficient  notice  of  the 
danger,  or  even  by  expressing  a  favorable  opinion  when  the  case  soon  after 
ends  fatally.  A  favorable  prognosis  should  seldom  be  expressed  without 
qualification.  If  the  urgent  symptoms  be  relieved,  still  the  disease  may  con- 
tinue as  an  ordinary  intestinal  inflammation,  which  in  hot  weather  is  formid- 
able and  often  fatal.  If  the  stools  become  more  consistent  and  less  frequent 
without  the  occurrence  of  cerebral  symptoms,  while  the  limbs  are  warm  and 
the  pulse  good,  we  may  confidently  express  the  opinion  that  there  is  no  pres- 
ent danger. 

The  duration  of  true  cholera  infantum  is  short.  It  either  ends  fatally,  or 
it  begins  soon  to  abate  and  ceases,  or  it  continues  and  is  not  to  be  distin- 
guished in  its  subsequent  course  from  an  attack  of  summer  diarrhoea  begin- 
ning in  the  ordinary  manner. 

Treatment  of  Infantile  Diarrhcea. — Obviously,  efficient  preventive 
measures  consist  in  the  removal  of  infants  so  far  as  practicable  from  the  ope- 
ration of  the  causes  which  produce  the  disease.  Weaning  just  before  or  in 
the  hot  weather  should,  if  possible,  be  avoided,  and  removal  to  the  country 
should  be  recommended,  especially  for  those  who  are  deprived  of  breast-milk 
during  the  age  when  such  nutriment  is  required.  If  for  any  reason  it  is 
necessary  to  employ  artificial  feeding  for  infants  under  the  age  of  ten  months, 
that  food  should  obviously  be  used  which  most  closely  resembles  human  milk 
in  digestibility  and  in  nutritive  properties. 

It  is  also  very  important  that  the  infant  receive  its  food  in  proper  quan- 
tity and  at  proper  intervals,  for  if  the  mother  or  nurse  in  her  anxiety  to  have, 
it  thrive  feed  it  too  often  or  in  too  large  quantity,  the  surplus  food  which  it 
cannot  digest,  if  not  vomited,  undergoes  fermentation,  and  consequently 
becomes  irritating  to  the  gastro-intestinal  sui-face.  The  physician  should  be 
able  to  give  advice  not  only  in  reference  to  the  frequency  of  feeding,  but  also- 
in  regard  to  the  quantity  of  food  which  the  infant  requires  at  each  feeding. 
Correct  knowledge  and  advice  in  this  matter  aid  in  the  prevention  and  cure  of 
the  diarrhoeal  maladies  of  infancy.  The  reader  is  referred  to  the  chapters 
relating  to  the  feeding  of  infants. 

The  indications  for  treatment  are  :  1st.  To  provide  the  best  possible  food 
which  will  afford  sufficient  nutriment  and  be  easily  digested  ;  2d.  To  aid  the 
digestive  functions  of  the  infant;  3d.  To  employ  such  medicinal  agents  as  can 
be  safely  given  to  check  the  diarrhoea  and  cure  the  intestinal  catarrh  ;  4th.  To 
procure  fresh  air,  which  is  especially  needed  if  the  diarrhoea  be  that  of  the 
summer  season. 

We  will  here  repeat  certain  facts  in  reference  to  the  feeding  of  infants 
which  are  of  the  highest  importance  in  the  treatment  of  the  diarrhoeal  mal- 
adies. Milk  designed  for  the  nursery  should  always  be  sterilized  by  the 
action  of  heat  at  or  a  little  below  the  boiling-point,  prolonged  from  one  to  two 
hours.     I  uniformly  direct  that  the  morning  supply  of  milk  designed  for  the 


804  INTESTINAL   CATARRH  OF  INFANCY. 

infant  be  as  soon  as  received  placed  in  or  over  water  in  a  steamer  or  other 
suitable  vessel  and  subjected  to  a  heat  at  or  a  little  below  212°  during  two 
hours.  This  milk  is  used  during  the  following  twenty-four  hours.  Barley 
or  wheat  flour,  subjected  to  the  prolonged  action  of  heat,  by  which  its  starch 
is  changed  more  or  less  into  dextrin,  is  also  required.  By  the  proper  admix- 
ture of  the  farinaceous  food  with  the  milk  the  best  possible  diet  for  the 
bottle-fed  infant  will  be  obtained.  The  reader  is  referred  to  the  appropriate 
chapters  for  details  relating  to  infant  feeding. 

The  infant  with  intestinal  catarrh,  the  prominent  symptom  of  which  is 
diarrhoea,  is  thirsty,  and  is  therefore  likely  to  take  more  nutriment  in  the 
liquid  form  than  it  requires  for  its  sustenance.  If  wet-nursed  it  craves  the 
breast,  or  if  weaned  it  craves  the  bottle  at  short  intervals.  No  more  nutri- 
ment should  be  allowed  than  is  required  for  nutrition,  and  the  thirst  may  be 
best  relieved  by  a  little  cold  water,  to  which  the  white  of  egg  is  added,  gum- 
water,  or  thin  barley-water,  containing  a  few  drops  of  whiskey  or  brandy. 

In  the  dietetic  treatment  of  the  summer  diarrhoea  of  the  bottle-fed  infant, 
in  which  not  only  diarrhoea  but  indigestion  and  vomiting  are  prominent  symp- 
toms, I  at  first  withhold  cow's  milk  and  allow  only  barley  gruel,  the  barley 
flour  having  been  previously  subjected  to  the  heat  of  boiling  water  seven  days. 
If  the  infant  e:xhibit  evidences  of  innutrition,  I  add  to  the  gruel  designed  for 
each  feeding,  when  it  is  cool,  the  white  of  a  fresh  egg,  the  mixture  contain- 
ing sufficient  salt  to  be  tasted,  and  usually  two  to  three  drops  of  whiskey  or 
brandy  for  each  month  of  the  infant's  age.  The  feeding  should  be  at  inter- 
vals of  three  hours.  This  food  should  be  at  a  temperature  not  higher  than 
50°  or  60°  F.,  on  account  of  the  egg,  and  the  infant  readily  takes  it  in  con- 
sequence of  the  thirst  if  not  from  hunger.  If  it  craves  drink  or  more  nutri- 
ment between  the  feedings,  take  one-third  of  a  tumblerful  of  water  previously 
boiled  and  its  temperature  reduced  to  40°  or  50°,  and  add  to  it  the  white  of 
the  egg,  with  a  little  brandy.  The  infant  will  take  this  readily,  and  if  old 
enough  to  speak  will  ask  for  more.  It  is  a  good  vehicle  for  the  powder  of 
bismuth  and  pepsin.  With  this  diet  the  infant  is  sufficiently  nourished  for  a 
week  or  more.  At  present  (August,  1890)  an  infant  whom  I  am  attending 
takes  the  white  of  eight  eggs  in  twenty-four  hours.  In  a  few  days,  when 
the  vomiting  and  to  a  certain  extent  the  diarrhoea  are  controlled,  milk,  pre- 
viously sterilized  by  heat  and  peptonized  by  peptogenic  powder,  may  be 
cautiously  added  to  the  barley  gruel  in  place  of  the  egg — three  tablespoonfuls 
for  a  child  of  five  months,  and  five  or  six  tablespoonfuls  for  one  of  twelve 
months. 

The  occasional  cases  of  infantile  diarrhoea  which  result  from  taking  cold 
require  to  be  treated  by  the  use  of  bland  and  easily-digested  diet,  and  med- 
icines that  are  soothing  and  such  as  restrain  the  evacuations  and  relieve  pain ; 
prominent  among  which  remedies  are  bismuth  and  an  opiate.  But  a  large 
majority  of  the  cases  of  diarrhoea  in  infancy  arise,  as  we  have  seen,  from 
improper  feeding  and  insanitary  conditions,  and  to  these  cases  the  following- 
remarks  apply.  The  summer  diarrhoeal  epidemics  of  the  cities  especially 
demand  our  attention  on  account  of  the  large  number  that  are  affected  and 
the  many  deaths  that  result. 

We  have  seen  that  the  two  factors  which  produce  the  microbic  diarrhoea 
of  infancy,  of  which  the  summer  epidemic  of  the  cities  is  the  type,  are 
improper  food  and  foul  air.  It  is  therefore  obvious  that  measures  should  be 
employed  to  render  the  atmosphere  in  which  the  infant  lives  as  free  as  pos- 
sible from  noxious  effluvia.  Cleanliness  of  the  person,  of  the  bedding,  and  of 
the  house  in  Avhich  the  patient  resides,  the  prompt  removal  of  all  refuse  ani- 
mal or  vegetable  matter,  whether  within  or  around  the  premises,  and  allowing 
the  infant  to  remain  a  considerable  part  of  the  day  in  shaded  localities  where 


TREATMENT.  805 

the  air  is  pure,  as  in  the  parks  or  suburbs  of  the  city,  are  important  measures. 
In  New  York  great  benefit  fias  resulted  from  the  floating  hospital  which  every 
second  day  during  the  heated  term  carries  a  thousand  sick  children  from  the 
stifling  air  of  the  tenement-houses  down  the  bay  and  out  to  the  fresh  air  of 
the  ocean. 

But  it  is  difiicult  to  obtain  an  atnios[)here  that  is  entirely  pure  in  a  large 
city  with  its  many  sources  of  insalubrity  ;  and  all  physicians  of  experience 
agree  in  the  propriety  of  sending  infants  aff"ected  with  the  summer  diarrhoea 
to  localities  in  the  country  which  are  free  from  malaria  and  sparsely  inhab- 
ited, in  order  that  they  may  obtain  the  benefits  of  purer  air.  Many  are  the 
instances  each  summer  in  New  York  City  of  infants  removed  to  the  country 
with  intestinal  inflammation,  with  features  haggard  and  shrunken,  with  limbs 
shrivelled  and  the  skin  lying  in  folds,  too  weak  to  raise  (or  at  least  hold) 
their  heads  from  the  pillow,  vomiting  nearly  all  the  nutriment  taken,  with 
stools  frequent  and  thin,  resulting  in  great  part  from  molecular  disintegration 
of  the  tissues — presenting,  indeed,  an  appearance  seldom  observed  in  any 
other  disease  except  in  the  last  stages  of  phthisis — and  returning  in  late 
autumn  with  the  cheerfulness,  vigor,  rotundity  of  health.  The  localities 
usually  preferred  by  the  physicians  of  this  city  are  the  elevated  portions  of 
New  Jersey  and  Northern  Pennsylvania,  the  Highlands  of  the  Hudson,  the 
central  and  northern  parts  of  New  York  State,  and  Northern  New  England. 
Taken  to  a  salubrious  locality  and  properly  fed,  the  infant  soon  begins  to 
improve  if  the  disease  be  still  recent,  unless  it  be  exceptionally  severe.  If 
the  disease  have  continued  several  weeks  at  the  time  of  the  removal,  little 
benefit  may  be  observed  from  the  country  residence  until  two  or  more  weeks 
have  elapsed. 

An  infant  weakened  and  wasted  by  the  summer  diarrhoea,  removed  to  a 
cool  locality  in  the  country,  should  be  warmly  dressed  and  kept  indoor 
when  the  heavy  night  dew  is  falling.  Patients  sometimes  become  worse 
from  injudicious  exposure  of  this  kind,  the  intestinal  catarrh  from  which 
they  are  suff"ering  being  aggravated  by  taking  cold  and  perhaps  rendered 
dysenteric. 

Sometimes  parents,  not  noticing  the  immediate  improvement  which  they 
have  been  led  to  expect,  return  to  the  city  without  giving  the  country  fair 
trial,  and  the  life  of  the  infant  is  then,  as  a  rule,  sacrificed.  Returned  to 
the  foul  air  of  the  city  while  the  weather  is  still  warm,  it  sinks  rapidly  from 
an  aggravation  of  the  malady.  Occasionally,  the  change  from  one  rural 
locality  to  another,  like  the  change  from  one  wet-nurse  to  another,  has  a  salu- 
tary effect.  The  infant,  although  it  has  recovered,  should  not  be  brought 
back  while  the  weather  is  still  warm.  One  attack  of  the  disease  does  not 
diminish,  but  increases,  the  liability  to  a  second  seizure. 

Medicinal  Treatment. —  Opiates. — It  is  evident  that  opiates  are  less  used 
than  formerly  in  the  treatment  of  the  microbic  diarrhoeas  of  infancy.  A 
proper  appreciation  of  the  pathology  of  these  diarrhoeas  naturally  leads  to 
the  belief  that  the  opiates  are  less  important  as  curative  agents  than  they 
were  formerly  supposed  to  be.  Opiates  diminish  the  peristalsis  and  the  num- 
ber of  stools,  but  they  do  not  destroy  the  microbes  or  the  ptomaines.  Their 
use  should,  I  think,  be  limited  to  cases  of  restlessness,  of  tenesmus,  and  of 
frequent  watery  stools.  They  may  be  useful  in  controlling  symptoms  till 
other  remedies  have  time  to  act.  One  drop  of  laudanum  or  fifteen  drops 
of  paregoric  may  be  given  to  an  infant  of  ten  months  and  repeated  in  three 
hours.  I  prefer  paregoric  to  any  other  opiate  in  the  treatment  of  the  sum- 
mer diarrhoeas  of  infancy,  since  they  are  attended  by  marked  prostration,  and 
this  agent  is  highly  stimulating,  from  the  camphor  which  it  contains. 

Antiseptics. — Although  the  pathology  of  microbic  diarrhoea  suggests  the 


806  INTESTINAL   CATARRH  OF  INFANCY. 

use  of  antiseptics,  my  observations  have  not  been  favorable  to  the  use  of 
salol,  naphthaline,  or  corrosive  sublimate.  They  have  seemed  to  me  to  do 
more  harm  than  good.  Guaita  employs  sodium  benzoate.  He  administers 
in  twenty-four  hours  one  drachm  or  a  drachm  and  a  half  in  three  ounces  of 
water,  with,  it  is  stated,  good  results.^  The  antiseptic  which  is  more  largely 
used  than  any  other,  and  which  more  than  any  other  has  the  confidence  of 
the  profession — and  justly  so — is  the  subnitrate  of  bismuth.  It  undergoes 
a  chemical  change  in  the  stomach  and  intestines,  becoming  a  bismuth  sulphide 
and  causing  dark  stools.  It  may  be  combined  with  chalk  or  pepsin,  and 
should  be  given  in  doses  of  ten  or  twelve  grains  to  an  infant  of  six  months. 

Irrigation  of  .the  Stomach. — Physicians  of  experience  in  New  York  and 
elsewhere  recommend  irrigation  of  the  stomach  with  warm  water  in  the 
treatment  of  malnutrition  and  gastro-intestinal  catarrh.  It  removes  from  the 
stomach  thick  curds  that  digest  with  difficulty,  as  well  as  other  aliment  that 
may  be  undergoing  gastric  digestion.  It  has  not,  perhaps,  been  sufficiently 
employed  to  determine  its  full  value,  but  from  what  I  have  seen  of  its  efi"ects 
I  am  not  able  to  recommend  it.  The  nutriment  should  be  given  so  prepared 
and  with  such  aids  to  digestion  that  the  heavy  casein  curds  do  not  form  in 
the  stomach!  Moreover,  the  gastric  juice  is  the  one  of  the  digestive  fer- 
ments that  is  especially  destructive  to  microbes,  so  that  it  is  needed  in  the 
stomach  for  its  germicide  as  well  as  digestive  action.  We  have  seen  from 
the  observations  of  Dr.  Max  Einhart  that  after  two  hours  the  stomach 
digestion  of  properly  prepared  milk  or  milk  and  barley  gruel  is  completed, 
and  the  stomach  in  a  state  to  receive  more  food.  For  these  reasons  irriga- 
tion of  the  stomach,  habitually  practised  even  in  cases  of  indigestion  or 
catarrh,  seems  to  me  more  likely  to  be  injurious  than  beneficial.  On  the 
other  hand,  when  the  stools  are  fermenting  and  imperfectly  digested,  and  are 
accompanied  by  tenesmus,  irrigation  of  the  rectum  frequently  gives  consid- 
erable relief. 

Alkalies. — Acids,  especially  the  lactic  and  butyric  products  of  faulty 
digestion,  often  collect  in  the  stomach  and  intestines.  These  acids,  which  are 
active  irritants,  should  be  neutralized  while  we  endeavor  to  prevent  their 
production  by  improving  the  diet  and  aiding  the  digestion.  In  a  few  days 
the  inflammatory  irritation  of  the  mucous  follicles  causes  an  exaggerated 
secretion  of  mucus,  which  is  alkaline,  and  which  neutralizes  the  acids  to  a 
considerable  extent.  An  alkali  is  therefore  required  in  most  cases.  It  is 
especially  useful  when  the  infant  has  acid  vomiting  and  acid  stools.  Lime- 
water,  the  sodium  bicarbonate,  and  the  various  preparations  of  chalk  are  the 
antacids  which  by  common  consent  are  employed  to  neutralize  the  acids  in 
the  diarrhoeal  maladies  of  infancy.  My  preference  is  for  the  mistura  cretae, 
given  midway  between  the  nursings  or  feedings.  An  alkali  is  incompatible 
with  pepsin,  and  as  pepsin  preparations  are  needed  to  assist  digestion,  they 
should  not  be  given  at  the  same  time  with  the  alkali. 

Astringents. — The  vegetable  astringents  were  formerly  much  used  in  the 
treatment  of  the  diarrhoeal  diseases  of  infancy,  but  they  are  now  seldom  pre- 
scribed for  these  cases.  Even  the  mineral  astringents,  acetate  of  lead  and 
nitrate  of  silver,  have  gone  out  of  use  in  the  treatment  of  the  infantile  diar- 
rhoeas.    The  alkalis  and  bismuth  have  taken  their  place. 

Stimulants. — The  diarrhoea,  if  severe,  soon  produces  symptoms  of  pros- 
tration or  heart  failure,  so  that  alcoholic  stimulation  is  needed.  Brandy  or 
whiskey  is  the  best  stimulant  in  this  disease — from  ten  to  twenty-five  drops 
according  to  the  age  every  second  hour. 

Occasionally  it  is  proper  to  commence  the  treatment  by  the  employment 
of  some  gentle  purgative,  especially  when  the  diarrhoea  begins  abruptly  after 
1  X  Y.  Med.  Record,  May  31,  1884. 


TREATMENT.  807 

the  use  of  irritating  and  indigestible  food.  A  single  dose  of  castor  oil  or 
syrup  of  rhubarb,  or  tlie  two  mixed,  will  remove  the  irritating  substance,  and 
afterward  remedies  designed  to  control  the  disease  can  be  more  successfully 
employed. 

The  following  are  useful  prescriptions : 

R.  Bismutli.  siibnitrat.,  .^ij  ; 

Mistnra  cretiP,  ,^ij.     Misee. 

Shake  thoroughly,  and  give  one  teaspoonful  every  two  hours  to  an  infant  of  six  to  ten 
months.  It  should  be  administered  midway  between  the  feedings,  for  the  reason 
stated  above. 

R.  Bismuth,  subnitrat.,  ,^ij  ; 

Mucil.  acacife,  5ss ; 

Aquiie  chinamomi,  ^iss.     Misce. 

Shake  bottle,  and  give  one  teaspoonful  hourly  until  the  vomiting  and  diarrhoea  cease. 

Some  physicians  of  large  experience,  as  Prof.  Henoch  of  Berlin,  recom- 
mend small  doses  of  calomel,  as  a  twelfth  or  twentieth  of  a  grain  three  or 
four  times  daily.  If  it  be  useful  it  probably  acts  as  a  germicide,  but  we 
have,  it  seems  to  me,  more  efficient  and  safer  remedies,  and  I  never  pre- 
scribe it. 

It  is  very  important  in  the  treatment  of  the  summer  diarrhoea  to  aid 
digestion  while  we  employ  an  antiseptic,  and  the  following  are  formulse 
which  I  have  employed  with  apparently  the  best  results  in  family  practice 
and  in  the  institutions  in  New  York  : 

R.  Acidi  hydrochloric!  dil.,  ^xvj  ; 

Pepsini  puri,  in  lamellis,  ^] ; 

Bismuthi  subnitrat.,  ^ij  ; 

Syrupi,  f^ij ; 

Aquie,  fjxiv.     Misce. 

Shake  bottle.  Give  one  teaspoonful  before  each  feeding  or  nursing  to  an  infant  of  ten 
months;  half  a  teaspoonful  to  an  infant  of  five  months. 

R.  Pepsini  saccharati,  .^i~ij  ; 

Bismuthi  subnitrat.,         ^ij.     Misce. 
Divide  in  chart.  No.  xii.     Give  one  powder  before  each  nursing  or  feeding  to  an  infant 
of  ten  mouths. 

R.  Pepsini  puri,  in  lamellis,  .^j  ; 

Bismutiu  subnitrat.,  ,^ss; 

Vini  pepsini,  N.  F.,  .^ss; 

Aquce  destillat.,  5 iiiss.     Misce. 

Shake  bottle.  Give  one  teaspoonful  before  each  feeding  to  an  infant  at  or  above  the 
age  of  six  mouths ;  half  a  teaspoonful  between  the  ages  of  two  and  six  months. 

R.  Pepsini  puri,  in  lamellis,  .^j ; 

Bismuthi  subnitrat.,  5ss.     Misce. 

Give  as  much  as  goes  on  a  ten-cent  piece  or  a  five-cent  nickel  piece  before  each  nursing 
or  feeding. 

If  the  diarrhoea  and  vomiting  have  ceased,  but  the  digestion  be  slow  and 
incomplete,  the  following  prescriptions  will  be  found  useful : 

R.  Pepsini  puri,  in  lamellis,  ,^j ; 

Lactopeptone,  ^ss. 

Give  as  much  as  will  go  on  a  ten-cent  piece  or  as  much  as  will  cover  a  nickel  five-cent 
l^iece  before  each  feeding. 


808  ENTERITIS  AND   COLITIS  IN  CHILDHOOD. 

R.  Pepsini  puri,  in  lamellis,  gj  j 

Vini  pepsini,  N.  ¥.,  o^^'i 

Aqii£e  destillat.,  5iiiss.     Misce. 

Give  half  a  teaspoonful  to  one  teaspoonful,  according  to  tlie  age,  before  each  feeding. 

If  cerebral  symptoms  appear,  as  rolling  the  head,  drowsiness,  etc.,  indicat- 
ing the  commencement  of  spurious  hydrocephalus,  an  alcoholic  stimulant,  as 
whiskey  or  brandy,  is  required ;  and  although  there  may  be,  at  times,  great 
restlessness,  explicit  and  positive  directions  should  be  given  to  withhold 
opiates  if  they  have  been  previously  employed.  One  of  the  bromides,  with 
an  alcoholic  stimulant  or  the  aniseed  cordial  of  the  National  Formulary,  to 
allay  restlessness,  would  be  the  proper  remedy  in  addition  to  bismuth  and 
pepsin  if  symptoms  of  heart  failure  or  spurious  hydrocephalus  occur. 

In  protracted  cases,  when  the  vital  powers  begin  to  fail,  as  indicated  by 
pallor,  more  or  less  emaciation,  and  loss  of  strength,  the  following  tonic  will 
sometimes  be  useful  in  restraining  the  diarrhoea  and  increasing  the  appetite 
and  strength.  It  should  not  be  prescribed  until  the  diarrhoea  has  assumed  a 
subacute  or  chronic  character : 

R.  Tinct.  columbfe,  f^iij  ; 

Liq.  ferri  nitratis,        TTLxxvij  ; 
Syr.  simplic,  ^j  ; 

Aquae,  ^i].     Misce. 

Dose :  One  teaspoonful  every  three  or  four  hours  to  an  infant  of  one  year. 

External  Treatment. — In  the  gastro-intestinal  catarrh  of  the  cool  months, 
produced  by  exposure  to  cold,  light  and  mildly  stimulating  applications  over 
the  abdomen  are  sometimes  useful,  as  a  light  poultice  of  flaxseed  to  which 
one-sixteenth  or  one-twentieth  part  of  mustard  is  added,  or  a  poultice  of 
cloves,  cinnamon,  and  ginger,  or  even  camphorated  oil,  on  the  under  surface 
of  a  flaxseed  poultice,  covered  with  oil-silk.  But  in  those  forms  of  gastro- 
intestinal catarrh  due  to  improper  feeding  or  insanitary  conditions,  and  hav- 
ing a  bacterial  origin,  external  measures  are  commonly  useless,  and  in  the 
summer  months  they  might  do  injury  by  increasing  the  warmth. 


CHAPTER    IX. 

ENTERITIS  AND  COLITIS  IN  CHILDHOOD. 

Intestinal  inflammation  in  childhood  diff'ers  materially  from  the  form 
or  type  which  it  commonly  presents  in  infancy.  Its  causes,  symptoms,  and 
extent  vary  in  important  particulars  in  the  two  periods.  In  childhood  there 
is  not  ordinarily  such  extensive  inflammation  of  the  mucous  membrane  of 
the  intestines  as  we  have  seen  is  present  in  the  majority  of  cases  in  infancy, 
and  it  may  therefore  be  properly  treated  as  two  diseases,  according  to  the 
seat  of  the  morbid  process — to  wit,  enteritis  and  colitis.  Both  these  afi"ec- 
tions  in  childhood  resemble  so  closely  the  form  which  they  exhibit  in  adult 
life  that  no  extended  description  is  needed  in  this  connection. 

Causes. — A  main  cause  is  sudden  reduction  of  temperature  by  exposure 
to  cold  or  to  currents  of  air,  which  checks  perspiration  and  causes  determina- 
tion of  blood  from  the  surface  to  the  viscera.  These  inflammations  are  also 
caused  sometimes  by  irritating  substances  in  the  intestines.     I  have  known 


SYMPTOMS— PROGNOSIS.  80^ 

fecal  accuniuliitions,  as  well  as  worms,  to  produce  severe  dysentery  in  the 
child,  accompanied  by  the  characteristic  tenesmus  and  muco-sanguineous 
stools,  and  ceasing  as  soon  as  the  offending  substances  were  expelled.  The 
use  of  unripe  or  stale  vegetables,  if  there  be  a  strong  predisposition  to 
mucous  inflammation,  may  be  a  sufficient  cause,  and  some  of  the  most  dan- 
gerous cases  are  due  to  the  accumulation  in  the  intestines  of  seeds  and  the 
parenchyma  of  fruits.  But  the  most  common  cause  is  that  mentioned — to 
wit,  sudden  exposure  to  cold  when  the  body  is  heated,  a  danger  to  which 
children  are  especially  liable  on  account  of  the  easy  disturbance  of  the  cir- 
culatory system  in  them,  and  their  heedless  exposure  of  themselves  unless 
incessantly  watched.  Enteritis  and  colitis  are  also  frequently  secondary  dis- 
eases occurring  in  childhood  as  complications  or  sequehc  of  the  eruptive 
fevers,  especially  measles. 

Symptoms. — The  alvine  discharges  in  enteritis  and  colitis  in  childhood  are 
such  as  occur  in  these  diseases  at  a  more  advanced  age.  In  enteritis  they 
are  thin  and  of  the  natural  color,  or  occasionally  green  ;  in  colitis  they  are 
more  consistent  than  in  enteritis  and  are  largely  muco-sanguineous.  Some- 
times in  enteritis,  if  the  inflammation  be  not  intense,  the  diarrhoea  is  slow  in 
appearing,  or  it  may  be  slight,  so  as  not  to  attract  special  attention.  The 
disease  may  then  resemble  remittent  fever,  for  which  it  is  at  times  mistaken. 
The  upper  part  of  the  small  intestines  is  less  frequently  affected  than  the 
lower.  If  there  be  duodenitis,  the  flow  of  bile  is  occasionally  impeded  from 
tumefaction  of  the  mouth  of  the  common  bile-duct,  and  the  icteric  hue 
appears.  In  both  enteritis  and  colitis  there  is  abdominal  tenderness,  with, 
more  or  less  constant  pain  if  the  disease  be  severe,  and  in  colitis  tormina  and 
tenesmus.  The  pulse  is  accelerated,  the  heat  of  surface  augmented,  the  face 
flushed  and,  except  in  mild  cases,  expressive  of  pain.  In  many  children  at 
the  commencement  of  the  inflammation  the  nervous  system  is  profoundly 
affected,  as  indicated  by  headache,  stupor,  twitching  of  the  limbs,  and  some- 
times by  convulsions.  The  chief  danger  at  the  commencement  of  the  dis- 
ease is,  indeed,  from  this  source.  Sometimes  irritability  of  the  stomach 
occurs  and  the  food  is  rejected,  though  much  less  frequently  than  in  the 
intestinal  inflammation  of  infancy.  Anorexia  and  thirst  are  common  symp- 
toms. If  the  inflammation  continue  there  is  soon  perceptible  emaciation^ 
with  loss  of  strength.  The  eyes  become  hollow,  the  face  pallid,  and  the 
surface  cool.  Death  may  occur  at  an  early  period,  the  vital  powers  succumb- 
ing from  the  intensity  of  the  inflammation.  In  other  cases  the  acute  dis- 
ease ends  in  a  subacute  or  chronic  inflammation  ;  the  patient  becomes  grad- 
ually more  reduced,  till  he  dies  in  a  state  of  extreme  emaciation,  such  as  we 
often  observe  in  the  entero-colitis  of  infancy ;  or  from  this  state  he  may 
recover  by  degrees,  though  perhaps  with  an  irritable  state  of  the  bowels, 
which  continues  for  months.  In  a  majority  of  cases,  however,  enteritis  and 
colitis  in  childhood,  if  properly  treated,  soon  begin  to  yield,  and  they  termi- 
nate favorably  in  one  or  two  weeks. 

Diagnosis. — It  is  not  difficult  to  determine  the  existence  of  the  inflam- 
mation. This  is  indicated  by  the  fever,  abdominal  tenderness,  and  the  relaxed 
state  of  the  bowels.  Whether  the  disease  be  enteritis  or  colitis  is  determined 
by  the  character  of  the  stools,  the  seat  of  the  tenderness,  and  the  presence  or 
absence  of  tenesmus. 

Prognosis. — It  has  been  stated  above  that  enteritis  and  colitis  in  chil- 
dren commonly  terminate  favorably.  The  result  depends  not  only  on  the 
extent  and  severity  of  the  inflammation,  but  the  constitution  and  previous- 
health.  The  inflammation  is  more  serious  when  secondary  than  when  pri- 
mary. Extensive  and  great  tenderness  of  the  abdomen,  features  pallid,  anx- 
ious, and  expressive  of  suffering,  pulse  frequent  and  feeble,  should  excite  the 


810  ENTERITIS  AND  COLITIS  IN  CHILDHOOD. 

most  serious  apprehensions.  Frequent  vomiting  also  denotes  a  grave  form 
of  the  disease.  Stupor,  and  especially  convulsive  movements,  show  that  the 
nervous  centres  are  affected,  and  should  make  us  guarded  in  the  prognosis. 
Improvement  in  the  disease  on  which  to  base  a  favorable  prediction  is  appa- 
rent in  the  diminution  of  the  tenderness,  improvement  in  the  pulse  and 
character  of  the  stools,  a  more  cheerful  countenance,  and  less  disrelish  of 
food. 

Treatment. — This  should  be  similar  to  that  employed  for  the  adult. 
In  enteritis  at  the  commencement  of  the  disease,  if  there  be  reason  to  sus- 
pect the  presence  of  any  irritating  substance  in  the  intestines,  and  ordi- 
narily in  colitis,  it  is  advisable  to  commence  treatment  by  the  use  of  some 
simple  evacuant,  like  castor  oil.  After  this  our  reliance,  so  far  as  internal 
treatment  is  concerned,  must  be  mainly  on  opiates  and  antiphlogistic  medi- 
cines. One  of  the  best  remedies  of  this  class  is  the  Dover's  powder,  which 
may  be  given  to  a  child  five  years  old  in  doses  of  three  grains  every  three 
hours.  A  corresponding  dose  of  any  of  the  other  opiates  may  be  given,  but 
with  less  sudorific  effect.  In  colitis  the  occasional  administration  of  a  laxa- 
tive should  not  be  neglected  if  the  stools  be  entirely  or  mainly  muco-sanguin- 
eous.  It  should  be  employed  so  as  to  prevent  accumulation  of  fecal 
matters  in  the  colon,  which  would  serve  as  an  irritant  and  increase  the 
inflammation.  The  dose  should  be  small,  merely  sufficient  to  produce  fecal 
evacuation,  and  repeated  as  required,  daily  or  less  frequently.  The  laxatives 
commonly  preferred  are  magnesia,  rhubarb,  or  castor  oil.  The  physician 
may  prescribe  an  opiate  mixture  containing  sufficient  of  the  laxative  to  have 
the  effect  desired,  though  ordinarily  it  is  better  to  prescribe  the  two  sepa- 
rately, so  that  the  laxative  can  be  given  or  withheld  according  to  circum- 
stances, while  the  opiate  is  continued  more  regularly.  Except  that  there  be 
some  irritating  substance  which  requires  removal  the  effect  of  laxatives  is 
injurious  instead  of  beneficial.  Instead  of  a  laxative  given  by  the  mouth, 
the  use  of  a  clyster  of  glycerin  and  sweet  oil  in  tepid  water  is  often  prefer- 
able. The  following  prescriptions  may  be  employed  for  a  child  of  five 
years : 

R.  Pulv.  opii,  gr.  v  ; 

Bismuth,  subnitrat.,        gij.     Misce. 
Divid.  in  pulveres  No.  xx.    Give  one  powder  every  two  to  four  hours. 

R.  Pulv.  ipecac,  comp.,  gj  ; 

Bismuth,  subnitrat..  ^ij.     Misce. 

Divid.  in  pulveres  No.  xxiv.     Give  one  powder  as  above. 

R.  Tine,  opii  deed orat.,         .^ss  ; 
Bismuth,  subnitrat.,         gij  ; 
Aq.  menth.  piperit., 
Syr.  zingiberis,  dd.  §j.     Misce. 

Shake  bottle.     Give  one  teaspoonfiil  from  two  to  four  hours. 

The  local  treatment  which  is  found  most  beneficial  consists  in  the  use  of 
emollient  applications  covered  with  oil-silk,  and  made  sufficiently  irritating 
by  mustard  or  otherwise  to  cause  constant  redness. 

The  diet  should  be  bland  and  unirritating.  In  the  first  stage  of  the 
inflammation  rice  or  barley-water  or  arrowroot  boiled  in  water  and  similar 
drinks  should  constitute  the  main  diet.  When  the  active  inflammation  has 
abated,  and  at  any  period  of  the  disease  if  there  be  a  tendency  to  pros- 
tration, more  nourishing  food  should  be  given.  Milk  and  animal  broths  may 
then  be  allowed.  In  cases  which  are  protracted  or  attended  with  symptoms 
of  exhaustion  alcoholic  stimulants  are  required. 


SYMPTOMATIC  CONSTIPATION.  811 


CHAPTER   X. 

•     CONSTIPATION. 

The  gastro-intestinal  portion  of  the  digestive  apparatus  has  a  double 
function.  First,  it  receives  and  retains  the  food  during  the  process  of  diges- 
tion ;  it  furnishes  the  most  important  of  the  liquids  by  which  digestion  is 
effected  ;  and  it  absorbs  those  products  of  digestion  which  are  required  for  the 
nutrition  of  the  body,  wliile  it  serves  as  a  barrier  against  the  admission  of 
refuse  matter.  Secondly,  it  has  an  excretory  function,  so  that  a  lai-ge  part 
of  the  waste  and  noxious  products  of  the  system  are  eliminated  from  its 
surface.  Having,  therefore,  a  relation  so  close  and  fundamental  to  the  gen- 
eral nutrition,  it  is  neces.sary,  for  the  normal  activity  of  the  organs  and  the 
maintenance  of  health,  that  its  functions  be  regularly  and  fully  performed. 
But  retention  of  fecal  matter  beyond  the  normal  period  is  one  of  the  most 
common  ailments  both  in  infancy  and  childhood,  and  occasionally  it  consti- 
tutes a  grave  disease.  The  reader  is  referred  to  page  155  for  remarks  relating 
to  constipation  of  the  newly-born. 

Constipation  is  of  two  kinds — namely,  sjjmptomafic  and  idiopathic. 

Symptomatic  Constipation. — Causes. — Many  of  these  are  obstruc- 
tive. The  more  common  of  them  are  the  following :  (a)  Congenital  strnosis, 
or  occlusion  of  the  anus  or  rectum.  The  anus  is  not  formed  or  it  terminates 
in  a  cul-de-sac,  while  the  lower  end  of  the  large  intestine  forms  another 
cul-de-sac.  These  two  cul-de-sacs,  lying  opposite  to  each  other,  one  look- 
ing upward  and  the  other  downward,  may  be  separated  from  each  other  by  a 
small  interspace,  a  fibrous  septum,  so  that  relief  can  be  obtained  by  a  punc- 
ture or  incision,  or  they  may  be  widely  separated,  so  that  there  is  no  possible 
mode  of  relief,  and  death  is  inevitable  unless  the  fecal  matter  escape  through 
a  congenital  fistulous  passage  upon  one  of  the  adjacent  mucous  surfaces; 
which  mode  of  relief  was  present  in  40  per  cent,  of  the  cases  of  this 
obstruction  collected  by  Leichtenstern.  Exceptionally,  this  malformation 
occurs  in  the  sigmoid  flexure,  while  the  rectum  is  normal.  The  stenosis,  if 
flight,  may  produce  little  delay  in  the  evacuations,  except  when  hardened 
masses  or  coarse,  indigestible  substances  descend  upon  it,  and  it  may  there- 
fore with  careful  selection  of  diet,  cause  little  inconvenience  for  a  length- 
ened period,  while  much  stenosis  causes  early   obstructive  symptoms. 

Karely  the  stenosis  is  at  the  ileo-caecal  orifice.     (See  page  155.) 

(i)  Intestinal  Dispfacenmits. — These  produce  obstructions  of  a  very  pain- 
ful and  dangerous  kind.  Intussusception  and  external  hernia  are  too  well 
known  to  require  description.  Both  are  likely  to  produce  complete  obstruc- 
tion if  not  soon  relieved,  but  there  are  cases  of  intussusception  in  children 
in  which  the  displaced  intestine  remains  pervious,  and  the  evacuations  occur 
with  more  or  less  regularity  ;  and  the  same  is  true  of  one  form  of  hernia — 
namely,  the  congenital — which,  although  painful,  seldom  produces  serious 
obstruction. 

Painful  and  dangerous  occlusion  and  consequent  arrest  of  alvine  evac- 
uations occasionally  result  from  the  imprisonment  of  a  loop  of  intestine  in  an 
opening,  usually  congenital,  in  the  mesentery  or  diaphragm,  or  from  the 
knotting  of  one  portion  of  intestine  with  another,  as  described  by  Leichten- 
stern, or  again  from  the  twisting  of  the  intestine.  Epstein  and  Soyka '  relate 
1  Centralb.  f.  d.  med.  Wi^sensch.,  April  24,  1879. 


812  CONSTIPATION. 

the  case  of  a  new-born  infant  that  died  in  the  second  week  after  birth  with 
symptoms  of  obstruction.  At  the  autopsy  a  portion  of  the  small  intestine 
with  its  mesentery  was  found  twisted  upon  its  axis  from  right  to  left,  without 
any  marked  evidence  of  inflammation. 

(c)  Substances  which  have  been  swallowed  or  substances  whose  nuclei 
have  been  swallowed,  and  which  consist  of  a  deposit  of  carbonate  and  phos- 
phate of  lime,  or  substances  which  have  been  produced  entirely  in  the  sys- 
tem, and  which,  lodged  in  narrow  parts  of  the  intestine,  cause  obstruction. 
Such  substances,  some  of  which  occur  most  frequently  in  children  and  others 
in  elderly  people,  produce  acute  constipation.  Indigestible  matter  contained 
in  the  food,  as  seeds  or  the  parenchymatous  portions  of  fruits,  occasionally 
collects  in  considerable  quantity  and  obstructs  the  intestine.  A  large  gall- 
stone having  escaped  from  the  common  bile-duct,  sometimes  lodges  in  the 
intestine,  either  at  the  ileo-caecal  valve  or  more  rarely  at  some  other  pointy 
and  retards  the  passage  of  fecal  matter.  But  this  seldom  occurs  in  children. 
In  one  instance,  and  in  only  one,  have  I  known  obstinate  constipation  to  be 
produced  by  worms.  The  patient  was  a  girl  of  about  four  years,  in  whom 
constipation  came  on  suddenly,  and  was  accompanied  by  distension  of  abdomen 
and  great  suffering.  This  continued  nearly  one  week,  when  a  mass  of 
intertwined  round  worms  was  expelled,  with  immediate  relief.  The  records 
of  medicine  also  contain  cases  in  which  neoplasms,  growing  from  the  coats 
of  the  intestines  internally,  have  attained  such  a  size  as  to  retard  the  evac- 
uations. 

((/)  Abscesses  and  tumors,  especially  when  occurring  in  the  pelvis,  alsa 
sometimes  cause  constipation  by  pressing  upon  the  intestine  and  obstructing 
or  narrowing  the  passage  through  it.  Thus,  in  1868,  Mr.  Thomas  Smith 
related  to  the  London  Pathological  Society  the  case  of  an  infant,  aged  four- 
teen months,  in  whom  both  alvine  and  urinary  evacuations  were  retarded  by 
a  cancerous  tumor  growing  between  the  rectum  and  bladder,  and  ending  fatally 
in  three  months  after  the  occurrence  of  the  first  symptoms. 

(e)  Peritonitis,  during  its  continuance,  is  known  to  constipate  the  bowels. 
It  is  supposed  that  inflammatory  oedema  occurs  around  the  muscular  fibres 
of  the  middle  coat,  by  which  their  contractility  is  impaired.  Hence  the  lax 
state,  the  meteorism,  and  inaction  of  the  intestines  in  this  disease.  When 
the  peritonitis  abates  the  normal  action  is  restored  and  the  evacuations  occur 
regularly  if  the  free  surface  of  the  peritoneum  have  undergone  no  unfavor- 
able change.  But,  unfortunately,  peritonitis  often  produces  more  lasting 
injury,  so  as  to  interfere  seriously  with  the  intestinal  movements  and  produce 
an  habitually  torpid  state  of  the  bowels.  This  occurs  from  adventitious 
bands  of  inflammatory  origin  which  lie  across  the  intestines,  compressing 
them  at  the  points  of  contact  and  restraining  their  movements,  and  from 
adhesion  of  the  intestinal  loops. 

The  most  marked  cases  which  I  have  observed  of  this  were  children  who- 
had  had  tubercular  peritonitis.     The  following  was  an  interesting  example  : 

Case. — Charles,  aged  four  years,  was  returned  to  the  New  York  Foundling 
Asylum  on  April  16,  1877,  to  be  treated  for  tumor  albus  of  the  left  knee  and  for 
general  ill-health.  His  parentage  and  early  history  were  unknown.  The  nurse 
in  the  city  to  whom  he  had  been  entrusted  when  quite  small  stated  that  he  had 
no  sickness  when  with  her  except  sore  eyes,  and  that  about  April  1,  1877,  the 
enlargement  of  the  knee  was  first  observed.  The  head  of  the  boy  was  large  and 
the  abdomen  much  distended,  but  without  any  decided  tenderness  on  pressure ; 
its  entire  lower  part  had  a  purplish  color.  Percussion  over  it  gave  a  dull  sound, 
except  upon  and  near  the  epigastrium,  where  there  was  some  resonance;  umbili- 
cus prominent ;  circumference  of  body  over  abdomen,  twenty-three  inches  ;  pulse 
128  ;  axillary  temperature  99°.  It  was  stated  that  he  had  no  stool  Avithout  medi- 
cine, and  that  usually  one  tablespoonful  of  castor  oil  was  required  to  produce  it. 


IDIOPATHIC  CONSTIPATION.  813 

The  urine  contained  no  albumen  and  was  apparently  normal.  As  the  appearance 
indicated  struma,  a  mixture  of  cod-liver  oil,  syrup  of  the  hictophosphate  of  lime, 
and  iron  was  prescribed,  to  be  given  three  times  daily,  and  directions  were  given 
to  rub  cod-liver  oil  over  the  abdomen  also  three  times  each  day  for  five  minutes 
each  time.  Some  nodules  were  felt  on  pressure  upon  the  abdomen,  which  we 
suspected  were  enlarged  mesenteric  glands.  From  the  day  on  which  the  friction 
and  kneading  of  the  abdomen  were  commenced  the  stools  began  to  occur,  on  the 
average,  about  twice  daily.  The  kneading  proved  the  safest,  as  well  as  most 
efficient,  method  of  producing  defecation. 

On  May  4th  the  circumference  of  the  trunk  over  the  most  prominent  part  of 
the  abdomen  was  reduced  to  twenty-two  inches.  The  records  on  May  11th  state: 
"Same  treatment  is  continued ;  has  tolerable  appetite,  but  is  pallid,  and  his  flesh 
flabby  and  soft."  On  May  22d  the  circumference  of  the  trunk  gave  twenty-two 
and  three-quarter  inches.     The  tumor  albus  remained  about  the  same. 

I  saw  the  patient  again  during  attendance  in  the  asylum  in  August  and 
November.  The  record  in  November  states  that  he  is  feeble  and  failing;  is 
becoming  weaker  and  thinner ;  breath  and  exhalations  from  the  surface  offen- 
sive ;  he  is  kept  quiet  on  account  of  the  knee.  From  this  time  he  gradually 
failed,  and  died  April  11,  1878.  There  was  no  cough  to  attract  attention,  and 
instead  of  constipation  a  diarrhoea  of  some  weeks'  continuance  preceded  death. 

Autopsy. — Lungs  healthy,  except  a  little  exudation  over  the  summit  of  right 
lung ;  bronchial  glands  cheesy ;  numerous  tubercles,  some  of  them  cheesy,  upon 
the  parietal  and  visceral  surface  of  the  peritoneum.  Loops  of  the  intestines  were 
united  to  each  other  by  old  adhesions,  and  the  small  intestines  were  generally 
bound  down  by  bands"  into  a  "  uniform  conglomeration ;"  mesenteric  glands 
enlarged  and  cheesy ;  a  large  ulcer  upon  the  surface  of  the  rectum,  and  numer- 
ous small  round  ulcers  upon  the  surface  of  small  and  large  intestines,  apparently 
occupying  the  site  of  the  solitary  follicles. 

Occasionally  a  false  band,  the  result  of  peritonitis,  lies  across  the  intes- 
tines, without  resti-aining  their  movements  and  producing  no  marked  symp- 
toms, and  probably  no  symptoms  at  all,  until  a  loop  happens  to  pass  under- 
neath it,  when,  if  not  soon  released,  it  is  liable  to  become  strangulated,  with 
complete  obstruction  to  the  passage  of  fecal  matter.  This  displacement  might 
properly  be  classified  with  the  internal  hernias  described  above.  In  my  own 
person  at  the  age  of  twelve  years  such  an  accident  occurred  about  two  months 
after  the  peritonitis.  Upon  the  abatement  of  the  inflammation  a  sensation 
of  traction  had  been  noticed  in  the  umbilical  region  almost  daily  during  exer- 
cise, and  the  displacement  was  indicated  by  the  extreme  pain  which  character- 
izes such  cases,  and  which  ceased  suddenly  when  the  parts  were  released 
after  about  eighteen  hours. 

(/)  ^^  hile  it  is  important  that  the  diet  and  glandular  secretions  should 
be  such  that  the  feculent  matter  may  have  proper  consistence  for  easy  pro- 
pulsion along  the  intestinal  tube,  the  important  agent  by  wdiich  alvine  evacua- 
tions are  effected  is  obviously  muscular  contraction.  The  muscular  fibres  of 
the  intestines  produce  the  vermicular  and  peristaltic  movements  by  which  the 
excrement  is  carried  forward,  and  the  abdominal  muscles  by  their  powerful 
contraction  are  the  chief  agents  of  expulsion.  Now,  any  pathological  state 
which  impairs  the  innervation  of  these  muscles  or  renders  it  abnormal, 
destroying  the  proper  balance  between  "  exciting  and  inhibiting  impulses." 
is  likely  to  cause  constipation.  Hence  meningitis,  myelitis,  and  certain  other 
diseases  of  the  cerebro-spinal  axis,  rachitis,  general  weakness,  etc.,  are  com- 
monly attended  by  a  sluggish  state  of  the  intestines,  either  from  tonic 
contraction  of  the  muscular  fibres  of  the  middle  coat,  as  in  meningitis  or 
from  paralysis. 

Idiopathic  Constipation. — Causes. — These  are  quite  numerous.  The 
more  prominent  of  them  are  the  following :  First,  too  little  liquid  in  the 
excrement,  so  that  it  is  too  firm  for  ready  evacuation.  There  may  be  too 
little  liquid  taken  in  the  ingesta  or  too  scanty  secretion  of  the  liquids  which 


814  CONSTIPATION. 

mix  with  the  food,  as  those  of  the  pancreas,  liver,  and  mucous  follicles,  or 
there  may  be  too  great  an  absorption  of  liquid  through  the  coats  of  the 
intestines,  and  too  active  an  excretion  of  water  from  the  skin,  kidneys,  or 
lung.  The  firmer  the  fecal  matter  the  greater  the  tendency  to  constipation. 
Those  who  lose  a  large  amount  of  water,  as  in  diabetes,  night  sweats,  or  from 
occupations  which  expose  to  heat  or  from  residence  in  a  hot  climate,  are  espe- 
cially liable  to  constipation,  except  as  the  loss  of  liquid  is  compensated  by  an 
increased  amount  of  drink. 

The  character  of  the  food,  apart  from  the  amount  of  liquid  which  it  con- 
tains, obviously  has  a  marked  influence  upon  the  consistence  and  frequency 
of  the  stools.  Occasionally,  the  intestines  act  sluggishly  from  insufficiency 
of  food.  Thus,  the  infant  sometimes  hangs  an  unusually  long  time  on  the 
brea.st,  and  the  mother  or  wet-nurse  believes  it  to  be  a  hearty  nurser,  when 
there  is  really  a  deficiency  of  milk,  and  the  stools  are  scanty  and  infrequent 
from  lack  of  material.  Again,  constipation  is  not  uncommon  in  infants  who 
nurse  heartily  and  seem  to  obtain  a  sufficient  quantity  of  milk,  and  the  cause 
of  it  is  not  in  the  state  of  the  digestive  organs,  but  in  the  milk.  "We  find 
that  now  and  then  breast-milk  Kas  a  constipating  efi'ect,  although  we  discover 
nothing  to  cause  this  result  in  the  mother's  diet  or  health.  The  comparison 
of  ordinary  milk  with  colostrum  may  furnish  a  clew  to  the  explanation. 
Colostrum  is  known  to  be  more  laxative  than  ordinary  milk,  and  it  dififers 
from  it  chemically  in  containing  more  butter,  sugar,  and  salts.  Hence  the 
theory  seems  plausible  that  when  breast-milk  is  constipating  these  elements 
occur  in  less  than  the  normal  quantity.  And  we  shall  see  hereafter  that  treat- 
ment suggested  by  this  theory  obviates  the  constipation. 

The  use  of  a  diet  which  consists  chiefly  of  assimilable  substances,  as  ani- 
mal food,  and  from  which,  after  the  digestive  process,  little  coarse  and  stimu- 
lating residuum  remains,  is  obviously  liable  to  produce  a  sluggish  state  of  the 
bowels.  On  the  other  hand,  coarse  food,  as  fruits  with  their  seeds,  coarsely- 
ground  meal,  etc.,  which  stimulates  the  peristaltic  action  and  the  secretions,, 
increases  the  number  and  frequency  of  the  alvine  discharges. 

Habit  also  exerts  a  decided  influence  upon  defecation.  One  who,  for 
whatever  reason,  neglects  or  resists  the  desire  for  a  stool  soon  becomes  less 
conscious  of  the  daily  recurring  need  and  establishes  a  constipated  habit. 
Constipation  is  more  liable  to  occur  in  those  who  lead  a  quiet  life  than  in 
those  who  are  active.  A  constipated  habit  is  established  in  many  school- 
children by  neglecting  or  repressing  the  desire  for  a  stool  during  school  hours. 

But  there  are  cases  in  which  there  seems  to  be  a  constitutional  tendency 
to  constipation — a  tendency  quite  independent  of  the  usual  conditions.  Thus 
I  have  met  children  who  were  bright  and  active,  free  from  obstruction  or 
disease  which  might  retard  the  evacuations,  apparently  far  from  having 
sluggish  muscular  contractility,  and,  so  far  as  I  could  see,  with  proper  diet^ 
and  yet  with  defecation,  except  as  it  was  produced  by  measures  employed, 
occurring  no  oftener  than  each  second,  third,  or  fourth  day. 

But  it  must  be  borne  in  mind  that  what  is  constipation  in  one  child  may 
not  be  in  another,  for  occasionally  one  does  well  with  only  one  evacuation 
every  second  or  third  day,  while  a  large  majority  require  daily  defecation  in 
order  to  the  maintenance  of  perfect  health. 

In  the  adult  the  sacculi  or  pouches  which  occur  in  the  walls  of  the  colon^ 
produced  by  contraction  of  the  longitudinal  bands  acting  at  right  angles  to 
the  direction  of  the  circular  fibres,  and  consisting  of  the  internal  and  exter- 
nal tunics  without  the  muscular,  become  the  receptacles  for  fecal  matter  in 
those  who  are  constipated,  and  obviously  tend  to  increase  the  constipation. 
In  children  these  sacculi  are  much  less  developed  relatively,  and  in  young 
infants,  whose  intestines  lack  the  longitudinal  bands,  are  absent,  so  that  this 


SYMPTOMS.  815 

anatomical  condition  by  which  tho  passage  of  fecal  matter  is  delayed,  is 
unimportant  as  a  cause  ol'  constipation  in  the  young. 

On  page  157  we  have  stated  that  Gautier  of  (Geneva,  Switzerland,  has 
called  attention  to  an  anal  fissure  as  a  cause  of  constipation  in  the  newly- 
born  and  in  older  children.  The  constipation  occurs  IVoni  the  endeavor  to 
resist  defecation  on  account  of  the  pain. 

We  have  also  remarked  on  page  157  that  constipation  has  a  tendency  to 
perpetuate  itself,  since  retained  feculent  matter  becomes  more  consistent  and 
firmer,  and  the  contractile  power  of  the  muscular  tunic  becomes  weakened 
by  long  distension.  Obviously,  also,  an  abnormal  length  of  the  large  intes- 
tine, so  that  it  doubles  on  itself,  whether  congenital  or  the  result  of  con- 
stipation, and  a  malposition  which  diminishes  the  space  occupied  by  the  colon, 
and  therefore  increases  its  flexures,  have  a  tendency  to  produce  constipation. 

Symptoms. — When  there  is  a  mechanical  cause  which  retards  the  pas- 
sage of  fecal  matter  the  acuteness  of  symptoms  and  the  suffering  are  gen- 
erally proportionate  to  the  degree  of  obstruction.  Symptomatic  constipa- 
tion occurring  in  an  obstructive  disease,  whether  adhesions,  peritoneal  bands^ 
intussusception,  knots  or  twisting  of  the  irttestine,  incarceration  in  a  false 
passage,  or  from  biliary  or  intestinal  stones  or  fecal  masses,  is  attended  by 
severe  symptoms,  such  as  intense  colicky  pain,  vomiting,  loss  of  appetite, 
and  rapid  prostration.  The  ingesta  accumulate  above  the  point  of  obstruc- 
tion, producing  distension  of  the  intestine  with  fecal  matter  and  gas,  while 
below  the  point  of  obstruction  the  intestine  is  soon  empty.  The  symptoms 
indeed  have  the  severity  and  the  state  involves  the  danger  present  in  ordinary 
strangulated  hernia,  while,  from  being  internal,  and  therefore  less  accessible- 
for  treatment,  the  danger  is  even  greater.  If  the  intestinal  tract  be  narrowed^ 
whether  by  a  false  ligament,  the  result  of  an  old  peritonitis,  or  other  cause^ 
and  there  be  still  perviousness,  so  that  excrementitious  matter  passes  by  the 
obstruction,  though  slowly  and  with  more  or  less  difficulty,  the  patient  may 
be  comparatively  comfortable  if  the  food  be  such  that  no  hard  masses 
remain  ;  but  according  to  the  degree  of  stenosis  and  the  amount  and  coarse- 
ness of  the  fecal  matter  symptoms  occur  referable  to  the  obstruction.  If  the 
excrement  be  propelled  with  difficulty  through  the  narrowed  part,  the  mus- 
cular coat  above  the  obstruction  gradually  becomes  more  developed  from 
hypertrophy  of  the  muscular  fibres,  just  as  the  heart  enlarges  from  obstruc- 
tive disease  of  its  valves,  while  below  the  obstruction  the  intestine  atrophies 
and  its  calibre  diminishes  from  disuse.  Colicky  pains,  accumulation  of  fecal 
matter  above  the  obstruction,  distension  of  abdomen,  eructation  of  gas,  vom- 
iting, impaired  appetite,  and  consequent  decline  of  the  general  health  are 
common  results.  There  is  constant  danger  in  these  cases  that  the  narrow 
passage  may  become  obstructed  by  fecal  matter  if  it  happen  to  contain  hard 
masses  or  coarse  indigestible  substances.  The  gravest  form  of  constipation 
is  obviously  that  due  to  mechanical  agencies  which  act  as  obstacles,  but  as 
the  obstacles  are  numerous,  differently  located,  and  of  different  character,  sa 
there  is  great  difi"erence  in  the  gravity  of  the  cases. 

Idiopathic  constipation  generally  comes  on  gradually.  It  at  first  attracts 
little  attention  and  is  neglected.  The  symptoms  of  course  vary  greatly 
according  to  the  degree  and  stage  of  constipation.  In  mild  cases  the  reten- 
tion is  only  in  the  rectum  or  rectum  and  sigmoid  flexure,  and  there  are  no 
marked  symptoms  except  a  sensation  of  fulness  or  distension  of  these  parts, 
which  one  or  two  evacuations  relieve.  Between  these  mild  cases  and  the 
graver  forms  of  constipation  there  is  every  intermediate  grade,  attended  by 
symptoms  proportionately  severe.  It  is  surprising  sometimes  to  observe  how 
long  patients  live  with  extreme  constipation,  though  with  constant  suffering 
and  ill-health ;  and — which  I  wish  especially  to  be  noticed  in  this  connection 


SI  6  CONSTIPATION. 

— a  large  proportion  of  the  fatal  cases  of  idiopathic  constipation  occurring  in 
adults  and  recorded  in  the  literature  of  the  profession  began  in  early  life, 
even  in  infancy,  at  which  time  they  probably  might  have  been  relieved  by 
proper  remedies  and  a  life  of  suffering  prevented.  This  important  practical 
fact  shows  the  need  of  greater  attention  on  the  part  of  parents  and  nurses  to 
the  state  of  the  bowels  in  children,  that  their  sluggish  action  may  be  cor- 
rected before  it  becomes  habitual  and  those  anatomical  changes  of  distension 
and  muscular  paralysis  occur  which  are  with  difficulty  corrected. 

A  case  quite  remarkable  and  of  recent  date  occurred  in  the  practice  of  Dr. 
Strong^  of  Westfield,  N.  Y. : 

Case. — This  patient  at  the  age  of  two  years  usually  had  one  stool  in  two 
weeks,  and  several  years  later  only  one  in  six  weeks.  When  an  adult  he  was 
treated  by  Dr.  Strong,  who  found  great  distension  of  the  abdomen,  so  that  the 
lower  ribs  were  pressed  outward  in  nearly  a  horizontal  direction,  and  the  tho- 
racic organs  upward,  so  that  the  apex-beat  of  the  heart  was  about  one  inch 
above  the  nipple.  At  this  time  months  elapsed  between  the  stools,  the  longest 
intervals  being  eighteen  months  and  sixteen  days.  Defecation  when  it  did  occur 
lasted  from  two  to  four  days,  and  was  attended  by  violent  gastric  and  intestinal 
pain,  vomiting,  and  prostration.  At  one  of  these  prolonged  stools  forty  pounds 
of  feces,  resembling,  as  it  usually  did,  chewed  brown  paper,  were  evacuated,  the 
quantity  being  accurately  ascertained  by  weighing  the  patient  before  and  after- 
ward. He  had  appetite  and  was  able  to  do  certain  kinds  of  farm-work  during 
the  year  preceding  his  death,  which  occurred  at  the  age  of  twenty-eight  years. 
At  the  autopsy  the  colon  was  found  to  have  a  length  of  six  feet  and  three  inches 
and  a  circumference  of  thirteen  inches,  while  the  lungs  were  pressed  upward  and 
backward  as  when  compressed  by  a  pleuritic  exudation. 

While  such  extreme  cases  are  infrequent,  all  physicians  of  experience  are 
<;onsulted  from  time  to  time  by  adults  who  have  had  habitual  constipation 
from  their  earliest  recollection  ;  and  these  cases,  that  aggregate  so  large  a 
number,  might,  there  is  little  reason  to  doubt,  have  been  prevented  for  the 
most  part  during  childhood   when  the  habit  was  being  formed. 

In  long-continued  constipation,  in  which  there  is  a  large  fecal  accumula- 
tion, not  only  is  the  diameter  of  the  colon  increased,  as  stated  above,  but  this 
part  of  the  intestine  becomes  elongated.  This  may  lead  to  change  in  its 
position,  the  curves  of  the  sigmoid  flexure  extending  farther  to  the  right,  and 
the  central  part  of  the  transverse  colon  by  its  weight  curving  downward. 
This  abnormal  lengthening  and  the  consequent  curvatures  have  a  tendency 
to  increase  the  constipation,  as  has  been  stated  above  in  our  remarks  relating 
to  the  etiology. 

In  these  cases  of  extreme  constipation,  which  fortunately  are  rare  in  chil- 
dren, as  they  are  also  in  adults,  the  distension  of  the  colon  at  the  ileo-csecal 
orifice  has  a  tendency  to  widen  this  orifice,  so  that  the  valve,  which  in  the 
ordinary  state  prevents  the  return  of  any  substance  which  has  once  passed 
by  it,  is  liable  to  become  insufficient.  The  adjacent  folds  which  constitute 
the  valve  become  separated,  so  that,  if  vomiting  and  antiperistaltic  move- 
ments occur,  fecal  matter  may  pass  from  the  colon  toward  the  stomach.  In 
aggravated  cases,  in  which  there  is  retention  of  a  large  amount  of  fecal  mat- 
ter, distension,  muscular  paralysis,  etc.,  similar  to  those  which  we  have  seen 
produced  in  the  colon,  are  liable  to  occur,  though  to  a  less  extent,  in  the 
small  intestines,  especially  in  the  ileum. 

Retained  excrementitious  matter  accumulating  in  large  masses  evidently 
becomes  an  irritant,  so  that  by  its  pressure  it  excites  muscular  contractions, 
which  if  ineffectual  in  propelling  the  mass  cause  colicky  pains.  The  retained 
fecal  matter  also  undergoes  more  or  less  decomposition,  producing  gases  which 
by  increasing  the  distension  also  increase  the  pain. 

'  Amer.  Jour,  of  Med.  Sc.i.,  1874  and  1876. 


TREATMENT.  817 

Any  irritating  substance  applied  to  a  mucous  surface  is  liable  to  excite 
increased  secretion  from  the  mucous  follicles  or  from  the  glands  whose  ori- 
fices connect  with  the  mucous  nieuihrane  at  the  point  of  irritation.  Many 
familiar  examples  will  at  once  be  recalled  to  mind,  as  the  defluxion  from  the 
nostrils  from  the  use  of  snufts  and  increased  mucous  secretion  and  salivation 
from  objects  held  in  the  mouth.  In  the  same  way,  retained  excrement,  form- 
ing hard  masses  which  press  upon  the  intestinal  surface,  excite  a  secretion, 
and  not  infrequently  produce  thereby  a  diarrhoja  which  is  conservative,  and 
which  may  for  the  time  unload  the  bowels,  or  it  may  remove  a  part  of  the 
scybahvj,  while  the  rest  remain.  Hence  we  sometimes  hear  patients  speak  of 
having  irregular  evacuations,  constipation  alternating  with  diarrhoea.  In 
aggravated  cases  the  pressure  of  impacted  feces  sometimes  produces  inflam- 
mation of  the  surface,  when,  in  addition  to  abdominal  pain,  there  are  tender- 
ness on  pressure  and  some  (usually  quite  moderate)  elevation  of  tempera- 
ture. In  cases  which  have  terminated  fatally  after  a  longer  or  shorter 
time,  destruction  of  the  mucous  surface  has  been  found  in  places  in  conse- 
quence of  the  pressure  and  inflammation.  We  can  readily  believe  that,  as 
in  cases  of  typhoid  ulcerations,  if  the  ulcers  reach  a  certain  depth  they  may 
also  give  rise  to  localized  peritonitis,  and  that  occasionally  perforation  may 
result  at  the  ulcerated  or  gangrenous  point.  The  expulsion  of  hardened 
masses  which  have  collected  in  the  rectum  is  slow  and  painful,  and  accom- 
panied by  more  or  less  tenesmus,  which  not  infrequently  causes  a  portion  of 
the  mucous  membrane  at  the  anal  orifice  to  descend  below  the  sphincter  ani 
and  protrude,  by  which  hemorrhoids  are  produced.  Occasionally,  as  I  have 
observed  in  certain  cases,  the  entire  circumference  of  the  rectal  mucous  mem- 
brane, to  the  distance  of  half  an  inch  or  more  above  the  anus,  becomes  so 
loosened  from  its  attachment  to  the  connective  tissue  that  it  descends  below 
the  sphincter  ani  and  protrudes  during  each  defecation.  But  this  displace- 
ment, known  as  prolapsus  recti,  more  commonly  results  in  children  from  pro- 
tracted intestinal  catarrh,  attended  by  diarrhoea,  loss  of  flesh,  and  by  dimin- 
ished tonicity  of  the  tissues. 

A  beautiful  and  conservative  provision  in  the  system  is  that  by  which 
vicarious  functions  are  established  to  relieve  organs  which  imperfectly  per- 
form their  part.  While  the  intestinal  surface  is  to  a  great  degree  elimina- 
tive,  so  that  noxious  and  effete  products  are  largely  expelled  from  the  system 
in  the  stools,  it  possesses  also  in  high  degree  an  absorbent  function,  as  all 
who  employ  rectal  alimentation  are  aware.  Now,  if  the  intestine  fail  to  per- 
form its  function  of  defecation  and  feculent  matter  collect  within  it  and 
begin  to  exert  pressure  upon  the  intestinal  surface,  more  or  less  of  the  liquid 
portion  is  taken  up  by  the  vessels,  and,  entering  the  general  circulation,  finds 
a  mode  of  escape  through  other  emunctories.  The  general  ill-health  or 
languor,  the  furred  tongue,  headache,  and  foul  breath  which  characterize  these 
cases  are,  no  doubt,  due  to  the  absorption  into  the  blood  or  retention  in  it  of 
noxious  products  contained  in,  and  which  in  part  constitute,  the  feculent 
matter.  The  fact  that  patients  may  live  for  years  with  tolerable  appetite, 
and  with  only  one  dejection  every  second  or  third  week,  receives  explanation 
in  the  fact  that  other  organs,  as  the  lungs,  kidneys,  skin,  etc.,  act  as  depur- 
ants  for  such  excrementitious  matter  as  can  be  taken  up  in  a  liquid  or  gas- 
eous form  by  the  intestinal  surface. 

In  infants,  constipation,  even  when  slight  and  temporary,  often  causes  fret- 
fulness,  which  is  indicated  by  the  character  of  their  cries  and  the  movement 
of  the  thighs  over  the  abdomen.  Continuing  for  a  time,  it  causes  more  or 
less  fever,  and  in  those  young  children  who  are  liable  to  eclampsia  it  predis- 
poses to  an  attack,  and  it  may  be  the  chief  cause. 

Treatment. — If  there  be  reason  to  suspect  the  presence  of  a  mechanical 
52 


8 1 8  CONSTIPA  TION. 

obstacle  whicli  prevents  normal  defecation,  a  careful  examination  should  be 
made  in  order  to  discover,  if  possible,  its  nature  and  location.  Often  it  is 
of  such  a  nature  that  it  cannot  be  removed,  but  its  constipating  effects  may 
sometimes  be  in  a  measure  obviated.  In  one  of  the  published  cases  in  which 
constipation  continued  from  early  childhood  to  adult  life,  and  finally  proved 
fatal,  its  cause  was  ascertained  to  be  a  septum  in  the  rectum,  which  probably 
might  have  been  relieved  by  surgical  measures.  In  all  cases  of  constipation 
which  the  history  shows  may  be  produced  by  mechanical  causes,  whether  the 
obstruction  be  complete  and  the  colicky  pains  and  other  symptoms  severe,  or 
there  be  occasional  scanty  evacuations  with  but  slight  or  moderate  sufferings 
the  history  of  the  patient  should  be  obtained  in  order  to  ascertain  if  there 
had  been  at  any  previous  time  symptoms  of  pei'itonitis  or  other  pathological 
state  which  might  throw  light  on  the  etiology.  The  abdomen  and  the  usual 
sites  of  hernia  should  be  carefully  explored  by  palpation,  and  the  rectum  by 
the  finger,  large-sized  catheter,  or  rectal  tube.  A  thorough  examination  thus 
instituted,  painless  to  the  patient,  will  usually  enable  the  practitioner  to  deter- 
mine either  the  exact  or  probable  obstacle  if  any  be  present. 

The  proper  treatment  of  symptomatic  constipation  obviously  requires  the 
removal,  so  far  as  possible,  of  the  primary  disease  or  the  cause,  whether  it  be 
obstructive  or  otherwise.  We  need  not, gtop  to  consider  the  special  meas- 
ures which  are  required,  and  will  pass  to  the  consideration  of  the  treatment 
of  idiopathic  constipation. 

Hygienic  Measures. — We  have  already  alluded  to  the  fact  that  habit  has  a 
powerful  control  over  the  action  of  the  intestines,  so  that  it  is  important  to 
obtain  a  daily  alvine  evacuation  at  a  certain  hour,  and  by  establishing  the 
habit  the  need  will  usually  be  experienced  when  that  hour  arrives  each  day. 
Many  cases  which  become  troublesome  and  obstinate  might  no  doubt  have 
been  prevented  had  this  physiological  law  been  heeded  and  a  daily  evacuation 
obtained  at  a  certain  hour.  The  constipated  habit,  mild  and  not  yet  fully 
established,  is  more  liable  to  be  overlooked  when  it  occurs  in  childhood  than 
in  infancy,  for  the  infant  is  closely  and  constantly  under  observation,  and  it 
soon  presents  symptoms,  as  fever  and  fretfulness,  if  it  do  not  have  the  regu- 
lar evacuation,  while  children  over  the  age  of  four  or  five  years  tolerate  better 
a  sluggish  state  of  the  bowels,  and  are  likely  to  be  constipated  for  a  consider- 
able time  before  it  is  ascertained.  They  therefore  require  more  attention  in 
this  regard  than  is  usually  bestowed  by  parents. 

The  nature  of  the  diet  is  obviously  important,  as  certain  kinds  of  food 
are  more  laxative  than  others.  Chicken  tea  and,  to  a  certain  extent,  beef 
and  mutton  tea,  are  laxative,  and  made  plainly  are  therefore  useful  in  con- 
nection with  other  articles.  The  various  kinds  of  berries  and  fruits  have 
also  a  decidedly  stimulating  effect  on  the  intestinal  surface  and  aid  in  remov- 
ing constipation.  The  apple  scraped  or  baked,  or  apple  sauce,  may  be  given 
to  quite  young  children ;  and  for  those  that  are  older  currants,  cherries,  and, 
among  dry  fruits,  pi'unes  and  figs,  are  laxative.  Unfermented  cider  in  its 
season,  which  has  been  found  so  useful  for  adults,  may  also  be  given  to 
children  in  moderate  quantity,  at  least  to  those  who  have  reached  the  age 
of  two  or  three  years. 

By  the  digestive  process  starch,  which  is  unassimilable,  is  changed  into 
grape-sugar,  which  can  be  absorbed  and  assimilated,  and  from  the  small  size 
of  the  salivary  glands  in  the  first  months  of  infancy  it  is  believed  that  the 
salivary  and  pancreatic  fluids  are  insufficient  to  convert  starch  into  grape- 
sugar  except  in  very  inadequate  quantity.  It  appears,  however,  highly  prob- 
able that  there  is  an  epithelial  ferment  which  converts  starch  into  sugar,'  sO' 

'  "  Chemical  Phenomena  of  Digestion,"  by  Charles  Ricliet,  Rev.  des  Set.  med.,  Oct.,. 
1878. 


TREATMENT.  819 

that  young  infants  can  digest  starchy  food  in  limited  quantity.  The  belief 
that  the  infantile  digestion  up  to  a  certain  age  is  inadequate  to  effect  the 
change  led  to  the  preparation  of  food  for  infants  in  which  the  change  of  starch 
into  grape-sugar  was  accomplished  l)y  a  chemical  process.  Now,  grape-sugar, 
given  in  considerable  quantity,  is  laxative,  and  I  have  found  it  necessary  to  give 
it  sparingly  and  with  other  food  in  the  hot  months,  when  infants  are  prone  to 
diarrhoea.  But  thit!  laxative  effect  renders  the  glucose  preparations  of  the 
shops  very  useful  in  the  treatment  of  habitual  constipation  of  infants,  whether 
we  employ  the  "  maltose  "  or  "  granulated  sugar  of  malt  "  or  the  preparations 
of  Liebig's  food.  Of  four  constipated  infants  in  the  New  York  Infant  Asy- 
lum to  whom  Horlick's  "sugar  of  malt"  was  given,  three  were  relieved. 
Any  of  the  glucose  preparations  can  be  given  quite  freely  to  a  constipated 
infant  without  impairing  the  digestive  function  or  producing  other  ill-effect, 
so  long  as  no  more  than  the  normal  evacuations  are  produced  ;  and  I  consider 
them  among  the  best  and  safest  of  the  foods  for  the  relief  of  constipation  in 
infants;  but  glucose  or  grape-sugar  is  only  feebly  laxative,  probably  not 
more  than  cane-sugar. 

Oatmeal  is  more  laxative  than  most  other  kinds  of  amylaceous  food. 
Made  into  a  gruel  and  strained,  it  may  be  given  to  the  nursing  infant,  and 
unstrained  tothose  who  are  older.  Bread  or  pudding  from  coarsely-ground 
or  unbolted  flour  or  meal,  and  vegetables  which  contain  saline  and  fibrous 
substances,  have  a  stimulating  and  laxative  efiect  on  the  surface  of  the  intes- 
tines, and  therefore  are  useful  for  constipated  children  of  the  age  of  two  or 
three  years  and  upward. 

There  can  be  no  doubt  that  the  free  use  of  water  in  the  ingesta  materially 
aids  in  relieving  costiveness.  In  one  of  the  numbers  of  the  London  Lancet 
a  physician  asks  the  profession  how  to  cure  obstinate  constipation  in  adults. 
Among  the  replies,  one  physician  suggests  drinking  a  tumblerful  of  cold 
water  on  retiring  to  bed  and  another  tumblerful  in  the  morning  ;  and  there  can, 
I  think,  be  little  doubt  that  the  laxative  eff"ect  of  broths,  gruels,  fruits,  and 
mineral  waters  is  partly  due  to  the  amount  of  water  which  they  contain. 
One  of  the  chief  causes  of  constipation,  we  have  seen,  is  too  great  firmness 
or  consistence  of  the  stools,  due  to  absorption  of  the  water ;  and  if  a  larger 
quantity  of  water  be  swallowed  during  or  after  the  meals  than  is  removed  by 
absorption,  so  that  the  stools  have  their  normal  or  less  than  normal  consist- 
ence, this  cause  of  constipation  is  removed.  An  excess  of  water  introduced 
into  the  system  is  to  a  great  extent  eliminated  by  the  kidneys,  and  in  hot 
weather  by  the  skin,  and  to  a  certain  extent  exhaled  from  the  lungs ;  but 
experience  shows  that  if  the  amount  of  liquid  received  be  so  great  that  the 
vessels  in  the  coats  of  the  intestines  continue  in  a  state  of  repletion,  only  a 
certain  part  of  it  is  absorbed,  while  the  rest  descends  and  mixes  with  the 
excrementitious  matter. 

The  simple  expedient  of  allowing  a  liberal  use  of  water,  so  useful  in 
adult  cases,  doubtless  also  has  a  laxative  efiect  in  children,  and  its  judicious 
use  is  proper  for  them.  Another  important  aid  in  overcoming  habitual  con- 
stipation is  frequent  kneading  of  the  abdomen.  My  attention  was  first  par- 
ticularly directed  to  this  in  the  treatment  of  the  case  related  above,  in  which 
obstinate  constipation,  occurring  in  a  child  of  three  years  from  peritoneal 
bands  and  adhesions,  was  to  a  great  extent  corrected  by  friction  over  the 
abdomen  for  three  or  four  minutes  at  a  time,  with  cod-liver  oil  three  or  four 
times  daily.  The  manipulation  probably  did  the  good,  and  not  the  oil,  but 
the  use  of  one  of  the  oils  for  inunction  renders  the  kneading  less  painful 
and  ensures  its  more  thorough  performance  by  the  nurse.  All  obstetricians 
in  certain  emergencies  stimulate  the  uterine  muscular  fibres  to  contraction  by 
kneading  the  abdomen,  and  it  is  probable  that  the  muscular  fibres  of  the 


8  20  CONSTIPA  TION. 

intestines  are  stimulated  in  a  similar  manner,  so  that  the  intestinal  move- 
ments are  increased  by  which  feculent  matter  is  carried  forward. 

The  external  application  of  cold,  so  effectual  in  contracting  the  uterine 
muscular  fibres,  also  stimulates  the  contractile  power  of  the  muscular  fibres 
of  the  intestines.  Cold-water  bathing,  the  sudden  application  of  a  cloth 
wrung  out  of  cold  water  to  the  abdomen,  and  in  certain  obstinate  cases  even 
the  douche,  may  be  used  to  stimulate  the  muscular  coat  of  the  intestines  and 
the  abdominal  muscles  to  greater  activity.  Trousseau  says:  "  Before  leaving 
the  subject  of  the  treatment  of  constipation,  let  me  refer  to  the  application 
of  cold  to  the  abdomen — a  minor  method  which  I  have  seen  recommended, 
and  have  myself  prescribed  with  astonishing  success.  On  rising  in  the  morn- 
ing let  there  be  placed  on  the  abdomen  a  compress  of  several  folds  soaked  in 
cold  water,  and  let  it  be  separated  from  the  clothes  by  a  sheet  of  gutta-percha 
or  caoutchouc.  This  compress  ought  to  remain  on  for  three  or  four  hours." 
This  recommendation  by  Trousseau  is  for  adults,  who  are  much  less  suscept- 
ible to  the  influence  of  cold  than  children.  So  prolonged  an  application  of 
cold  and  wet  to  a  child,  even  the  most  robust,  would  involve  danger,  while  its 
application  during  the  brief  period  occupied  in  an  ordinary  bath,  with  proper 
exercise  afterward  or  with  other  measures  to  prevent  chilling,  could  have  no 
ill-eifect. 

Therapeutic  Measures. — For  temporary  constipation  and  many  cases  that 
are  habitual  enemata  should  be  employed,  since  they  promptly  unload  that 
part  of  the  intestines  in  which  feculent  matter  is  ordinarily  retained,  while 
they  do  not  impair  the  appetite  or  produce  the  prostration  which  so  often 
results  from  purgatives.  For  temporary  constipation  a  warm  clyster  may  be 
given,  and  it  commonly  is  more  agreeable  to  the  patient  than  one  of  lower 
temperature  than  the  body.  Among  the  enemata  which  have  been  found 
useful  are  castile  soap  with  molasses  and  water,  salt  and  water,  the  various 
oils,  as  sweet  oil  with  or  without  castor  oil,  linseed  oil  alone  or  with  molasses, 
and  the  gruels,  as  that  of  oatmeal  or  cornmeal  made  thin.  The  belief  that 
the  frequent  use  of  warm  clysters  produces  a  relaxing  efiect  is  probably  cor- 
rect, so  that  if  it  be  necessary  to  employ  clysters  often  in  consequence  of  the 
torpid  state  of  the  intestines,  cool  water,  the  eff"ect  of  which  is  tonic  and  stim- 
ulating, should  be  used.  I  prefer  the  use  of  glycerin  and  water  as  a  laxative 
enema.  For  ordinary  constipation  in  an  infant  the  injection  into  the  rectum 
of  one  teaspoonful  of  glycerin  and  one  teaspoonful  of  water  from  a  gutta- 
percha or  glass  syringe,  at  a  certain  hour  each  day,  will  rarely  fail  to  give 

relief. 

For  infants,  a  clyster  of  one  or  two  ounces  usually  suffices,  administered 
by  a  gutta-percha  or  glass  syringe,  while  for  older  patients  a  proportionately 
larger  quantity  is  required,  administered  by  preference  through  a  Davidson, 
India-rubber,  or  a  fountain  syringe.  In  certain  long-continued,  aggravated 
cases  the  frequent  injection  of  a  large  quantity  of  tepid  water  is  indispensa- 
ble in  order  to  wash  away  the  accumulation  of  fecal  matter.  Thus  in  1854, 
Mr.  Gay  exhibited  to  the  London  Pathological  Society  a  boy  of  seven  years 
who  at  the  age  of  three  years  had  had  typhus  fever  with  dysenteric  stools. 
After  convalescence  he  had  habitual  obstinate  constipation,  so  that  when  Mr. 
Gay  began  treatment  there  had  been  no  fecal  evacuation  for  nearly  four 
months,  and  the  girth  of  the  body  over  the  abdomen  was  forty-nine  inches, 
and  yet  the  appetite  and  general  health  were  not  seriously  impaired.  The 
shape  of  the  abdomen  and  the  examination  showed  great  distension  of  the 
rectal  ampulla  and  the  descending  colon.  Mr.  Gay  first  distended  the 
sphincter  ani,  so  that  it  admitted  a  speculum,  and  through  a  rectal  tube,  well 
introduced  into  the  colon,  the  excrement  was  repeatedly  washed  away,  so  that 
at  the  time  of  the  exhibition  of  the  boy  to  the  society  the  measurement  in 


TREATMENT.  821 

girth  gave  only  twenty-four  inches.  Evidently  in  cases  like  the  above  no 
other  treatment  except  repeatedly  washing  out  the  intestines  with  warm  water 
would  have  answered,  and  the  dilatation  of  the  sphincter  ani  and  the 
introduction  of  the  speculum  to  facilitate  the  escape  of  fecal  matter  are 
noteworthy. 

Suppositories  may  sometimes  be  usefully  employed  in  place  of  enemata  ; 
cocoanut  butter,  molasses  candy,  or  soap  cut  in  shape  of  a  pencil  may  be 
used  for  this  purpose.  In  the  adult,  long-continued  constipation  is  not  very 
rare  in  which  the  rectal  ampulla  becomes  so  impacted  that  it  is  necessary  to 
use  the  anal  curette,  the  handle  of  a  spoon,  or  the  finger  introduced,  in  order 
to  break  up  the  masses  and  allow  them  to  pass.  In  children  necessity  for 
such  treatment  is  much  more  rare,  but  there  are  occasional  cases,  like  that 
above  described  by  Mr.  Gay,  in  which  it  may  be  needed.  Dr.  Nagel  states 
that  the  evil  may  be  removed  by  the  introduction  of  a  suppository  of  brown 
gelatin.  This  is  steeped  in  water  for  twelve  hours,  and,  having  been  thus 
softened,  is  introduced  into  the  rectum  and  an  evacuation  obtained.  The 
doctor  attributes  the  laxative  effect  to  the  hygrometric  action  of  the  gelatin. 
The  glycerin  suppository  of  the  shops  is  also  very  effectual. 

The  known  effect  of  the  galvanic  current  in  producing  contraction  of  the 
uterine  muscular  fibres  suggests  its  employment  to  relieve  constipation  by 
stimulating  the  muscles  of  the  abdomen  and  the  muscular  coats  of  the  intes- 
tines ;  and  those  who  have  employed  it  speak  favorably  of  its  use.  Habershon 
says :  "  A  galvanic  current,  transmitted  through  the  abdominal  walls,  induces 

a  very  speedy  action,  or  rather  emptying,  of  the   colon A  case   of 

partial  paraplegia,  in  which  injections  did  not  act  satisfactorily  and  drastic 
purgatives  were  undesirable,  was  treated  by  a  galvanic  current  passed  through 
the  abdomen  every  morning.  In  a  few  hours  a  free  evacuation  was  produced 
without  any  discomfort."  But  the  constipation  of  children  very  seldom 
requii'es  the  use  of  galvanism. 

The  ordinary  purgatives  should  not  be  given  habitually  to  relieve  a  con- 
stipated habit.  They  are  liable  to  irritate  the  intestines,  causing  a  catarrh, 
or  else  the  intestines  become  accustomed  to  their  action  and  a  larger  dose  is 
needed  to  effect  purgation.  Given  habitually,  they  cannot  fail  also  to  disturb 
the  digestive  and  nutritive  processes.  One  or  two  doses  for  present  relief, 
both  in  habitual  and  temporary  constipation,  is  sometimes  required,  provided 
that  an  injection  is  for  any  reason  not  preferred.  For  this  purpose,  castor 
oil  or  a  few  grains  of  calomel  mixed  with  syrup  of  rhubarb,  the  syi'up  of 
senna,  or  the  compound  liquorice-powder  of  the  German  Pharmacopoeia  may 
be  administered  with  advantage.  But  for  habitual  constipation  I  strongly 
advise  to  discard  the  ordinary  purgative  medicines,  and  if  the  measures  of 
a  dietetic  or  hygienic  character  recommended  above  are  not  sufficient,  to 
employ  such  remedial  agents  as  promote,  or  at  least  do  not  impair,  nutrition. 
Probably  the  best  purgative  for  habitual  use  is  maltine  with  fluid  extract  of 
cascara  sagrada. 

Belladonna,  so  highly  recommended  by  Trousseau  and  others,  I  have  often 
administered  to  children,  especially  in  pertussis,  in  large  doses  during  several 
consecutive  days,  but  it  has  not  seemed  to  me  to  have  any  decided  laxative 
effect.  Though  it  may  be  useful  in  certain  mixtures  for  adults,  our  experi- 
ences in  this  country  with  reliable  preparations  certainly  have  not  been  such 
as  to  justify  its  employment  as  the  sole  or  main  remedy  for  constipation.  It 
diminishes  reflex  irritability,  and  may  render  the  action  of  purgatives  less 
painful,  but  from  its  known  phj'siological  effects  we  cannot  believe  that  it 
increases  the  intestinal  secretions  or  the  action  of  the  muscular  fibres,  one  or 
the  other  of  which  results  we  expect  from  the  use  of  an  agent  which  is  really 
laxative.     On  the  other  hand,  nux  vomica  and  its  active  principle,  strychnia, 


822  INTESTINAL   WORMS. 

are  doubtless  valuable  adjuncts  to  purgative  mixtures  from  their  eflFect  in 
increasing  the  action  of  muscular  fibres. 

Physicians  are  not  infrequently  at  a  loss  what  to  prescribe  for  the  habitual 
constipation  of  nursing  infants,  which  is  by  no  means  infrequent.  But 
recollecting  that  colostrum  is  more  laxative  than  ordinary  milk,  and  that  it 
differs  from  it  in  containing  more  sugar,  salts  (largely  phosphates),  and  butter, 
we  have  a  hint,  as  stated  above,  as  to  what  is  probably  lacking  in  the  milk, 
and  what,  therefore,  should  be  supplied.  I  am  in  the  habit  of  giving  the  oil, 
sugar,  and  salts  in  the  following  formula,  and  usually  with  the  desired  laxa- 
tive effect : 

R.  01.  morrhuEe,  2  parts. 

Aq.  calcis, 

Syr.  calcis  lactoplios.,  ad.  1  part. 

One-quarter,  one-third,  or  one-half  teaspoonful  may  be  given  with  each 
nursing,  or  a  larger  quantity,  as  a  teaspoonful  or  more,  three  times  daily. 
Breast-milk  with  this  addition  becomes  more  nearly  like  colostrum  in  its 
laxative  properties,  while  it  does  not  possess  those  properties  of  colostrum 
which  disturb  the  digestive  process.  I  know  no  agent  of  a  medicinal  nature 
which  meets  the  indication  so  well  as  this  for  infantile  constipation.  But  in 
my  practice  I  have  found  it  necessary,  in  not  a  few  instances,  to  rely  mainly 
on  enemata  of  glycerin  and  water  for  the  relief  of  the  constipated  habit  till 
the  infants  reached  the  age  when  a  mixed  diet  was  proper. 

The  habitual  constipation  of  older  children  may  ordinarily  be  relieved  by 
the  remedies  recommended  above,  but  occasionally  a  more  active  purgative 
effect  may  be  needed.  Since  the  portion  of  intestine  which  is  chiefly  impli- 
cated in  ordinary  forms  of  constipation  is  the  colon,  it  is  evident  that  if  it  be 
necessary  to  employ  frequently  any  of  the  active  purgatives  of  the  Phar- 
macopoeia, such  should  be  selected  as  produce  little  or  no  irritation  of  the  long 
tract  of  the  small  intestines,  while  they  stimulate  the  function  of  the  colon. 
The  aloetic  preparations  are  used  for  this  purpose,  as  the  tincture  of  aloes 
and  myrrh  or  the  simple  tincture  of  aloes,  which  may  be  given  in  dose  of 
part  of  a  teaspoonful  in  a  convenient  syrup  or  in  coffee  or  milk.  But  I  think 
a  preferable  remedy  is  maltine  with  fluid  extract  of  cascara  sagrada,  as 
recommended  above,  a  half  teaspoonful  of  which  may  be  given  daily,  if 
necessary,  to  a  child  of  eight  years. 


CHAPTER     XI. 

INTESTINAL   WORMS. 

The  belief  has  been  prevalent  in  the  profession  in  former  times,  and  is 
now  among  the  people,  that  worms  in  the  intestines  constitute  a  frequent 
disease,  especially  in  children.  As  pathology  and  the  means  of  diagnosticat- 
ing diseases  are  better  understood,  this  idea  has  been  gradually  abandoned 
by  physicians  and  the  intelligent  portion  of  the  community.  Still,  these 
parasites  must  be  considered  an  occasional  cause  of  serious  derangements, 
and  in  rare  instances  a  cause  even  of  death.  They  indeed  often  exist  in 
small  numbers  without  producing  any  appreciable  deviation  in  the  individual 
from  the  healthy  state ;  but  the  most  common  and  best-known  species,  when 
they  have  once  effected  a  lodgment  in  the  intestines  of  man,  ordinarily  grow 


INTESTINAL   WORMS.  823 

and  multiply  so  as  to  produce  symptoms  and  require  medicines  for  their 
expulsion. 

So  far  as  is  now  ascertained  by  observations  in  different  countries,  about 
fifty  animal  parasites  make  their  abode  in  man.  It  is  not  improbable  that 
the  number  will  yet  be  found  greater  by  observations  in  distant  uncivilized 
countries.  Of  these  fifty,  twenty-one  reside  in  the  alimentary  canal  (Heller), 
several  of  them  being  microscopic.  Of  those  occupying  the  intestines  only, 
the  following  species  are  specially  interesting  to  the  practising  physician  on 
account  of  their  relation — for  the  most  part  causative — to  certain  path- 
ological states  :  to  wit,  the  ascaris  lumbricoides,  or  round-worm  ;  the 
oxyuris  vermicularis,  or  thread-worm ;  the  bothriocephalus  latus ;  and 
three  species  of  taenia,  or  the  tape-worm,  and  the  trichocephalus  dispar,  or 
whip-worm. 

Ascavis  Lumbricoides. — The  round-worm  has  a  dingy  reddish  or  yellowish- 
red  color  and  a  cylindrical  form,  tapering  toward  both  extremities  from  the 
point  of  its  greatest  diameter,  which  is  a  little  posterior  to  the  middle.  The 
dead  worm  is  paler  than  the  living.  The  anterior  extremity  is  tipped  with 
three  tips,  between  which  and  the  body  is  a  circular  groove.  Between  these 
three  tips  anteriorly  is  the  aperture  of  the  mouth,  from  which  the  oesophagus 
extends  to  the  distance  of  one-fourth  to  one-third  of  an  inch.  The  intestine, 
which  has  a  light  brownish  color,  extends  from  the  oesophagus  to  near  the 
posterior  extremity  of  the  animal,  where  it  terminates  in  the  anus.  The  fe- 
males are  in  numerical  excess  of  the  males,  and  their  size  is  also  greater. 
The  shape  of  the  worm  is  like  that  of  the  common  earth-worm,  from  which 
it  derives  the  name  lumbricus,  but  it  is  somewhat  more  pointed  and  its  color 
paler  red.  The  tail  of  the  male  worm  is  curved  like  a  hook,  while  that  of 
the  female  is  straight. 

The  total  number  of  eggs  contained  in  a  fully-developed  female  has  been 
estimated  at  sixty  millions.  The  eggs  when  immature  are  conical  and  are 
attached  to  a  longitudinal  band ;  when  mature  they  are  oval,  with  dark  gran- 
ular contents  and  a  strong  double  shell,  and  their  diameter  is  about  -g-g-jj-  of 
an  inch.  They  are  expelled  in  countless  numbers  with  the  feces,  and  at  tlie 
time  of  expulsion  are  surrounded  by  an  albuminous  coating  stained  with  bile. 
Their  vitality  is  retained  under  apparently  very  unfavorable  circumstances, 
even  for  years.  They  hatch  after  they  have  been  repeatedly  frozen  or 
desiccated. 

The  ascaris  lumbricoides  inhabits  the  small  intestines,  whei'e  it  is  rapidly 
developed  from  the  embryonic  state.  The  remark  made  by  Heller,  that  when 
found  in  the  colon  it  is  always  dead,  cannot  be  true,  for  many  live  worms  are 
expelled  in  the  stools. 

The  round-worm,  more  than  ail  other  intestinal  worms,  is  inclined  to  wan- 
der away  from  its  usual  abiding-place — namely,  from  the  jejunum  and  ileum 
— producing  symptoms  of  more  or  less  gravity  referable  to  the  part  over 
which  it  crawls.  It  occasionally  enters  the  stomach,  from  which  it  is  vom- 
ited, or  it  ascends  the  oesophagus  into  the  fauces,  from  which  it  is  soon 
removed  by  the  efforts  of  the  individual.  Cases  are  on  record — one  of  which 
Andral  witnessed — in  which  the  worm  entered  the  larynx,  producing  suffoca- 
tion and  speedy  death.  31.  Tonnelle  also  witnessed  such  a  case.  A  child 
nine  years  old  was  suddenly  seized  with  great  difficulty  of  respiration  and 
pain  in  the  upper  part  of  the  chest.  A  careful  examination  of  the  thorax 
gave  a  negative  result.  Death  occurred  in  from  twelve  to  fifteen  hours,  and 
at  the  post-mortem  examination  a  lumbricus  was  found  filling  the  cavity  of 
the  larynx.  M.  Blandin  also  witnessed  a  case  when  interne  of  the  Hopital  des 
Enfants.  An  infant  was  suffocated  by  one  of  these  worms,  which  had  pene- 
trated as  far  as  the  right  bronchus.     Very  rarely  they  ci'awl  from  the  fauces 


824  INTESTINAL    WORMS. 

into  the  nasal  passages.  This  worm  is  so  strong  and  active  that  there  is  no 
recess  or  reflexion  of  the  mucous  membrane  of  the  digestive  apparatus  which 
it  could  possibly  penetrate  in  which  it  has  not  been  found.  It  has  been  dis- 
covered in  the  appendix  vermiformis,  in  the  pancreatic  duct,  in  the  common 
bile-duct,  and  even  in  the  gall-bladder.  The  number  of  these  worms  found 
in  the  intestines  is  very  various.  There  may  be  only  one  or  the  number  may 
be  incredibly  large.  Thus,  Barrier  relates  the  case  of  an  infant  thirty  months 
old  who  died  in  Hopital  Necker.  It  was  believed  to  be  tubercular.  Numer- 
ous tumors  which  could  be  felt  in  the  abdomen  were  supposed  to  be  tuber- 
cular masses.  On  making  the  post-mortem  examination  the  mesenteric  glands 
were  found  healthy,  but  the  intestines  throughout  their  entire  extent  were 
filled  with  lumbrici.  The  masses  which  during  life  were  supposed  to  be 
tubercular  glands  were  found  to  consist  of  worms.  The  caecum  especially 
was  greatly  distended  by  them.  The  intertwining  or  collection  in  balls  of 
these  worms  constitutes,  indeed,  one  of  the  chief  dangers,  as  it  renders  them 
so  much  the  more  difiicult  of  expulsion. 

The  round-worm  possesses  no  organs  of  penetration  ;  still,  if  the  intestine 
be  weakened  by  disease,  especially  by  ulceration,  it  may,  by  pressure  with  its 
head,  force  an  opening,  through  which  it  escapes  into  the  cavity  of  the  abdo- 
men, causing  peritonitis  and  death.  This  worm  is  commonly  found,  whether 
single  or  in  masses,  surrounded  by  mucus,  which  serves  as  a  partial  protec- 
tion to  the  intestines. 

The  portion  of  the  mucous  membrane  in  contact  with  lumbrici  is  often 
found  inflamed,  either  from  movements  of  the  worm  or  from  pressure  of  a 
mass  of  worms,  or  even  of  a  single  worm  in  a  confined  position,  as  the 
appendix  vermiformis.  This  inflammation,  continuing  and  increasing,  may 
end  in  ulceration,  and  thus  a  weakened  spot  be  produced  which  may  be  rup- 
tured by  simple  pressure  of  the  mouth  of  the  worm.  In  this  way  are  to  be 
explained  those  apparent  cases  of  perforation  which  have  led  some  observers 
to  believe  that  lumbrici  have  actually  the  power  of  penetrating  the  healthy 
coats  of  the  intestines.  The  perforation  is  obviously  most  liable  to  occur  in 
those  who  have  been  enfeebled  and  whose  tissues  have  been  rendered  less 
firm  and  resisting  by  antecedent  disease,  as  by  typhoid  fever. 

M.  Guersant  describes  a  case  in  which  the  appendix  vermiformis  con- 
tained an  ulcerated  opening  through  which  two  round-worms  had  partly 
passed  into  the  abdominal  cavity,  producing  fatal  perityphlitis.  The  efi"ect 
of  their  impaction  in  this  narrow  cul-de-sac  was  much  like  that  of  a  bean  or 
seed  lodged  in  the  same  situation. 

The  ascaris  lumbricoides  has  occasionally  been  found  in  the  most  remark- 
able locations — namely,  in  abscesses  lying  without  the  intestines.  They 
have  been  known  to  effect  a  lodgment  in  the  liver  and  produce  an  abscess 
there,  no  doubt  by  crawling  up  and  distending  a  bile-duct.  Their  lodgment 
in  other  viscera  which  have  no  pervious  connections  with  the  intestinal  tract 
is  probably  accomplished  through  fistulous  openings  produced  by  inflamma- 
tion, which  they  had  no  part  in  causing,  as,  for  example,  in  the  bladder  and 
kidneys,  of  which  there  are  well-authenticated  cases.  Worm-cysts  in  the 
abdominal  walls  have  been  found  to  occur  in  most  instances  in  the  usual  site 
of  hernias — namely,  at  the  umbilicus  in  children  and  in  the  inguinal  region 
in  adults.  It  is  presumed,  therefore,  that  the  worms  had  entered  hernial 
protrusions,  from  which  they  had  passed  by  ulceration  into  the  abdominal 
walls  and  had  there  become  encapsulated. 

The  oxj/aris  vermicular  is.,  or  thread-worm,  so  called  from  its  resemblance 
to  pieces  of  ordinary  white  sewing-thread,  is  also  frequent  in  childhood  and 
not  infrequent  in  the  adult.  The  length  of  the  male  oxyuris  is  from  one- 
sixth  to  one-fifth  of  an  inch  ;  that  of  the  female,  from   one-third  to  one-half 


INTESTINAL   WORMS.  825 

an  inch.  The  posterior  extremity  of  the  male  is  blunt,  and  is  curved  or 
rolled  up  toward  its  abdomen  ;  that  of  the  female  is  slender  and  pointed 
like  an  awl. 

The  head  of  this  worm  is  relatively  broad,  from  an  unusual  thickness  or 
fulness  of  the  cuticle,  and  the  mouth,  surrounded  by  "  three  nodular  lips," 
is  situated  in  the  centre  of  the  extremity.  The  oesophagus  extends  back- 
ward from  the  mouth,  gradually  growing  larger  like  the  segment  of  a  long 
and  narrow  cone,  and  ending  in  a  globular  enlargement  which  has  been  desig- 
nated the  pharynx.  From  the  pharynx  the  intestine  runs  in  nearly  a 
straight  line  through  the  worm. 

Tlie  eggs  are  numerous,  so  completely  filling  the  interior  of  the  female 
as  to  conceal  the  organs  from  view.  They  are  flattened  on  one  side,  but  are 
rounded  or  convex  on  other  parts  of  their  circumference.  One  end  is  more 
pointed  than  the  other,  as  in  the  eggs  of  birds.  Certain  of  the  eggs  in  the 
mature  female  are  seen  to  be  undergoing  segmentation  preparatory  to  hatch- 
ing, while  others  more  advanced  contain  tadpole-shaped  embryos,  and  othera 
still  contain  worm-shaped  embryos  either  lying  within  the  shells  or  protrud- 
ing from  them.  The  hatching  and  growth  of  this  worm,  which  have  been 
observed  under  the  microscope,  are  very  rapid  under  favorable  circumstances, 
"  I  once,"  says  Heller,  •'  saw  the  metamorphosis  from  the  tadpole-.shaped 
embryo  to  the  worm-shaped  embryo  completed  in  about  one  hour,"  but  the 
usual  time  is  longer.  Leuckhart  saw  oxyurides  one-fourth  of  an  inch  in  length 
fourteen  days  after  the  eggs  had  been  swallowed. 

Oxyurides  may  be  developed  so  rapidly  from  eggs  swallowed  in  the 
ingesta  that  they  attain  nearly  or  quite  their  full  growth  while  still  in  the 
small  intestines,  so  that,  although  their  chosen  residence  is  in  the  large  intes- 
tines, some  of  them  are  not  infrequently  found  in  the  ileum,  and  even 
in  the  jejunum,  of  full  size  and  active.  The  part  of  the  intestinal  tract 
which  the  oxyurides  prefer,  and  in  which  the  largest  colony  of  them  reside, 
is  the  caecum  and  appendix  vermiformis,  and  not  in  the  rectum,  as  stated  in 
most  of  the  books ;  and  in  this  situation,  where  they  have  been  little  dis- 
turbed, their  habits  and  the  relative  proportion  of  the  sexes  can  be  best 
observed.  But  they  are  ordinarily  found  both  in  the  cascum  and  rectum  in 
the  same  individual,  and  indeed  upon  all  parts  of  the  intervening  surface  of 
the  colon. 

The  number  of  oxyurides  in  the  individual  varies  greatly.  They  are 
occasionally  so  numerous  upon  the  intestinal  surface  that  they  resemble  fur^ 
and  when  they  are  so  abundant  they  are  commonly  found  above  the  ileo- 
caecal  valve  as  well  as  below  it.  The  males  are  smaller  and  apparently  more 
fragile  and  perishable  than  the  female.  Therefore  in  the  rectum  and  other 
exposed  situations  there  is  a  numerical  excess  of  the  females ;  but  in  reflex- 
ions of  the  intestines,  where  they  are  securely  lodged,  as  in  the  appendix 
vermiformis,  no  marked  diff"erence  has  been  observed  in  the  relative  number 
of  the  two  sexes.  Since  the  males  are  more  delicate,  transparent,  and 
smaller  than  the  females,  they  are  more  likely  to  be  overlooked  in  a  hasty 
post-mortem  examination. 

The  term  tape-ioorm  is  applied  to  several  species  of  the  taenia  and  to  at 
least  two  species  of  the  bothriocephalus,  but  all  except  four — to  wit,  the 
taenia  solium,  taenia  saginata  or  medio-canellata,  taenia  elliptica  or  cucumer- 
ina,  and  the  bothriocephalus  latus — are  rare  in  Europe  and  North  America, 
and  are  therefore  of  little  interest  to  the   practising  physician. 

The  tape-worm  is  an  hermaphrodite,  each  segment  containing  the  tw& 
sexual  organs.  The  head,  or  scolex,  is  small,  or  about  the  size  of  a  pin's 
head,  and  segment  after  segment  is  produced  by  a  budding  process  from  the 
head.     The   sefrments  are  attached  to  each  other  at  their  extremities,  and 


826  INTESTINAL   WORMS. 

«acli  segment  as  it  becomes  farther  and  farther  removed  from  the  head  by 
the  formation  of  new  intervening  segments  at  the  upper  end  of  the  chain, 
becomes  also  larger  and  more  matured.  The  oldest  segments,  having 
attained  their  full  growth,  are  detached,  and  have  an  independent  existence. 
A  separation  of  the  chain  of  segments  at  any  point  does  not  compromise  the 
life  of  the  parasite.  If  only  the  head  remain  uninjured,  the  segmentation 
continues  from  it,  and  in  time  the  former  number  of  segments  and  former 
length  of  the  chain  are  restored.  This  worm  resides  in  the  small  intestines, 
the  larger  species  sometimes  extending  from  the  upper  part  of  the  jejunum 
to  near  the  ileo-caecal  valve. 

The  tse.nia  solium  is  developed  from  an  embryo  known  as  the  cysticercus 
cellulosae,  contained  in  the  muscles  of  the  hog.  It  has  also  been  found  in 
some  other  animals,  as  the  dog,  deer,  and  polar  bear.  It  is  a  vesicle  about 
the  size  of  a  pea  or  small  bean,  having  a  delicate  cell-wall,  and  is  nearly 
spherical,  except  as  its  shape  is  changed  by  compression  between  the  muscu- 
lar fibres.  At  one  point  of  the  cell-wall  is  a  depression,  attached  to  the  inner 
surface  of  which,  and  lying  within  the  cyst,  is  a  whitish,  pear-shaped,  solid 
body,  which  is  the  head  of  the  cysticercus,  and  is  identical  in  appearance  and 
character  with  the  head  of  the  taenia  solium  turned  inside  out.  Many  experi- 
ments have  shown  the  close  relationship  of  the  cysticercus  and  taenia  solium 
— that  they  are  two  forms  of  existence  of  the  same  parasite.  Segments  of 
the  taenia  solium  have  been  repeatedly  fed  to  pigs,  and  the  cysticercus  pro- 
duced in  their  muscles,  though  in  what  way  the  ovum  or  embryo  passes 
from  the  stomach  to  the  muscles  is  not  known.  On  the  other  hand,  swine 
flesh  containing  cysticerci  has  been  fed  to  animals  who  were  soon  after  killed, 
when  the  taenia  was  found  in  their  intestines.  It  is  evident  that  this  parasite 
occurs  only  in  those  who  eat  swine  flesh,  as  sausages,  either  raw  or  but 
slightly  cooked. 

The  head  of  this  species  of  taenia,  which  is  about  the  size  of  a  small  pin's 
head,  has  at  the  top  a  conical  protuberance,  upon  which  is  a  corona  of  hook- 
lets,  arranged  in  two  circles,  the  booklets  of  the  outer  circle  being  smaller 
than  those  of  the  inner.  The  projecting  points,  however,  of  the  two  rows 
fall  together,  forming  one  circle.  The  booklets  are  inserted  into  depressions 
in  the  head,  and  many  of  them  have  fallen  out  in  most  specimens  which  we 
have  had  an  opportunity  of  examining.  The  depressions  in  which  the  hook- 
lets  are  lodged  are  often  dark  from  pigmentation.  Back  of  the  circle  of  hooks 
are  four  sucking  discs,  which  the  worm  is  able  to  protrude  and  move  freely. 
When  protruded  they  appear  as  small  tubercles  with  slender  pedicles.  The 
neck,  which  is  slender  and  about  one  inch  in  length,  shows  markings  from 
commencing  segmentation,  and  it  is  succeeded  by  very  small  and  delicate  seg- 
ments, which  gradually  increase  in  size  as  the  distance  froin  the  head  increases. 

The  mature  segments  (proglottides)  vary  in  size  accordingly  as  they  are 
in  a  state  of  contraction  or  relaxation.  When  relaxed  their  length  is  about 
half  an  inch  and  breadth  one-quarter  of  an  inch.  The  genital  organs  are 
situated  on  the  margin  of  each  segment,  a  little  posterior  to  the  middle,  and 
there  is  an  alternation  in  their  location  between  the  right  and  left  mai'gins  in 
the  chain  of  segments.  The  uterus  lies  in  the  centre  of  the  segment,  form- 
ing a  longitudinal  straight  line.  From  seven  to  twelve  branches  are  given 
ofi"  from  each  side  of  the  uterus,  and  these  divide  and  subdivide  like  the 
branches  of  a  tree.  The  male  genital  organs  lie  in  the  same  aperture  or  pore 
in  the  margin  of  the  segment,  with  which  the  uterus  and  ovaries  connect. 

The  eggs  of  the  taenia  solium  are  globular,  with  a  diameter  of  about 
Y^-^th  of  an  inch,  and  with  thick  shells,  which  are  striated  like  mosaic-work 
by  lines  which  cross  each  other.  It  is  estimated  that  not  less  than  fifty  mil- 
lion eggs  are  contained  in  all  the  segments  of  a  matured  taenia. 


INTESTINAL    WORMS.  827 

This  parasite  is  very  liable  to  abnormal  development.  In  some  instances 
two  or  more  segments  are  fused  together,  and  often  they  are  stunted  in  their 
growth,  or  they  contain  holes,  fissures,  and  flaws,  either  from  their  original 
development  or  produced  by  rupture  of  the  distended  uterus.  Again,  rarely, 
two  tienia  are  blended,  so  that  along  the  flat  side  of  one  chain  another  is 
united  by  the  margin,  so  that  a  section  of  the  double  parasite  resembles  the 
Roman  letter  T  or  Y.  The  nutrition  of  the  segments  is  maintained  through 
a  vessel  running  the  whole  length  of  the  worm  near  each  margin,  and  having 
communicating  branches. 

The  txnia  saffinata,  designated  also  medio-canellata,  is  much  larger,  stronger, 
and  thicker,  both  as  regards  the  head  and  segments,  than  the  taenia  solium. 
When  fully  matured  it  measures  eighteen  feet.  The  diameter  of  the  head  is 
nearly  one  line  (y-^^  inch).  It  is  furnished  with  four  strong  sucking  discs, 
but  it  lacks  the  cii'clet  of  hooks  which  characterizes  the  taenia  solium.  Instead 
of  the  hooks  the  head  is  furnished  with  a  small  frontal  sucking-disc.  The 
heads  of  some  specimens  of  this  worm  are  free  from  pigment,  but  other 
specimens  present  various  shades  of  pigmentation,  from  a  slight  staining  to  a 
jet  black  color.  The  neck  is  short,  and  very  near  the  head  are  marlcings 
which  indicate  commencing  segmentation.  The  matured  segments  vary  in 
measurement  when  relaxed — from  a  length  of  eight  lines  and  breadth  of  two 
lines,  to  a  length  of  nine  lines  and  breadth  of  three  lines.  As  in  the  taenia 
solium,  the  genital  pores  are  situated  on  the  margins  of  the  segments,  vary- 
ing irregularly  from  side  to  side,  and  the  uterus  has  lateral  branches  which 
divide  dichotoniously.  There  is  but  little  difference  in  the  sexual  apparatus 
•of  the  t;\3nia  solium  and  taenia  saginata,  but  the  eggs  of  the  latter  are  some- 
what larger  than  those  of  the  former,  and  are  oval. 

The  development  of  the  ta3nia  saginata  is  sometimes  irregular,  producing 
monstrosities,  as  in  the  taenia  solium.  The  embryos  of  this  parasite  occur 
chiefly  in  the  muscles  of  ruminating  animals,  as  the  ox,  sheep,  goat,  etc.,  and 
therefore  its  presence  in  man  is  attributable  to  the  use  of  the  flesh  of  these 
animals  either  slightly  cooked  or  raw.  The  cysticercus  of  this  species 
appears  to  be  less  tenacious  of  life  than  that  of  the  taenia  solium,  and  when 
it  perishes  it  becomes  changed  into  a  greenish-yellow  pulp,  surrounded  by  the 
capsule  and  imbedded  in  the  muscular  or  other  tissue  where  it  had  lodged. 

It  is  easy  to  distinguish  this  worm  from  the  taenia  solium,  if  the  head  be 
found,  by  its  larger  size,  the  larger  size  of  its  sucking-discs,  and  the  absence 
of  the  circle  of  hooks.  The  segments  are  distinguished  by  their  greater  size 
and  greater  number,  and  the  dichotomous  division  of  the  branches  of  the 
uterus.  This  species  occurs  over  a  much  greater  area  of  the  earth's  surface 
than  the  taenia  solium. 

The  tsenia  elliptica  or  cucumerina  is  a  more  delicate  worm  than  the  pre- 
ceding species,  measuring,  when  fully  grown,  from  seven  to  ten  or  eleven 
inches  in  length.  Upon  its  head  is  a  rostellum  or  beak,  which  the  worm  is 
able  to  thrust  forward,  and  on  which  are  about  sixty  hooks  irregularly 
arranged.  The  anterior  portion  of  the  parasite  is  very  delicate,  like  a  thread, 
and  its  segments  are  small,  but,  as  in  the  other  species,  they  become  larger  as 
their  distance  from  the  head  increases.  The  matured  segments,  which  have 
a  reddish-white  color,  are  readily  detached,  and  when  separated  they  move 
about  actively.  This  taenia  is  also  an  hermaphrodite,  and  a  genital  pore  con- 
taining a  double  set  of  genital  organs  is  located  on  each  margin  of  the  seg- 
ment. The  taenia  elliptica  inhabits  the  small  intestines  of  the  dog  and  cat, 
and  many  children  in  diff'erent  localities  have  been  afl"ected  with  it. 

Heller  states  that  the  segments  of  another  and  rare  species  of  taenia, 
which  were  expelled  from  a  child  of  nineteen  months,  are  preserved  in  the 
Museum  of  Pathological  Anatomy  in  Boston.     Nearly  in  the  middle  of  the 


828  INTESTINAL   WORMS. 

posterior  half  of  each  segment  is  a  yellow  spot — namely,  the  receptaculum — 
full  of  ova,  and  therefore  the  name  flavo-punctata  has  been  applied  to  this 
worm.  Little  is  known  in  regard  to  the  taenia  nana  and  taenia  Madagascarien- 
sis,  since  they  occur  in  distant  countries. 

The  hothriocephahis  latus  is  the  largest  of  the  tape-worms,  attaining  the 
length  of  fifteen  to  twenty-four  feet.  It  is  one  of  the  most  important  of 
the  intestinal  parasites.  The  head  has  an  almond-shape  or  the  shape  of 
an  elongated  and  somewhat  flattened  globe,  its  length  being  about  one 
line  and  its  diameter  from  one-third  to  one-half  a  line.  Running  longi- 
tudinally along  each  flattened  side  of  the  head  is  a  groove  or  fissure  contain- 
ing the  apparatus  of  suction.  Those  segments  which  are  still  in  the  process 
of  growth  have  a  breadth  three  or  four  times  greater  than  their  length,  while 
the  matured  segments  are  nearly  square.  The  genital  pore  occurs  in  the 
centre  of  one  side  of  the  segment,  and  in  the  chain  of  segments  all  the  pores 
are  found  on  the  same  side.  A  brownish,  rosette-shaped  spot  is  observed  at 
the  site  of  each  ripe  pore,  produced  by  the  convolutions  of  the  uterus  and 
the  numerous  eggs  which  this  organ   contains. 

The  egg,  which  is  oval,  has  a  thin  shell,  a  light-brown  color,  and  at  one 
end  of  it  is  a  lid  or  operculum  which  is  separated  from  the  rest  of  the  egg  by  a 
well-defined  line.  At  the  hatching  an  embryo  provided  with  six  hooks  escapes 
from  the  lid.  When  it  has  separated  from  the  egg  it  is  provided  with  an  albu- 
minous covering,  from  which  cilia  radiate  in  all  directions,  by  the  movement 
of  which  it  is  propelled.  After  a  few  days  this  covering  is  lost,  and  the 
embryo  now  moves  about  by  amoeboid  extension  and  contraction.  It  is 
believed  that  in  this  embryonic  state  it  enters  an  aquatic  animal,  a  mollusk 
or  fish,  where  it  undergoes  further  development,  and  from  the  mollusk  it  is 
received  into  the  stomach  in  the  food. 

The  bothriocephalus  occurs  not  only  in  man,  but  also  in  some  of  the 
domestic  animals  which  eat  fish,  as  the  dog.  This  parasite  is  believed  to  be 
rare  outside  of  Europe,  and  in  Europe  it  is  chiefly  met  in  countries  bordering 
on  inland  lakes  and  seas. 

The  tricliocephalus  dispar  is  comparatively  unimportant  to  the  physician^ 
since  it  is  uncertain  whether  it  materially  impairs  the  health  or  produces 
symptoms.  It  inhabits  the  caecum,  but  in  rare  instances  it  has  been  found 
in  the  ileum  and  appendix  verniiformis.  The  number  of  these  parasites  is 
usually  small,  but  as  many  as  seventy  to  one  hundred  have  been  observed  in 
the  intestine  of  the  adult. 

The  trichocephalus  dispar  occurs  also  in  the  monkey,  and  a  very  similar 
if  not  identical  worm  has  been  found  in  the  pig.  It  is  not  frequent  in 
children,  and  it  has  not  been  observed  in  very  young  children.  It  occurs  in 
man  in  every  part  of  the  globe,  and  in  some  countries,  as  Egypt,  Nubia,  and 
Syria,  it  is  said  to  be  very  common.  This  worm,  which  is  also  sometimes  desig- 
nated the  whip-worm  from  its  shape,  attains  the  length  of  one  and  a  half  to  two 
inches,  the  female  being  longer  than  the  male.  Its  anterior  two-thirds  are  thin, 
delicate,  and  flexible,  like  a  small  thread.  The  posterior  one-third,  which  con- 
tains the  generative  organs  and  intestinal  canal,  is  considerably  thicker,  and  it 
ends  abruptly.  On  the  under  surface,  extending  nearly  the  whole  length  of 
the  body,  is  a  longitudinal  band,  the  width  of  which  is  about  one-third  the 
circumference  of  the  body.  In  the  female  the  posterior  or  thick  portion  of  the 
worm  is  slightly  bent  or  curved  like  the  stock  of  a  hunting-whip,  while  that 
of  the  male  is  rolled  in  the  spiral  form.  The  digestive  tube  consists  of  an 
oesophagus  which  extends  through  the  anterior  thread-like  part,  and  the 
stomach  and  rectum,  which  lie  in  the  posterior  thick  division.  The  genitals  of 
the  female  lie  in  the  commencement  of  the  thick  portion,  and  the  uterus,  when 
distended  with  eggs,  occupies  nearly  the  whole  of  this  section.     In  the  male. 


INTESTINAL    WORMS.  829 

the  pore  which  contains  the  genitals  lies  in  tlie  posterior  extremity  of  the 
thick  part,  wliere  it  forms  a  cloaca  with  the  termination  of  the  intestinal 
canal.  The  eggs,  which  are  numerous,  are  oval,  brownish,  and  with  a  glis- 
tening protuberance  at  each  extremity,  giving  them  the  shape  of  a  lemon. 
They  have  great  vitality,  hatching  after  repeated  desiccation  and  freezing. 
Their  development  from  the  e\!:y:;  is  slow.  It  is  believed  that  the  trichoceph- 
alus  is  produced  directly  from  the  egg,  which  has  lodged  in  the  intestine,  and 
therefore  does  not  have  or  require  an  intermediate  stage  of  preparation  in 
another  animal.  This  parasite  resides  in  the  caecum,  but  when  many  are 
present  some  are  found  in  the  ascending  colon,  and  occasionally  a  few  are 
ob.served  in  the  small  intestine. 

The  taenia  is  rare  in  early  life,  but  it  now  and  then  occurs  in  young  chil- 
dren. I  have  met  cases  in  this  city  under  the  age  of  five  years.  liosen  and 
Bremser  report  cases  between  the  ages  of  six  and  eleven  years,  and  Hufe- 
land  one  at  the  age  of  six  months.  Wawruch  collected  206  observations  of 
tccnia,  in  22  of  which  the  age  was  less  than  fifteen  years ;  the  youngest  was 
a  girl  of  three  years.  A  most  remarkable  case  of  taenia  is  reported  in  the 
Gazette  medicaJc  of  Paris  in  1837.  M.  Miiller  was  called  to  treat  a  foster- 
child  five  days  old  for  slight  constipation.  The  bowels  were  evacuated  by 
the  use  of  rhubarb,  manna,  and  a  few  grains  of  salt,  and  in  the  excrement 
a  foot  and  a  half  of  taenia  were  discovered.  This  worm  had  evidently  existed 
during  the  foetal  life  of  the  infant. 

A  similar  case  was  treated  by  Prof.  Skene  in  the  Long  Island  Hospital  in 
September,  1871,  and  reported  by  Dr.  Armor.'  The  infant  was  born  Septem- 
ber od  of  a  hearty  Irish  servant-girl.  On  the  7th  it  refused  to  nurse,  and 
was  observed  to  have  a  mild  form  of  tetanus.  On  the  8th,  small  doses  of 
calomel  having  been  given,  followed  by  castor  oil,  two  segments  of  a  taenia 
solium  were  passed  from  the  bowels,  and  on  subsequent  days  ten  more  seg- 
ments, after  which  the  tetanus  ceased.  The  remedies  employed  after  Sep- 
tember 8th  were  the  oil  of  male  fern  and  turpentine.  The  mother,  who  had 
presented  no  symptoms  of  taenia,  was  ordered  an  emulsion  of  pumpkin-seeds, 
which  '*  she  faithfully  took  for  twenty-four  hours,  at  the  end  of  which  she 
passed  over  seventy  segments  of  taenia."  This  case  is  interesting  as  throw- 
ing light  on  a  possible  mode  of  the  production  of  taenia  quite  different  from 
the  ordinary  and  recognized  mode,  and  also  as  showing  the  causative  relation 
of  intestinal  worms  to  tetanus  infantum. 

Cau.se.s. — It  is  obvious  that  intestinal  worms  are  developed  from  eggs  or 
embryos  which  are  introduced  into  the  stomach  in  the  ingesta.  The  eggs  of 
the  ascaris  lumbricoides  have  been  found  by  Mosler^  in  drinking-water,  but  it 
is  probable  that  in  most  instances  they  are  contained  in  fruits  and  vegetables 
which  are  eaten  raw.  The  eggs  of  the  oxyuris  vermicularis  are  received 
from  some  one  who  is  himself  affected  with  the  disease.  Both  Zender  and 
Heller  state  that  they  have  frequently  discovered  ripe  eggs  of  this  worm 
around  the  nails  of  persons  who  were  troubled  with  oxyurides — a  fact  readily 
explained  from  the  itching  which  they  cause.  If  these  eggs  are  upon  the 
fingers  of  the  mother  or  nurse,  it  is  easy  to  understand  how  they  are  acquired 
by  the  child.  We  can  understand  also  why  this  worm  is  so  common  in 
degraded  and  filthy  families.  In  reference  to  the  etiology  of  the  tape- 
worm nothing  need  be  added  to  what  has  been  stated  above,  and  little  is 
known  in  reference  to  the  manner  in  which  the  eggs  of  the  trichocephalus  are 
received. 

Certain  conditions  of  the  intestinal  surface  favor  the  occurrence  of  worms. 
Thus  children  in  advanced  typhoid  fever  are  not  unfrequently  affected  with 
the  ascaris  lumbricoides. 

'  New  York  Mtdical  Journal.  ^  Virchow's  Archii;  1860. 


830  INTESTINAL    WORMS. 

Symptoms  of  the  Ascaris  Lumbricoides. — These  are  in  part  constitu- 
tional and  in  part  local,  due  to  the  mechanical  eifect  of  the  entozoa  on  the 
coats  of  the  intestines.  Writers,  especially  Rilliet  and  Barthez,  have 
described  with  minuteness  the  symptoms  supposed  to  indicate  lumbrici. 
Those  of  a  constitutional  character  are  the  following  :  Features  at  one  time 
flushed,  at  another  pallid,  and  in  some  children  of  a  leaden  hue ;  lower  eye- 
lids swollen,  and  sometimes  surrounded  by  a  blue  semicircle  ;  thirst,  nausea, 
or  even  vomiting ;  appetite  diminished  or  augmented  or  variable ;  breath 
foul ;  papillae  of  the  tongue  red  and  projecting;  pulse  accelerated  and  irreg- 
ular. Rilliet  and  Barthez  state  that  they  observed  this  irregularity  of  the 
heart's  action  in  a  boy  three  years  old  at  the  time  he  was  passing  a  large 
number  of  lumbrici.  The  irregularity  afterward  disappeared.  Acceleration 
of  the  pulse  and  increase  in  temperature  are  common  symptoms  of  these 
worms,  and  hence  the  popular  belief  in  a  worm  fever.  This  fever  i& 
often  remittent  and  mild,  but  occasionally  it  is  continuous  and  of  a  high 
grade. 

The  symptoms  pertaining  to  the  nervous  system  are  important.  In  mild 
cases  these  may  be  absent,  as  when  there  are  few  lumbrici  and  the  child  is 
robust  and  over  the  age  of  five  years,  but  in  severe  cases  certain  neuropathic 
symptoms  are  frequently  present,  such  as  dilatation  of  the  pupils,  especially 
inequality  of  dilatation,  to  which  Munro  attached  diagnostic  value,  strabis- 
mus, twitching  of  the  muscles,  clonic  convulsions,  somnolence,  headache,  neur- 
algic pains,  delirium.  Rarely  chorea,  deafness,  and  paralysis,  it  is  believed, 
may  result.^  Dr.  Leedom^  of  Montgomery  county,  Pa.,  relates  the  case  of  a 
boy  of  seven  years  who  had  night-blindness  due  to  a  large  number  of  lum- 
brici in  the  intestines.  By  the  employment  of  pinkroot  and  calomel  these' 
were  passed  and  the  blindness  ceased.  Hypersesthesia  of  the  abdominal 
surface  was  present  in  a  case  which  I  attended,  and  which  subsided  as  soon  as 
the  lumbrici  were  expelled.  Grinding  the  teeth  in  sleep  and  picking  the  nos- 
trils are  symptoms  to  which  families  attach  great  value.  Observations,  how- 
ever, show  that  though  sometimes  due  to  worms  they  more  frequently  have 
another  cause. 

The  local  symptoms  or  disorders — in  other  words,  those  having  a  mechan- 
ical origin — are  colicky  pains,  experienced  chiefly  in  the  umbilical  region  , 
stools  sometimes  natural ;  in  other  cases  diarrhoea  with  fecal  or  muco-san- 
guineous  stools  ;  flatulence.  M.  Davaine  at  a  recent  period  made  the  import- 
ant discovery  that  the  feces  of  patients  affected  with  worms  contain  the  ova 
of  the  particular  species  present  in  large  numbers.  These  ova,  which  have 
been  described  above,  can  be  seen  through  a  lens  magnifying  one  hundred  and 
fifty  diameters. 

In  exceptional  cases  there  are  local  symptoms,  due  to  the  presence  of 
these  worms  in  unusual  situations,  such  as  a  crawling  sensation  in  the  oesoph- 
agus ;  a  sense  of  constriction  in  this  tube  or  the  pharynx ;  nausea  and  vomit- 
ing ;  a  cough,  especially  if  the  worm  have  Crawled  to  the  upper  part  of  the 
oesophagus  ;  rarely  the  most  urgent  dyspnoea  and  probable  suffocation  if 
a  lumbricus  have  entered  the  larynx.  Earache  and  perhaps  convulsions  if 
the  worm  have  entei*ed  the  Eustachian  tube  (case  Davaine,  p.  144).  The 
most  dangerous  symptoms  arise  from  the  crawling  of  the  worm  into  narrow 
openings. 

The  enteritis  and  colitis  to  which  these  worms  sometimes  give  rise  are 
ordinarily  mild,  but  in  rare  instances  ulceration  occurs,  which  may  be  attended 
by  profuse  and  even  fatal  hemorrhage.  Occasionally  very  painful  and 
dangerous  constipation  results  from  an  accumulation  of  worms  in  a  ball  or 
mass  too  large  to  be  expelled,  unless  with  much  delay  and  suff"ering,  prevent- 

*  Gaz,  des  Hopilaux,  1867.  ^  Amer.  Jour,  of  Med.  SoL,  for  July,  1867. 


INTESTINAL   WORMS.  831 

ing  the  passage  of  fecal  matter  and  producing  severe  abdominal  pains.  The 
symptoms  in  these  cases  resemble  closely  those  of  intussusception.  A  marked 
example  of  constipation  produced  in  this  way  occurred  in  a  family  with  whom 
I  am  acquainted  and  who  then  resided  in  the  interior  of  this  State.  A  little  ' 
girl  of  three  or  four  years  was  suddenly  aflFected  with  obstinate  constipation. 
The  physicians  prescribed  active  purgatives,  calomel  among  others,  and  finally 
croton  oil  and  various  injections,  without  relief.  There  was  great  pain  with 
distension  of  the  abdomen,  and  death  seemed  inevitable,  when  after  the  lapse 
of  several  days  a  free  evacuation  occurred,  and  in  the  stool  was  a  mass  of 
worms  firmly  intertwined. 

Children  often  have  lumbrici  without  any  appreciable  impairment  of  the 
genei'al  health,  but  their  presence  may  intensify  the  symptoms  of  intercur- 
rent diseases  and  greatly  increase  the  danger.  Thus  I  recollect  two  children 
of  three  and  three  and  a  half  years  with  pneumonia  who  at  the  same  time 
had  lumbrici,  one  passing  in  the  course  of  a  few  days  thirty  and  the  other 
twelve  of  these  entozoa.  Both  presented  well-marked  physical  signs  of 
pneumonia,  and,  though  they  recovered,  the  fever  and  nervous  symptoms 
were  apparently  aggravated  by  the  intestinal  affection.  One  had  convulsions 
in  the  commencement  of  the  inflammation,  followed  by  profound  stupor  and 
amaurosis  lasting  two  or  three  days. 

Often  the  symptoms  due  to  lumbrici  coexist  with  those  of  a  protracted  and 
distinct  intestinal  disease.  Thus,  as  we  have  seen,  the  intestinal  secretions 
of  typhoid  fever  and  of  chronic  diarrhoeal  maladies  afford  a  nidus  for  the 
growth  of  worms,  and  accordingly  at  an  advanced  stage  of  these  diseases 
lumbrici  are  common. 

The  symptoms  produced  by  the  oxyuris  vermiculark  are  somewhat  differ- 
ent. These  worms  do  not  usually  cause  the  fever,  disturbed  digestion,  the 
colicky  pains,  or  the  dangerous  nervous  symptoms  which  arise  from  the 
presence  of  lumbrici.  Nor  do  they,  like  lumbrici,  endanger  life  by  crawl- 
ing into  unusual  situations.  In  one  recent  case  I  could  detect  no  other  cause 
of  chorea  than  the  presence  of  oxyurides,  and  eclampsia  has  been  attributed 
to  them,  but  such  a  result  is  exceptional,  if  indeed  the  cause  be  rightly 
assigned. 

Although  the  caecum  is  the  chosen  abode  of  this  worm,  and  here  more 
than  elsewhere  it  exists  in  its  normal  state,  it  is  not  certain  that  it  produces 
any  appreciable  symptoms  in  this  part  of  the  intestinal  tract. 

The  symptoms  which  render  this  the  most  annoying  of  all  the  intestinal 
parasites  are  produced  by  these  oxyurides,  chiefly  the  females,  which  descend 
into  the  rectum,  where  by  their  active  movements  they  produce  intense 
itching.  A  small  number  of  worms  cause  little  inconvenience,  but  when 
many  are  present  in  the  folds  of  the  rectum  their  crawling  produces  such 
intense  pruritus  that  the  patient  can  with  difficulty  remain  quiet.  Usually 
this  symptom  is  most  marked  in  the  early  evening,  when  the  child  is  warm 
in  bed.  It  sometimes  causes  onanism  in  the  girl  as  well  as  boy.  This  symp- 
tom may  be  nearly  or  quite  absent  during  the  day,  but  it  returns  so  regularly 
at  night  as  to  resemble  and  be  mistaken  for  a  periodical  nervous  affection. 
So  eminent  a  physician  as  Cruveilhier  confesses  that  he  has  made  this  mistake 
of  diagnosis.  In  the  female  child  the  oxyuris  occasionally  passes  from  the 
rectum  to  the  vulva,  producing  leucorrhoea. 

In  many  instances  tape-worms  exist  in  children  as  well  as  adults  who 
thrive  and  present  no  symptoms,  but  in  other  instances  there  is  more  or  less 
disturbance  of  the  digestive  function,  with  an  uncomfortable  sensation  in  the 
abdomen.  This  sensation  is  more  noticed  after  fasting  or  after  the  use  of 
certain  kinds  of  food,  and  it  is  diminished  by  a  full  meal.  Great  hunger  and 
a  feeling  of  faintness  are  also  common,  according  to  authorities,  but  I  have 


832  INTESTINAL    WORMS. 

not  particularly  remarked  them  in  children.  Irregular  action  of  the  bowels, 
vomiting,  and  various  nervous  symptoms,  as  itching  of  the  nostrils  and  anus, 
headache,  tinnitus  aurium,  cardialgia,  numbness,  deafness,  blindness,  etc., 
have  with  more  or  less  correctness  been  attributed  to  the  tape-worm.  Cer- 
tainly, such  symptoms  occasionally  arise  from  this  cause,  for  they  cease  with 
the  expulsion  of  the  worm.^  Intermittent  colicky  pains  in  the  umbilical 
region  were  the  only  marked  symptoms  in  a  child  with  tasnia  which  I  recently 
treated.  Since  the  cysticercus  cellulosae  is  the  embryonic  form  of  the  taenia 
solium,  it  is  quite  possible  that  individuals  possessing  the  latter  may  be 
infected  from  its  ova  with  the  former,  so  that  symptoms  which  have  been 
attributed  to  the  intestinal  parasite  have  sometimes  been  due  to  the  encysted 
embryo.  We  are  unacquainted  with  the  symptoms  of  the  trichocephalus,  if 
any  occur,  and  this  worm  is  very  rare  in  children. 

Diagnosis. — Bremser  long  since  made  the  remark — and  it  has  been 
repeated  by  most  writers  on  diseases  of  children — that  there  is  no  sign  or 
symptom  which  affords  positive  proof  of  the  presence  of  intestinal  worms 
except  the  expulsion  of  one  or  more.  In  recent  years,  however,  microscopic 
investigations  have  revealed  a  pathognomonic  sign — namely,  the  presence  of 
ova  in  the  feces,  which  indicates  not  only  the  nature  of  the  disease,  but  the 
species  of  the  worm. 

The  symptoms  and  disorders  produced  by  lumbrici  may  all  occur  from 
other  causes.  Still,  if  several  of  them  be  present  and  a  careful  examina- 
tion disclose  no  other  cause,  the  presence  of  worms  should  be  suspected, 
provided  that  the  child  be  over  the  age  of  two  years.  The  microscope  may 
then  be  used  for  diagnosis.  A  little  tentative  treatment,  entirely  safe  to 
the  child,  will  also  determine  whether  the  suspicion  be  correct.  One  or 
two  doses  of  medicine,  administered  under  such  circumstances,  like  the 
surgeon's  exploring-needle  may  reveal  the  nature  of  the  disease  and  indicate 
the  means  of  cure. 

In  the  case  of  the  oxyuris  vermicularis  the  itching  directs  attention  to 
the  anus  as  the  place  of  the  disease,  and  here  the  oflPending  entozoa  may  often 
'be  discovered  by  the  eye. 

Prognosis. — Intestinal  worms  produce  a  fatal  result  in  only  a  small 
proportion  of  cases.  Oxyurides  never  prove  fatal,  unless  in  rare  instances 
through  convulsions.  The  manner  in  which  death  may  be  produced  by 
lumbrici  has  already  been  pointed  out. 

In  general,  when  the  nature  of  the  disease  is  ascertained  the  worms  are 
readily  expelled  by  treatment  and  the  patient  restored  to  health.  Therefore, 
if  there  be  no  complicating  disease  the  prognosis  is  good. 

Treatment. — Much  injury  has  been  done  to  children  by  the  use  of 
anthelmintics  occasionally  employed  by  physicians,  but  oftener  by  parents 
before  the  physician  is  called.  Medicines  of  this  kind  are  usually  irritants, 
and,  in  many  of  those  diseases  which  simulate  the  verminous  affection,  but 
are  distinct  from  it,  there  is  already  an  irritated  if  not  an  inflamed  state  of 
the  intestinal  mucous  surface. 

Vermifuges  administered  under  such  circumstances  obviously  do  harm, 
and  in  all  acute  diseases  in  which  they  are  not  required,  even  if  their  action 
be  harmless,  their  employment  is  to  be  regretted,  since  it  consumes  time, 
which  is  very  precious.  It  is  thus  that  many  lives  are  lost  by  the  use  of 
anthelmintic  nostrums  which  are  extensively  advertised  and  which  com- 
mand a  ready  sale,  inasmuch  as  the  belief  in  the  presence  of  worms  as  a 
frequent  cause  of  disease  pervades  all  classes. 

A  safe  rule,  followed  by  many  physicians — and  it  would  be  much  better 
if  it  were  general — is  not  to  give  anthelmintics  unless  the  child  have  passed 
^  Medico-Chir.  Rev.,  January,  1868. 


TREATMENT.  8:i3 

one  or  more  worms  or  their  ova  be  found  in  the  feces,  and  not  then  if  the 
symptoms  seem  to  be  referable  to  a  coexisting  disease.  In  doubtful  cases  in 
which  the  symptoms  resemble  those  of  worms  a  purgative  dose  of  calomel 
or  calomel  and  rhubarb  may  be  employed.  It  will  generally  bring  away  one 
or  more  lumbrici  or  a  mass  of  ascaris  vermicularis  if  either  species  of  entozoa 
be  present.  This  purgative  may  be  safely  employed  if  there  be  no  previous 
diarrhoea  or  debility.  If  after  one  or  two  doses  and  a  free  purgation  no 
worms  be  passed,  anthelmintic  remedies  should  not  be  given,  for  it  is  almost 
certain  that  none  exist. 

A  large  number  of  medicines  have  been  employed  for  the  purpose  of 
expelling  lumbrici.  Santonin,  the  active  principle  of  the  European  wormseed, 
is  one  of  the  best,  and  is  much  en)ployed  in  this  country  and  in  Europe.  It 
is  nearly  tasteless  ;  it  may  be  given  in  powder  spread  on  bread  with  butter.  It 
is  kept  in  shops  in  one  or  two-grain  lozenges,  with  and  without  calomel.  It 
has  the  advantage  of  easy  administration,  and  is  destructive  to  both  the 
round-  and  thread-worm.  M.  Bouchut  considers  it  preferable  to  all  other 
remedies  in  the  treatment  of  the  round-worm.  "To  children  two  years  of 
age  he  administers  it  in  doses  of  ten  centigrammes  (1.54  grains),  and  in 
patients  above  this  age  the  quantity  is  increased  by  five  centigrammes  (0.75 
grain)  for  every  additional  year."  lie  gives  in  addition  occasional  doses  of 
calomel  or  castor  oil.  In  this  country  santonin  is  usually  administered  in 
one  to  three-grain  doses  once  or  twice  each  day,  with  an  occasional  purga- 
tive. The  purgative  is  required  to  aid  not  only  in  the  expulsion  of  the  worm, 
but  also  of  the  ova.  In  over-doses  santonin  causes  vomiting,  diarrhcea,  and 
altered  vision,  so  that  objects  appear  yellow,  but  in  medicinal  doses  it  pro- 
duces no  unpleasant  consequences.  Other  medicines  are  preferable  if  there 
be  symptoms  of  enteritis.  Treatment  by  santonin  from  two  to  three  days 
suffices.  For  many  years  the  anthelmintic  most  employed  in  this  counti'y 
was  the  pinkroot,  the  root  of  the  Sjyirjelia  ynarilandica,  an  indigenous  plant. 
It  was  not  only  prescribed  by  physicians,  but  employed  by  families  as  a 
domestic  remedy.  It  is  liable  to  cause,  if  the  dose  be  large,  cerebral  symp- 
toms, as  vertigo,  dimness  of  sight,  spasm  of  the  facial  muscles,  stupor,  and 
even  convulsions.  These  effects  less  frequently  occur  if  the  pinkroot  be 
given  with  a  purgative,  and  it  has  been  cu.stomary  to  administer  it  in  com- 
bination with  senna  in  an  infusion.  A  half  ounce  of  spigelia  with  an  equal 
quantity  of  senna  is  macerated  for  two  hours  in  a  pint  of  boiling  water  and 
then  strained.  For  a  child  two  or  three  years  old  the  dose  is  half  an 
ounce  to  one  ounce.  So  popular  has  this  vermifuge  been  in  this  country  that 
probably  a  majority  of  the  native-born  old  people  in  the  States  recollect  the 
nauseating  doses  of  pinkroot  administered  by  anxious  parents.  Pharmacy 
now  provides  us  with  the  same  medicine  in  a  more  convenient  and  acceptable 
form,  that  of  the  fluid  extract: 

R.  Fluid,  ext.  spigel.,  f^j  ; 

Fluid,  ext.  sennae,  f.5ss.     Misce. 

One  teaspoonful  to  a  child  from  three  to  five  years. 

The  officinal  fluid  extract  of  spigelia  and  senna  may  be  given  in  the  same  dose 
as  the  above.  Professor  Proctor  recommends  the  addition  of  santonin  to  this 
extract : 

R.  Fluid,  ext.  spigel.  et  senna?,  f^j  ; 

Santonin,  gr.  viij.     Misce. 

This  is  probably  the  best  anthelmintic  that  can  be  employed  for  the 
destruction  of  the  round-worm  in  uncomplicated  cases,  and  it  is  also  very 
useful   in  treating   the  ascaris  vermicularis.     Chenopodium   is   also   a   good 

5.S 


834  INTESTINAL    WORMS. 

anthelmintic.  It  is  efficient,  and  at  the  same  time  one  of  the  safest  in  case 
the  mucous  membrane  be  inflamed.  If  there  be  abdominal  tenderness,  with 
stools  too  frequent  and  thin  or  mucous  and  tinged  with  blood,  I  should  prefer 
the  chenopodium  to  most  of  the  other  vermifuges.  To  a  child  of  three  years 
five  drops  of  the  oil  may  be  given  three  times  daily.  It  may  be  continued 
for  a  longer  period  than  would  be  safe  for  most  of  the  other  vermifuges. 
Twice  a  week,  during  its  use,  a  mild  purgative  should  be  given,  as  castor  oil, 
rhubarb,  or  magnesia,  unless  the  bowels  are  open.  It  may  be  given  dropped 
on  sugar  or  in  a  mucilaginous  mixture. 

Dr.  J.  F.  Meigs  says  :  "  I  myself  rarely  give  any  other  remedy  than 
wormseed  oil  in  slight  and  especially  in  doubtful  cases,  unless  this  has  already 
been  tried  and  failed.  From  my  own  experience  I  believe  that  this  remedy 
is  all-sufficient  in  a  large  majority  of  the  cases  that  occur  in  this  city,  as  these 
are  almost  always  of  a  mild  character,  and  as  it  not  only  prodiices  the  expul- 
sion of  the  parasites  when  they  exist,  but  also  acts  beneficially  upon  the 
forms  of  digestive  irritation  which  simulate  so  closely  the  symptoms  pro- 
duced by  worms.  I  am  persuaded,  indeed,  that  of  all  the  cases  that  have 
come  under  my  notice  in  which  it  seemed  probable  that  worms  might  be 
present,  none  were  expelled  in  nearly  half,  and  yet  the  signs  of  disturbed 
health  have  passed  away  under  the  use  of  the  remedy."  .  .  .  .  "  The  follow- 
ing is  a  very  good  formula  for  the  administration  of  this  remedy : 

"  R.  01.  chenopodii,  gtt.  Ix  vel  fgj  ; 

P.  g.  acacife,  ,^ij  ; 

Syrup,  simplic,  ,^j  ; 

Aq.  cinnamom.,  ^ij.     Misce. 

Give  a  dessertspoonful  three  times  a  day  for  three  days,  and  repeat  after  several  days." 

In  cases  of  protracted  intestinal  disease  attended  by  an  increased  and 
vitiated  secretion  from  the  mucous  surface,  a  state  which  often  gives  rise  to 
worms,  turpentine  is  one  of  the  best  anthelmintics.  In  fact,  in  some  of  these 
cases  there  is  no  good  substitute  for  it.  For  example,  a  boy  of  about  ten 
years,  attended  by  myself,  October,  1864,  had  reached  or  nearly  reached  the 
fourth  week  of  typhoid  fever,  when  he  passed  from  his  bowels  a  large  quan- 
tity of  blood.  He  was  previously  emaciated  and  weak,  and  there  had  been, 
as  is  usual  in  such  cases,  considerable  diarrhoea.  The  hemorrhage  was 
attended  with  great  prostration,  from  which,  however,  he  partially  rallied  by 
the  use  of  stimulants.  On  the  following  day  an  equally  severe  hemorrhage 
occurred,  attended  with  coldness  of  the  face  and  extremities  and  great  feeble- 
ness of  pulse,  so  that  death  appeared  imminent.  Turpentine  was  now  admin- 
istered every  six  hours,  a  few  lumbrici  were  passed,  and  the  case  thenceforth 
progressed  favorably.  The  mechanical  eff'ect  of  the  lumbrici  on  the  ulcerated 
surface  of  intestine  had  probably  given  rise  to  the  hemorrhage.  Turpentine 
may  be  given  in  doses  of  from  five  to  ten  minims  three  times  daily  to  a  child 
five  years  old.  Sweetened  milk  or  sugar  in  powder  is  a  good  vehicle  for  it, 
or   it  may  be  given  in  a  mucilaginous  mixture. 

R.  Spts.  terebinth,  rec,        gij  ; 
01.  limonis,  gtt.  v  ; 

Mucil.  gum  acac, 
Syr.  simplic,  da.  .^vj  ; 

Aq.  anisi,  Jii-iij.     Misce. 

Dose :  One  teaspoonful  every  six  hours. 

The  following  formula  for  the  employment  of  this  agent  is  recommended  by 
Dr.  Condie : 


TREATMENT.  835 


R. 

Miicil.  fiiim  acac, 

.5i.i ; 

Sawli.  alb., 

3^; 

Spts.  ;t'tlier.  iiitr., 

.^i'.i 

; 

Spts.  terebintli.  rect., 

.^''.i 

> 

Magnes.  caloiiiat., 

.^.i; 

Aqiiii'  menthje, 

li- 

Misce. 

It  is  useless  to  enumerate  the  many  anthelmintic  mixtures  which  have 
been  extolled  from  time  to  time.  Those  mentioned  above  are  the  least 
nauseous,  and  rarely  disappoint  the  practitioner.  One  other  antidote  for  the 
round-worm  should  be  mentioned,  as  it  has  been  much  used  and  is  efficient — 
namely,  cowhage.  This  consists  of  the  bristles  which  cover  the  pods  of  the 
Mucuna  2)riirinis,  a  tropical  plant.  The  pods  are  dipped  in  plain  syrup  of 
the  ordinary  consistence,  and  the  bristles  are  scraped  off  with  the  syrup. 
When  enough  of  the  medicine  is  added  to  render  the  syrup  of  the  consist- 
ence of  thick  honey,  it  is  ready  for  use.  The  dose  is  a  teaspoonful  every 
morning  for  three  days,  after  which  a  cathartic  should  be  administered.  I 
have  never  prescribed  cowhage,  although  it  is  not  unfrequently  ordered  by 
physicians,   and  a  popular  nostrum   consists   chiefly  of  it. 

One  affected  with  tape-worm  is  obviously  cured  only  when  the  head  of 
the  parasite  is  expelled  ;  but  in  the  majority  of  cases  which  I  have  observed 
the  head  has  not  been  found  in  the  evacuations,  even  when  the  treatment 
had  effected  a  complete  cure,  as  shown  by  the  subsequent  history.  The 
chain  of  expelled  segments  commonly  terminated  very  near  the  head. 
This  I  believe  is  the  common  experience,  if  we  trust  the  friends  of  the 
patient  with  the  examination  of  the  stools.  The  physician  himself  should 
search  for  the  worm's  head,  the  evacuations  being  preserved.  The  nurse 
should  be  directed  to  add  a  little  carbolic  or  salicylic  acid,  and  a  sufficient 
quantity  of  water  to  nearly  fill  the  vessel.  The  liquid  should  not  be  roughly 
stirred  with  a  stick,  as  physicians  are  in  the  habit  of  doing,  since  this  breaks 
the  worm  into  small  portions  and  renders  the  inspection  more  difficult,  but  it 
should  be  shaken  frequently,  so  as  to  detach  the  segments  and  head,  if  it  be 
present,  from  the  fecal  matter.  After  it  has  stood  at  least  five  or  ten  min- 
utes, the  worm,  which  has  greater  specific  gravity  than  water,  sinks  to  the 
bottom,  and  the  upper  part  should  be  poured  off.  This  process  must  be 
repeated  till  the  water  is  nearly  colorless,  after  which  search  should  be  made 
for  the  fragments,  and  the  head,  if  present,  will  be  found. 

Since  entire  expulsion  of  the  tape-worm  is  effected  with  difficulty,  pre- 
paratory treatment  for  about  forty-eight  hours  should  be  employed  before 
the  vermifuge  is  administered.  During  this  time  the  patient  should  take  a 
mild  purgative  once  or  twice,  and  such  food,  in  moderate  quantity,  should  be 
allowed  as  leaves  little  residuum,  as  beef  tea,  milk,  etc.,  with  some  stimulant 
if  the  patient  feel  exhausted.  There  are  three  articles  of  food  which  expe- 
rience has  shown  to  be  especially  useful  in  this  preparatory  treatment,  per- 
haps from  a  sickening  effect  which  they  produce  upon  the  worm — namely, 
salt  herrings,  onions,  and  garlic.  They  may  therefore  be  taken  as  food  in 
the  twelve  or  eighteen  hours  preceding  the  employment  of  the  vermifuge, 
which  it  is  ordinarily  most  convenient  to  administer  in   the  morning. 

The  various  tfenicides  recommended  in  the  books  are  probably  all  more  or 
less  efficient,  but  the  one  which  has  given  most  satisfaction  in  the  Out-door 
Department  at  Bellevue,  where  probably  a  larger  number  of  these  cases  are 
treated  than  in  any  other  place  in  this  country,  is  the  oil  of  male  fern  ;  but 
it  is  found  necessary  to  employ  a  larger  dose  than  is  recommended  in  some 
of  the  books.  For  a  child  of  six  years  the  dose  employed  is  one  drachm  in 
any  convenient  vehicle,  as  the  syrupus  aurantii  florum.  This  should  be  fol- 
lowed in  about  four  hours  by  a  dose  of  castor  oil,  which  completes  the  treat- 


836  INTESTINAL    WORMS. 

ment.  Heller,  a  liigli  German  authority,  recommends  koosso  or  its  active 
principle  koossin,  in  the  use  of  which  I  have  had  no  personal  experience. 
The  pumpkin-seed  has  also  been  employed  at  Bellevue  and  in  other  parts  of 
this  city,  but  it  seems  to  be  less  efficient  than  the  oil  of  the  fern.  If  the 
chain  of  segments  break  near  the  head  and  the  head  be  not  seen,  it  will  be 
necessary  to  wait  two  or  three  months  in  order  to  determine  whether  the 
cure  is  complete. 

The  medical  journals  during  the  past  year  have  published  and  extolled 
the  following  formula  for  the  treatment  of  the  tape-worm.  It  is  so  difficult 
to  expel  the  head,  and  taenicides  employed  singly  so  often  fail  in  accomplish- 
ing this  result,  that  so  powerful  a  combination  of  taenicides  deserves  consid- 
eration, and  perhaps  trial.  The  dose  recommended  is  probably  for  the  adult, 
but  a  proportionate  dose  could  be  given  to  a  child : 

R.  Granati  corticis  radicis,  .^ss; 

Seminarum  peponis,  %] ; 

Pulveris  ergotse,  ,^j  ; 

Aquse  Bullient,  §viij-     Misce. 


Fiat  infus. 


Fiat  emulsionem. 


R .  Extracti  filicis  maris  fetheris,  f^j ; 

01.  tiglii,  TT^ij  ; 

Pulveris  acacise,  .^ij.     Misce. 


Mix  the  emulsion  with  the  infusion  and  give  them  at  10  A.  M.  A  full  dose 
of  Rochelle  salts  should  be  given  the  previous  evening,  and  no  breakfast 
taken. 

We  should  hesitate  to  administer  so  powerful  a  remedy  to  a  child  under 
the  age  of  eight  years.  Perhaps  it  might  be  best  to  recommend  one-quarter 
or  one-third  of  the  above  dose  to  a  child  of  eight  years,  and  half  the  dose  to 
one  of  twelve  or  fifteen  years. 

Since  the  symptoms  produced  by  the  oxyuris  vermicvlan's  are  referable 
chiefly  to  the  rectum,  and  are  caused  by  the  active  movements  of  the  worm, 
the  prompt  and  thorough  use  of  enemata,  which  causes  their  expulsion,  is 
evidently  required.  Enemata  are  more  efi"ectual  if  used  cool  than  if  warm  ; 
and  since  this  worm  inhabits  the  caecum  as  well  as  rectum,  large  enemata 
given  through  a  long  tube  or  a  large  catheter  are  more  effectual,  causing  the 
expulsion  of  a  larger  number  of  worms  than  are  expelled  by  small  enemata 
employed  in  the  usual  manner.  Various  substances  have  been  used  for  this 
purpose,  as  lime-water,  table  salt  in  water,  turpentine  in  milk,  decoction  of 
aloe,  decoction  of  garlic,  etc.  Heller  says  :  "  Simple  water  would  do  well  for 
this  purpose,  for  in  a  short  time  it  causes  the  worm  to  swell  up  and  burst ; 
but  it  is  not  altogether  without  an  injurious  effect  on  the  intestinal  mucous 
membrane.  Hence,  Vix  recommends  a  solution  of  castile  soap  in  distilled 
water  or  rain-water  of  the  strength  of  one  to  two  and  a  half  grains  to  the 
ounce.  This  has  no  unpleasant  action  on  the  intestinal  mucous  membrane, 
while  at  the  same  time  it  quickly  destroys  both  the  worms  and  their  eggs. 
....  Vix  has  tested  all  the  medicines  usually  used  in  enemata,  and  has 
found  the  above  solution  of  castile  soap  to  be  the  most  effectual."  The  use 
of  the  enema  in  the  evening,  although  only  a  small  quantity  of  liquid  be 
employed,  so  as  to  wash  out  the  rectum,  ensures  relief  from  the  itching  and 
sleeplessness  during  the  night. 

But  it  is  undeniable  that  enemata  alone  do  not  effect  a  complete  and  per- 
manent cure  in  a  large  proportion  of  cases,  and  hence  those  affected  with  this 
worm   remain   sufferers  for  years,  having  only  a  temporarj''  respite,  unless 


INTUSSUSCEPTION   WITHOUT  SYMPTOMS.  837 

medicines  be  administered  by  the  mouth.  Those  medicines  which  produce 
free  watery  evacuations  appear  to  be  the  most  effectual  in  dislodging  and 
expelling  oxyurides,  whose  attachment  to  the  intestinal  surface  is  not 
strong;  therefore  Heller  recommends  the  saline  purgatives  "joined  with 
copious  draughts  of  water."  The  solution  of  magnesium  citrate  found  in 
the  shops  is   useful  for  this  purpose. 


CHAPTER    XII. 

INTUSSUSCEPTION. 

Intussusception,  or  the  passage  of  one  portion  of  intestine  into  another, 
has  long  been  known  as  an  occasional  accident.  Hippocrates,  though  debarred 
from  the  study  of  morbid  anatomy,  appears  to  have  had  a  pretty  clear  idea 
of  this  displacement,  and  he  suggested  a  mode  of  treatment  which  has  been 
employed  till  the  present  time. 

Intussusception  without  Symptoms. 

This  is  not  properly  a  disease.  It  consists  in  a  displacement  without  any 
other  anatomical  change.  There  is,  therefore,  no  obstruction,  inflammation, 
or  even  congestion  present,  and  no  symptoms.  This  form  of  invagination 
might  ordinarily  be  reduced  by  the  normal  peristaltic  and  vermicular  move- 
ments of  the  intestine. 

Invagination  of  a  portion  of  the  small  intestine  into  the  part  immediately 
below  it  is  often  observed  at  the  post-mortem  examination  of  young  infants 
who  had  presented  no  symptoms  due  to  the  displacement.  The  invaginated 
mass  is  usually  from  half  an  inch  to  two  inches  in  length,  and  as  a  rule  this 
accident  is  multiple.  There  may  be  ten  or  more  distinct  intussusceptions  at 
distances  of  a  few  inches  from  each  other.  The  simple  displacement  is 
believed  to  occur  ordinarily  at  or  a  short  time  prior  to  the  moment  of  disso- 
lution. It  has  been  supposed  to  be  most  frequent  in  those  who  have  died  of 
cerebral  or  spasmodic  diseases,  but  its  occurrence  is  not  unusual  in  other 
pathological  states.  I  have  often  found  it  at  the  post-mortem  examination 
of  infants  who  have  had  subacute  or  chronic  entero-colitis.  Heven  states 
that  he  has  seen  it  at  the  Salpetriere  more  than  three  hundred  times.  Billard 
has  seen  it  especially  in  infants  who  have  been  subject  to  constipation.  Any 
irritant,  mechanical  or  other,  which  disturbs  the  regular  movements  of  the 
intestines  doubtless  may  produce  it.  It  has  been  caused  in  the  rabbit  by 
irritating  the  anus. 

It  is  not  improbable  that  simple  intussusception  occasionally  occurs  tem- 
porarily in  children  whose  health  remains  good  when  the  regular  movements 
of  their  intestines  are  disturbed  by  irritating  ingesta  or  other  causes.  This 
form  of  displacement  never  takes  place  in  the  large  intestine.  Its  usual  seat 
is  the  lower  part  of  the  jejunum  and  upper  part  of  the  ileum.  Since  it  pos- 
sesses little  interest  as  regards  pathology,  and  none  whatever  as  regards 
symptomatology  and  therapeutics,  it  may  be  ignored  in  our  description  of 
intussusception. 


838  INTUSSUSCEPTION. 

Intussusception  "with  Symptoms. 

Intussusception,  or  invagination,  is  one  of  the  most  painful  and  dan- 
gerous of  human  maladies,  but  fortunately  is  not  very  frequent.  I  have  the 
records  of  52  cases  occurring  in  children  in  addition  to  the  records  of  sev- 
eral cases  more  recently  observed.  From  these  the  facts  contained  in  this 
chapter  are  chiefly  derived.    The  patients  were  under  the  age  of  twelve  years. 

Previous  Health. — In  34  of  the  52  cases  the  state  of  the  health  pre- 
viously to  the  invagination  was  recorded.  From  the  following  table  it  is  seen 
that  one-half,  or  17,  were  previously  well,  the  remaining  half  suffering  from 
some  disease  or  derangement : 

Previous  Health. 


Age.  Good.        Disease  or  Derangement. 

One  year  or  under 15  8 

Over  one  year _2  ^ 

17  17 

MM.  Rilliet  and  Barthez,  whose  views  in  reference  to  intussusception  are 
derived  from  the  examination  of  the  records  of  25  cases,  state  that  the  pre- 
vious health  is  ordinarily  good,  and  the  intussusception  is  therefore  primary. 
Their  remark,  according  to  the  above  statistics,  is  seen  to  be  correct  as  regards 
patients  under  the  age  of  one  year,  but  incorrect  for  those  over  that  age. 

Most  of  the  17  who  had  previous  ill-health  had  diarrhoea,  dysentery,  or 
constipation,  or  diarrhoea  alternating  with  constipation.  Of  those  otherwise 
affected,  1  had  thread-worms,  2  obscure  abdominal  pains,  1  nausea  and  vomit- 
ing, and  1,  whose  age  was  four  months,  had  had  symptoms  of  invagination 
when  ten  weeks  old,  which  soon  passed  off.  It  is  seen  that  the  pre-existing 
affections  were  ordinarily  such  as  would  be  likely  to  accelerate  the  movements 
of  the  intestines  and  at  the  same  time  render  them  irregular. 

Causes. — The  above  statistics,  therefore,  show  that  intussusception  is 
often  preceded  by  disease  or  functional  derangement  of  the  intestines.  The 
two  opposite  conditions — namely,  constipation  and  the  diarrhoeal  maladies — 
so  often  precede  the  displacement  that  they  must  be  regarded  as  common 
causes.  Another  probable  cause  is  intestinal  worms,  which  by  their  mechani- 
cal action  stimulate  the  intestines.  They  were  present  in  3  of  the  52  patients, 
though  2  of  the  3  seemed  well  till  the  occurrence  of  the  intussusception,  but 
the  other  patient  had  complained  of  irritation  at  the  anus,  and  ascarides  had 
been  found  on  examination. 

The  use  of  irritating  and  indigestible  food  is  an  occasional  cause.  Thus, 
some  who  have  had  intussusception  have  been  in  the  habit  of  taking  fruits, 
candies,  and  pastries  freely.  Such  ingesta  may  be  an  immediate  cause  by 
their  irritating  effect,  or  a  remote  cause  giving  rise  to  diarrhoea,  which  in  turn 
produces  intussusception. 

Sex  is  a  predisposing  cause,  since  male  patients  are  largely  in  excess. 
Of  the  25  cases  collated  by  Rilliet  and  Barthez,  all  but  3  were  boys.  In 
our  own  collection  the  sex  of  34  of  the  patients  was  recorded,  and  of  these 
23  were  boys. 

In  rare  instances  external  violence  is  the  apparent  exciting  cause.  One 
patient  received  a  severe  contusion  of  the  abdomen  two  years  before  death, 
and  from  this  time  continued  to  complain  at  intervals  of  pain  in  the  bowels. 
One  writer  also  mentions  the  case  of  a  child  nine  years  old,  who  received  a 
blow  from  a  comrade  at  school,  and  from  this  time  had  alternately  diarrhoea 
and  constipation  till  the  invagination  commenced.  Rilliet  and  Barthez  also 
relate  the  cases  of  two  children  who  were  taken  suddenly  with  invagination 
when  their  parents  were  tossing  them  in  their  arms. 


3  were  3  months  old. 

12     "     4 

3    "     5 

5    "     6 

1  was  7 

1     "      8 

3  were  9 

INTUSSUSCEPTION  IN  THE  SMALL  INTESTINES  839 

Age. — Of  the  52  cases  embraced  in  our  statistics,  the  ages  were  as 
follows : 

1  was  10  months  old. 
1    "     11 

1  "     12       "         " 

2  were  from  1  to  2  years  old. 
8     «        "2  "    5     "       " 
8     "        "     5  "12     "       " 

3  not  given. 

Therefore,  no  cases  occurred  under  the  age  of  three  months  ;  23  cases  were 
between  the  ages  of  three  and  six  months,  or  nearly  one-half  of  the  entire 
number  ;  8  between  the  ages  of  six  months  and  one  year  ;  and  only  18  between 
the  ages  of  one  year  and  twelve.  These  statistics  correspond,  in  the  main, 
with  those  of  Rilliet  and  Barthez,  in  whose  collection  of  25  cases  no  one  was 
under  the  age  of  four  months.  Leichtenstern  '  says  :  "  Half  of  all  invagina- 
tions, according  to  my  statistics  of  473  cases,  occur  during  the  first  ten  years. 
The  first  year  after  the  third  month  is  remarkable  for  a  special  frequency — 
one-fourth  of  all  intussusceptions." 

The  great  liability  to  intussusception  in  infancy  is  due  partly  to  the  ana- 
tomical character  of  the  intestine  in  this  period  of  life,  and  partly,  doubtless, 
to  the  fixct  that  there  are  more  frequent  irregularities  in  the  intestinal  move- 
ments than  in  older  children.  In  the  infant  the  walls  of  the  intestines  are  thin, 
the  mucous  and  muscular  coats  and  the  connective  tissue  being  much  less 
developed  than  in  those  that  are  older ;  the  mesentery  and  meso-colon  have 
also  greater  depth  as  compared  with  the  same  in  other  periods  of  life,  except 
the  meso-colon  at  the  points  where  it  passes  over  the  kidneys,  in  which  places 
it  is  very  short  or  even  in  some  cases  nearly  absent.  Moreover,  the  space 
occupied  by  the  large  intestine,  in  which  part  of  the  digestive  tube  intussus- 
ception commonly  occurs,  is  much  .shorter  relatively  to  the  length  of  the 
intestine  than  in  those  that  are  older.  In  about  thirty  measurements  which 
I  have  made  of  the  length  of  the  large  intestine  and  the  space  occupied  by 
it,  the  latter  was  found,  on  the  average,  about  one-third  that  of  the  former, 
which  of  course  necessitates  doubling  of  the  intestine  on  itself.  These  pecu- 
liarities of  structure  in  the  infant  obviously  favor  the  occurrence  of  intus- 
susception. 

Seat  and  Pathological  Anatomy. — While  intussusception  occurring 
without  symptoms  is  usually  multiple,  that  form  which  occurs  with  symp- 
toms is  ordinarily  single.  Two  exceptional  cases  which  I  observed  will  be 
presently  related.  In  one  of  the  cases  embraced  in  the  statistics  an  invag- 
ination occurred  with  symptoms,  and  coexisting  with  it  was  another  in 
the  small  intestines  apparently  without  symptoms  and  quickly  reduced  by 
handling. 

While  intussusception  without  symptoms  occurs  in  the  small  intestine, 
the  seat  of  intussusception  with  symptoms  is,  with  occasional  exceptions,  the 
colon.  The  colon  constitutes  the  entire  invaginated  mass,  or  else  and  more 
frequently  it  forms  the  exterior,  while  the  incarcerated  portion  consists  wholly 
or  in  part  of  the  ileum. 

Intussusception  in  the  Small  Intestines. 

Bouchut  says :  "  M.  Rilliet  states  in  a  recent  treatise  that  in  infancy  the 
intestinal  invagination  is  always  accomplished  at  the  expense  of  the  large 
intestine,  and  that  there  is  never  invagination  of  the  small  intestine.     This 

^  Zianssen's  Encyclop. 


840  INTUSSUSCEPTION. 

is  incorrect.  I  have  observed  the  small  intestine  invaginated  in  the  adjacent 
inferior  part.  Taylor  has  reported  a  case  of  this  kind  in  a  child  twenty- 
months  old  who  died  after  an  attack  of  acute  peritonitis.  M.  Marage  has 
seen  another  case  in  a  child  thirteen  months  old,  who  recovered  after  having 
voided  the  invaginated  portion  furnished  with  two  of  those  diverticula  so 
frequent  in  the  small  intestine  of  the  foetus." 

But,  from  all  that  appears,  the  case  reported  by  M.  Marage  may  have 
been,  and  probably  was,  an  example  of  the  common  form  of  intussusception — 
to  wit,  the  prolapse  of  the  ileum  into  the  colon.  In  Mr.  Taylor's  case  the 
invagination  was  really  of  the  ileum  into  the  colon,  although  a  small  por- 
tion of  the  ileum  next  to  the  valve  had  not  been  inverted,  so  that  it  con- 
stituted a  little  of  the  exterior  of  the  mass. 

Nevertheless,  Bouchut  is  correct  in  stating  that  irreducible  and  fatal 
intussusception  may  occur  in  the  small  intestines.  Probably  the  displace- 
ment is  at  first  of  the  simple  variety,  but,  continuing  and  increasing  in 
extent,  its  return  becomes  impossible.  The  positive  statement  of  so  great 
an  authority  as  M.  Rilliet,  that  intussusception  with  symptoms  does  not 
occur  in  the  small  intestines,  justifies  the  publication  of  the  following  cases, 
which  establish  the  fact  that  there  are  instances,  though  not  frequent,  in 
which  the  displacement  does  have  this  location  : 

Case  1. — This  patient's  health  had  been  uniformly  good,  and  nothing  unusual 
was  observed  in  his  condition  till  the  age  of  four  and  a  half  months,  when  he 
became  restless,  as  if  in  almost  constant  pain,  with  occasional  exacerbations. 
Castor  oil  was  prescribed,  which  operated  freely,  and  then  the  following  mixture : 

R.  Magnes.  calcinat.,  9 j  ; 

Tinct.  opii  campliorat.,  ^ij  ; 

Tinct.  asafoet.,  ,^ss; 

Aq.  anisi,  ^j.     Misce. 

Dose :  Ten  to  twenty  drops,  repeated  according  to  the  pain. 

These  remedies  failed  to  give  relief,  as  did  also  chloroform  given  in  doses  of 
two  drops.  After  two  or  three  days  another  set  of  symptoms  arose,  those  cha- 
racteristic of  pneumonia — to  wit,  hurried  respiration,  accelerated  pulse,  short 
suppressed  cough,  and  expiratory  moan.  He  was  treated  with  the  oiled-silk 
jacket  and  mild  counter-irritation,  and  took  an  expectorant  mixture  containing 
ammonium  carbonate.  In  a  few  days  the  pulmonary  disease  was  evidently  sub- 
siding, but  the  pain  in  the  abdomen,  with  occasional  exacerbations,  continued. 
His  countenance  was  pallid  and  bore  an  expression  of  suflFering.  There  was  no 
distension  or  tenderness  of  abdomen  and  no  abdominal  tumor.  He  took  little 
nutriment  and  seldom  vomited.  In  the  last  part  of  his  sickness  the  dejections 
were  scanty,  and  the  last  three  days  his  stools  consisted  mainly  of  mucus  and  a 
little  blood.  The  pain  seemed  to  be  growing  less  when  he  was  seized  with  con- 
vulsions, and  died  the  same  day,  precisely  two  weeks  from  the  commencement 
of  his  sickness. 

Sectio  Cadaver. — Head  not  examined;  body  slightly  emaciated;  mucous 
membrane  of  trachea  and  bronchial  tubes  vascular ;  posterior  portion  of  the 
lower  lobe  of  each  lung  solid,  of  greater  specific  gravity  than  water,  and  allow- 
ing only  partial  inflation  ;  it  was  in  the  second  stage  of  pneumonia.  Stomach, 
duodenum,  jejunum,  healthy.  In  the  upper  part  of  the  ileum  Avas  an  intussus- 
ception two-thirds  of  an  inch  long,  presenting  no  trace  of  inflammation  either 
within  or  around  it,  and  its  vascularity,  when  it  was  examined  externally,  did 
not  seem  notably  increased.  Above  the  intussusception  the  intestine  was  empty  ; 
below  it,  and  chiefly  in  the  small  intestine,  was  a  dark-colored  substance,  evi- 
dently blood,  and  giving  in  a  few  hours  the  offensive  odor  of  decaying  animal 
matter.  There  was  a  passage  through  the  intussusception  at  least  two  or  three 
lines  in  diameter,  as  shown  by  a  probe.  The  intussusception  sustained  the 
weight  of  sixteen  inches  of  the  intestine,  and  it  would  have  apparently  sustained 
considerably  more.     The  remaining  organs  were  healthy. 


INTUSSUSCEl'llON  IN  THE  SMALL   INTESTINES.  841 

Case    2. — F.  S ,  a  female    infiuit    four    months  old,  was  treated  at  the 

New  York  Infant  Asylum  in  June  and  July,  18G5,  for  entero-colitis,  the  usual 
epidemic  of  the  summer  season.  The  following  records  show  the  state  of  the 
bowels  immediately  before  her  death: 

June  2!)th :  Has  five  or  six  stools  daily.  'M)i\\ :  Two  stools  in  twenty-four 
hours.     July  1st:  Had  two  stools  since  the  last  record;  no  vomiting.     3d:  Four 

Fk;.  47. 


stools  in  last  twenty-four  hours.  4th:  The  diarrhoea  continues,  as  before;  the 
stools  about  four  daily.     On  the  6th  of  July  she  died. 

Her  pulse  during  the  time  in  which  these  records  were  taken  generally  num- 
bered about  128  per  minute.  She  was  much  emaciated,  and  the  day  before  death 
she  frequently  struck  her  head  with  her  hand.  The  medicines  employed  were 
mainly  alkalies  and  astringents. 

Sectio  Cadaver. — Parietal  bones  united ;  serous  effusion  over  the  convolutions 
of  the  brain,  under  the  arachnoid;  occipital  bone  depressed  ;  commencing  at  a 
point  about  two  feet  below  the  stomach  w^ere  four  intussusceptions  two  or  three 
inches  from  each  other.  The  invaginated  masses  were  from  one  to  one  and  a 
half  inches  in  length,  and  three  of  them  were  found  to  be  very  vascular  in  their 
interior.  Above,  between,  and  immediately  below  the  intussusceptions  the  intes- 
tine was  healthy.  One  of  the  invaginations  was  tested  by  weight,  and  was  found 
to  sustain  a  foot  and  a  half  of  intestine,  and  would  have  sustained  more.  Water 
poured  above  these  intussusceptions  escaped  through  them  very  slowly ;  no 
fibrinous  exudation ;  descending  colon  vascular  and  thickened  and  solitary 
glands  enlarged. 

The  irreducible  character  of  the  intussusceptions  in  the  above  cases  was 
shown  by  the  fact  that  they  sustained  weights  which  doubtless  produced 
greater  traction  than  that  exerted  by  the  intestine  in  its  normal  action. 
That  the  displacement  existed  prior  to  the  moment  of  death  was  shown  by 
the  symptoms  in  one  of  the  cases  and  by  the  anatomical  changes  in  both. 
In  one  the  capillaries  of  the  incarcerated  mass  were  ruptured  during  the 
last  days  of  life,  so  as  to  produce  sanguineous  stools,  while  in  the  other 
there  was  intense  congestion  of  the  invaginated  mucous  membrane,  and 
that  portion  of  this  membrane  which  was  adjacent,  but  not  engaged,  was 
healthy. 

In  both  patients  the  symptoms  were  less  severe  than  in  ordinary  cases,  and 


842  INTUSSUSCEPTION. 

they  came  on  more  gradually,  for  the  invaginated  intestine  was  not  com- 
pletely closed,  so  that  it  allowed  the  passage  of  fecal  matter  in  one  till  the 
close  of  life,  and  in  the  other  till  near  its  close.  At  both  of  the  autop- 
sies water  poured  into  the  intestines  above  the  invaginations  passed  slowly 
through  them. 

Intussusception  in  the  small  intestines  in  the  infant,  commencing  as  the 
simple  form,  may  become  irreducible,  and  yet,  remaining  pervious,  may  con- 
tinue for  weeks  without  giving  rise  to  severe  or  dangerous  symptoms.  The 
following  case  was  an  example  of  this  : 

Case  3. — Male  child,  died  at  the  age  of  nineteen  months,  the  last  eleven  of 
which  he  was  under  observation.  The  mother  states  that  he  had  never  been 
well  since  the  age  of  one  month,  and  that  there  had  been  little  variation  in  the 
symptoms  of  his  disease.  During  the  period  in  which  he  was  under  observation 
he  was  ordinarily  fretful,  and  frequently  seemed  to  be  in  considerable  pain.  His 
stomach  during  this  whole  time  was  so  irritable  that  he  rarely  took  more 
than  three  or  four  spoonfuls  of  nutriment  without  vomiting.  There  was  usually 
more  or  less  diarrhoea,  but  no  tenderness  or  distension  of  abdomen.  He  became 
.slowly  but  gradually  more  emaciated,  and  finally  died  in  a  state  of  extreme 
emaciation  and  exhaustion.  He  had  no  convulsions,  and  was  conscious  to  the 
last. 

Sectio  Cadaver. — Brain  not  examined ;  lungs  healthy,  except  a  circumscribed 
portion  which  was  inflamed  at  the  summit  of  the  right  lung ;  liver  small  and 
almost  destitute  of  oily  matter,  as  shown  by  the  microscope.  In  the  jejunum, 
about  two  feet  below  the  stomach,  was  an  intussusception  two  inches  long,  the 
intestine  forming  Avhich  seemed  to  have  undergone  no  structural  change.  Above 
the  intussusception  the  intestine  was  of  small  calibre,  and  entirely  empty  and 
pale  ;  below  the  intussusception  the  intestine  was  somewhat  larger  than  above, 
but  it  seemed  quite  healthy.  The  invagination  was  sufficiently  pervious  to  allow 
water  to  pass  through  it,  and  it  readily  sustained  the  weight  of  two  feet  of  intes- 
tine. From  eight  to  ten  inches  below  this  intussusception  there  was  another, 
which  was  immediately  drawn  out  the  moment  the  intestine  was  disturbed.  The 
other  abdominal  viscera  were  healthy. 

There  is  uncertainty  as  to  the  duration  of  the  intussusception  in  the  above 
case,  but  the  symptoms  indicated  that  it  existed  a  considerable  time  prior  to 
death.  There  was  no  strangulation,  nor  indeed  any  appreciable  anatomical 
alteration  in  the  coats  of  the  intestine,  but  the  fact  that  the  invaginated  mass 
sustained  two  feet  of  intestine  and  required  considerable  traction  for  its  reduc- 
tion shows  that  it  was  not  a  case  of  simple  displacement  occurring  at  the 
moment  of  death  and  without  symptoms,  but  was  an  example  of  the  variety 
with  symptoms. 

Intussusception  in  the  Large  Intestines- 

In  most  cases  of  intussusception  occurring  in  infancy  and  childhood  the 
ileum  is  invaginated  in  the  colon  or  the  first  part  of  the  colon  is  invaginated 
in  the  part  succeeding  it.  Intussusception  not  infrequently  begins  in  the 
prolapse  of  the  ileum  through  the  ileo-csecal  valve,  in  the  same  way  that  pro- 
lapse of  the  rectum  occurs  through  the  sphincter  ani.  If  death  take  place 
early,  only  a  small  portion  of  the  ileum  may  have  passed  the  valve.  If  the 
case  be  protracted,  the  tenesmus  brings  down  more  and  more  of  the  ileum, 
with  its  accompanying  mesentery.  The  constriction  of  the  valve,  which  acts 
as  a  ligature,  soon  prevents  the  further  descent  of  the  ileum  ;  and,  the  tenes- 
mus continuing,  the  next  step  in  the  displacement  is  the  inversion  of  the 
caput  coli,  which  is  drawn  into  the  colon  by  the  descending  mass,  and  unless 
the  case  terminate  by  sloughing  or  death,  the  ascending  and  transverse  por- 
tions   of  the   colon  are    successively  invaginated.     The   records    show   that 


INTUSSUSCEPTION  IN   THE  LARGE  INTESTINES.  843 

intussusception  occurs  as  above  stated  in  a  large  proportion  of  cases.  In  one 
case  among  those  which  I  have  collated  the  invagination  began  a  few  inches 
above  the  valve,  so  that  the  ileum  constituted  a  small  portion  of  the  exterior 
of  the  mass.  Occasionally  the  caecum  is  the  part  primarily  inverted  and 
invaginatcd,  and,  descending  along  the  colon,  it  draws  after  it  the  ileum, 
which  sustains  its  natural  relation  to  the  ileo-caical  valve.  When  this  occurs 
the  cjccum  is  found  at  the  lower  end  of  the  mass,  and  two  orifices  are 
observed,  one  leading  through  the  valve  and  the  other  into  the  appendix  ver- 
miformis.  These  two  forms  of  invagination — that  in  which  the  ileum,  passing 
through  the  ileo-caecal  valve,  successively  inverts  and  draws  after  it  the  caput 
coli  and  the  divisions  of  the  colon,  and  that  in  which  the  caput  coli  is  pri- 
marily invaginatcd,  and,  descending  along  the  large  intestine,  inverts  the  lat- 
ter and  draws  after  it  the  ileum — constitute  the  vast  majority  of  cases  of  this 
disease  in  the  first  years  of  life. 

I  have  notes  of  45  fatal  cases  occurring  under  the  age  of  twelve  years  in 
which  the  portion  of  intestine  first  displaced  is  recorded.  In  four  of  these 
the  displacement  was  entirely  in  the  small  intestine,  involving  in  no  way  the 
colon  ;  in  38  cases  it  commenced  either  by  prolapse  of  the  ileum  through  the 
ileo-ca3cal  valve  or  by  the  inversion  of  the  caecum  into  the  ascending  colon, 
there  being  perhaps  not  much  difference  in  the  relative  frequency  of  these 
two  modes  ;  in  one  case  the  invagination  was  confined  to  a  segment  of  the  trans- 
verse colon,  in  another  to  a  segment  of  the  descending  colon,  and  in  the 
remaining  case  to  the  lower  part  of  the  descending  colon  and  the  upper  part 
of  the  rectum.  In  three  instances  the  invaginatcd  mass  itself  became  invag- 
inatcd, producing  an  intussusception  of  great  thickness,  and  necessarily 
fatal. 

Intussusception  is  sometimes  attended  by  so  little  constriction  of  the  incar- 
cerated portion  that  it  remains  pervious.  In  such  a  case  life  may  be  pro- 
tracted for  weeks  or  even  months  without  reduction  of  the  displacement  or 
any  material  change  in  it,  the  passage  of  fecal  matter  being  sufficiently  free 
for  the  maintenance  of  life.  Death  finally  occurs  in  a  state  of  exhaustion. 
Thus  in  one  instance  a  child  four  months  old  lived  six  weeks  after  the  symp- 
toms of  invagination  commenced,  and  seventeen  days  "  with  a  portion  of  the 
bowel  protruding  from  the  anus."  It  was  found  at  the  post-mortem  exami- 
nation that  part  of  the  ileum  had  descended  through  the  entire  colon,  and 
had  remained  pervious.  In  a  case  related  by  Dr.  Worthington '  symptoms 
of  intussusception  were  present  for  seven  months  before  death,  and  during 
the  last  six  weeks  of  life  the  invaginatcd  intestine  protruded  frequently  from 
the  anus,  and  was  replaced  by  the  mother.  In  this  case  "  the  caecum  was 
inverted,  and,  descending  through  the  colon  to  the  lower  portion  of  the  rec- 
tum, carried  with  it  the  ileum  and  the  entire  colon  except  the  last  ten  or 
twelve  inches."  In  another  case  the  symptoms  indicated  a  continuance  of 
the  disease  for  three,  if  not  eight,  months.  But  such  cases  are  exceptional. 
Ordinarily,  as  the  intestine  becomes  invaginatcd  its  mesentery  or  meso-colon 
is  also  invaginatcd  and  its  veins  compressed.  The  pathological  state  of  the 
incarcerated  mass  soon  becomes  that  of  intense  congestion.  In  infants, 
usually  in  a  few  hours,  so  great  is  the  distension  of  the  capillaries  that  they 
give  way,  blood  escapes  into  the  intestine,  and  passes  from  the  bowels  in 
scanty  motions.  On  examining  the  invaginatcd  intestine  after  death,  if  gan- 
grene have  not  occurred,  it  is  found  of  a  uniformly  intense  red  color,  some- 
times resembling  to  the  naked  eye  a  long  and  firm  clot  of  blood.  In  those 
who  die  early  no  traces  of  inflammation  are  seen,  but  in  more  protracted  cases 
the  attrition  between  the  serous  surfaces  excites  local  peritonitis.  In  none  of 
the  fifty-two  cases  which  I  have  collated  in  which  post-mortem  examinations 

'  Amer.  Jour,  of  Med.  Sci.,  for  January,  1849. 


844  INTUSSUSCEPTION. 

were  made  did  the  inflammation  extend  more  than  a  few  lines  beyond  the 
invagination.  Usually  the  intestine  forming  the  exterior  of  the  invaginated 
mass  is  much  drawn  together  or  puckered.  In  one  case  treated  by  myself 
the  entire  large  intestine  which  formed  the  exterior  of  the  mass  was  com- 
pressed within  a  space  of  six  inches  or  less,  since  about  twelve  inches  of  the 
ileum,  doubled  on  itself,  lay  within  the  entire  colon  and  protruded  from  the 
anus,  the  only  part  of  the  large  intestine  which  was  inverted  being  the  caput 
coli.  In  one  case  six  or  seven  inches  of  the  ileum,  which  formed  a  portion  of 
the  exterior  of  the  mass,  were  compressed  within  the  space  of  one  inch. 

The  abdomen,  at  first  of  natural  fulness  and  soft,  usually  becomes  more 
and  more  distended  till  the  close  of  life ;  but  in  cases  of  much  vomiting  the 
distension  is  moderate.  This  fulness  is  due  to  gas  and  fecal  accumulation 
above  the  invagination.  The  portion  of  the  intestine  below  the  displacement 
is  ordinarily  empty,  except  that  in  the  infant  it  commonly  contains  mu^us, 
mixed  with  more  or  less  blood  which  has  escaped  from  the  capillaries  of  the 
.strangulated  mass. 

There  are  few  anatomical  changes  in  this  disease  which  do  not  arise 
directly  from  the  intussusception,  and  are  therefore  located  either  within  the 
mass  or  in  its  immediate  vicinity.  In  those  who  recover  by  the  process  of 
sloughing  the  cicatricial  contraction  may  give  rise  to  symptoms  and  lesions  of 
greater  or  less  gravity.  Thus  the  late  Sir  James  Y.  Simpson  examined  a 
child  aged  nine  years  who  recovered  with  loss  of  ten  inches  of  intestine,  and, 
at  the  meeting  of  the  Medical  Society  ^  before  which  the  specimen  was  pre- 
sented, he  remarked  that  there  was  unusual  distension  of  the  cutaneous  veins 
of  the  patient,  due  probably  to  such  compressions  of  the  ascending  vena  cava 
by  the  cicatrix  that  the  venous  circulation  was  obstructed.  Mr.  Charles 
King  ^  relates  the  case  of  a  child  aged  six  years  who  on  the  eleventh  day  of 
the  disease  voided  the  caecum  and  a  part  of  the  colon.  Two  days  subse- 
quently pulsation  ceased  in  the  left  leg,  and  all  that  part  below  the  patella 
became  gangrenous.  The  patient  gi'adually  recovered  with  loss  of  the  leg. 
The  cause  of  this  unfortunate  sequel  was  doubtless  compression  from  the 
cicatricial  contraction  around  the  artery  which  supplied  the  leg,  and  probably 
the  formation  of  a  thrombus.  Dr.  F.  Bush^  relates  a  case  in  which  he  was 
enabled  to  observe  the  extent  and  appearance  of  the  cicatrix.  The  patient, 
aged  twelve  years,  discharged  from  the  bowels  fifteen  to  eighteen  inches  of 
the  ileum  on  the  eighth  day  of  the  intussusception,  after  which  convalescence 
was  rapid.  Fourteen  weeks  later  the  child  died  from  typhus  fever,  and  at  the 
autopsy  "  traces  of  the  diseased  bowels  were  visible  by  a  contraction  and 
puckering  where  the  slough  had  taken  place  and  the  parts  united."  But, 
fortunately,  in  most  instances  when  the  intestine  sloughs  and  the  child 
survives,  no  serious  or  permanent  injury  results  from  the  cicatrization.  The 
cicatrix  stretches  little  by  little  and  accommodates  itself  to  the  surrounding 
parts. 

Symptoms. — The  symptoms  vary  according  to  the  age  of  the  patient  and 
the  degree  of  strangulation.  Pain  in  the  abdomen,  usually  paroxysmal,  is 
among  the  first  and  is  one  of  the  most  conspicuous  symptoms.  It  is  often 
severe,  resembling  the  pain  of  hernia,  and  abating  only  with  the  failing 
strength  of  the  child.  After  the  first  few  days,  if  inflammation  arise,  the 
pain  is  continuous,  though  more  severe  in  paroxysms.  At  first  pressure  upon 
the  abdomen  is  tolerated,  but  afterward  there  is  tenderness.  This  is  due  to 
the  inflammation  which  occurs  in  and  around  the  invaginated  mass,  and  it  is 
therefore  confined  to  the  part  of  the  abdomen  in  which  the  tumor  lies.  At 
this  point  also  the  abdomen  is  more  full  than  elsewhere,  and  not  infrequently 

^  Trans.  Medico-Chir.  Soc.  Edin.  *  London  Lancet,  for  1854. 

*  Lond.  Med.  and,  Phys.  Jour.,  for  December  18,  1823. 


INTUSSUSCEPTION  IN  THE  LARGE  INTESTINES.  845 

the  physician  can  feel  the  invaginated  mass  and  detect  its  exact  location  and 
approximately  its  extent.  Sometimes,  at  an  early  period  as  well  as  late, 
cerebral  symptoms  occur,  as  in  a  case  related  by  Dr.  Coggswell,'  which  ter- 
minated in  convulsions  and  death  on  the  second  day.  Convulsions  are,  how- 
ever, comparatively  rare,  and  the  mind  is  generally  clear  till  the  last  moment. 
In  infants  the  countenance  in  the  intervals  of  pain,  in  the  first  stages  of  the 
complaint,  is  often  placid,  and  not  indicative  of  any  serious  disease,  but  in 
older  patients  constant  and  severe  local  symptoms,  referable  to  the  intus- 
susception, commence  early.  At  an  advanced  period,  whatever  the  age,  the 
countenance  becomes  anxious  and  haggard,  the  eyes  hollow  or  sunken,  the 
body  loses  its  plumpness,  and,  if  the  case  be  protracted,  becomes  emaciated. 

Vomiting  is  rarely  absent ;  in  39  out  of  47  cases  it  is  stated  to  have  been 
present,  in  7  cases  there  is  no  record  of  this  symptom,  while  it  is  recorded 
absent  in  onl}-  1  case  ;  but  in  this  case,  the  records  of  which  are  very  meagre, 
death  occurred  on  the  second  day.  The  vomiting  becomes  stercoraceous  in  a 
few  days,  and  it  ordinarily  continues  with  greater  or  less  frequency  till  the 
period  of  collapse.     It  relieves  partially  the  distension. 

The  appetite  is  impaired  and  often  entirely  lost.  Infants  at  the  breast 
commonly  nurse,  however,  for  several  days,  probably  from  thirst  rather  than 
hunger. 

In  most  patients  one  natural  evacuation  occurs  from  the  bowels  after  the 
intussusception  commences,  and  then  obstinate  constipation  succeeds.  This 
evacuation  consists  of  the  excrementitious  matter  below  the  invagination. 
In  children  under  the  age  of  one  year  scanty  motions  of  blood  mixed  with 
mucus  begin  to  occur  in  a  few  hours.  Of  27  children  under  this  age,  I  find 
that  24  had  such  evacuations,  occurring  in  most  of  them  several  times  in  the 
course  of  the  day ;  in  2  of  the  27  there  is  no  record  of  this  symptom,  but  in 
the  remaining  case  it  is  stated  to  have  been  absent.  Scanty  evacuations  of 
blood  unmixed  with  fecal  matter  have  been  considered  pathognomonic  of 
intussusception  in  the  infant,  and  we  see  the  ground  for  such  belief  ;  but  in 
exceptional  instances  the  invaginated  mass  is  partly  pervious,  and  although 
the  dejections  may  contain  blood  they  are  also  excrementitious.  In  our  col- 
lection of  cases  are  3  examples  of  this  in  infants  under  the  age  of  one  year. 
One  has  already  been  referred  to.  In  this  case  there  was  the  rare  anomaly  of 
so  large  an  opening  through  the  ileo-csecal  valve  as  to  allow  not  only  prolapse 
and  descent  of  the  ileum  through  the  entire  colon,  so  as  to  protrude  six  inches 
from  the  anus,  but  also  fecal  passage  through  it  daily. 

In  children  above  the  age  of  one  year  the  capillaries  of  the  invaginated 
intestines  are  not  so  frequently  ruptured  as  under  this  age,  and  sanguineous 
evacuations  are  therefore  less  common.  I  have  records  of  19  cases  between 
the  age  of  one  year  and  twelve,  in  only  6  of  which  it  is  stated  that  there  were 
bloody  motions,  and  in  these  the  blood  was  nob  passed  frequently,  nor  even 
in  some  cases  daily,  as  in  infants,  nor  in  so  pure  a  state,  unless  in  2  cases, 
the  records  of  which  are  not  explicit  on  this  point.  Two  of  these  6  patients 
passed  moderate  bloody  evacuations  after  protracted  periods  of  con.stipation, 
one  had  fecal  discharges  with  the  blood  through  the  entire  sickness,  and  in 
one  blood  was  passed  at  first,  but  finally  the  stools  were  entirely  fecal. 

In  those  above  the  age  of  one  year  obstinate  constipation  was  ordinarily 
present,  no  dejections,  either  bloody  or  fecal,  occurring  for  several  days ;  but 
there  were  a  few  exceptions.  In  3  cases  the  bowels  were  relaxed.  The 
ileum  in  these  3  had  descended  through  the  entire  colon  or  the  larger  part 
of  the  colon,  and,  being  pervious,  the  feces  escaped  from  the  anus  without 
detention  in  the  large  intestine  or  with  detention  only  in  its  lower  portion, 
and  were  therefore  liquid. 

'  London  Lancet,  for  July,  1853. 


846  INTUSSUSCEPTION. 

Tenesmus  is  another  symptom.  It  is  not  always  present,  but  in  a  large 
proportion  of  cases,  even  when  the  invagination  is  in  the  upper  part  of  the 
large  intestine,  it  is  a  frequent  and  distressing  symptom.  It  often  does  not 
commence  till  there  is  a  considerable  amount  of  displacement,  and  it  ceases 
when  the  strength  is  much  reduced. 

The  temperature  of  the  surface  is  normal  in  the  commencement  of  intus- 
susception ;  but  finally,  as  febrile  reaction  symptomatic  of  the  inflammation 
comes  on,  it  rises  and  continues  above  the  healthy  standard  till  the  intestine 
sloughs  or  till  the  stage  of  collapse  occurs  which  ushers  in  death.  The  pulse, 
especially  in  the  infant,  is  tranquil  at  first,  but,  whatever  the  age,  it  soon 
becomes  accelerated  from  the  paroxysms  of  pain,  and  subsequently  from  the 
inflammation  which  occurs  in  the  invaginated  mass.  There  is  no  disturbance 
of  respiration,  except  that  it  is  somewhat  hurried  from  the  fever  andfrom 
the  pain  felt  in  advanced  cases  on  full  inspiration. 

It  will  be  seen  that  the  symptoms  vary  in  certain  particulars  under  the 
age  of  one  year  from  those  occurring  over  that  age,  but  difi"erences  in  the 
symptoms  depend  more  on  the  degree  of  invagination  and  constriction  than 
on  the  age  and  exact  location  of  the  disease. 

Diagnosis. — The  diagnosis  of  intussusception  is  not,  in  general,  difficult, 
except  at  its  commencement.  When  the  inversion  has  reached  that  degree 
at  which  obstruction  occurs,  the  symptoms  are,  in  most  cases,  such  that  the 
disease  can  be  readily  diagnosticated.  In  the  cases  whose  records  I  have  col- 
lated a  correct  diagnosis  was  made  with  few  exceptions,  and  at  an  early  period. 
In  the  infant  the  disease  for  which  intussusception  is  most  frequently  mis- 
taken is  dysentery,  on  account  of  the  tenesmus  and  the  muco-sanguineous 
stools.  In  certain  of  the  reported  cases  this  mistake  was  not  rectified  until 
it  was  ascertained  that  purgatives  produced  no  fecal  evacuations. 

The  symptoms  which  are  commonly  present,  and  which  indicate  the 
nature  of  the  disease,  are  obstinate  constipation,  vomiting,  paroxysmal  pain 
referred  to  the  seat  of  the  disease,  and  tenesmus.  In  the  infant  also  scanty 
evacuations  from  the  bowels  of  mucus  and  blood  or  of  pure  blood  are,  as  we 
have  seen,  an  important  diagnostic  sign.  It  should  be  borne  in  mind,  how- 
ever, that  in  exceptional  cases  the  displaced  bowel  may  remain  pervious,  and 
the  usual  symptoms  which  possess  diagnostic  value  therefore  be  absent. 
There  may  be  no  vomiting  or  tenesmus,  and  diarrhoea  may  even  occur  in  place 
of  constipation,  as  in  the  cases  related  above.  As  an  aid  to  diagnosis  it 
should  be  stated  that,  whatever  the  age  of  the  child  aff'ected  with  intussus- 
ception, clysters  are  often  administered  with  difficulty,  and  are  quickly  and 
forcibly  returned,  on  account  of  the  resistance  opposed  by  the  invaginated 
mass.  We  have  stated  above  that  the  seat  and  even  extent  of  displacement 
can  be  ascertained  in  a  large  proportion  of  cases  by  digital  examination  of 
the  abdominal  walls.  The  tumor  can  be  felt  hard,  enlongated,  and  tender  on 
pressure,  so  that  the  diagnosis  is  clear.  If  the  invagination  have  extended 
to  the  lower  part  of  the  large  intestine,  it  can  usually  be  discovered  by  an 
examination  per  rectum. 

Duration. — In  the  following  table  the  duration  of  the  intussusception 
in  49  cases   is  given   as  nearly  as  it  can  be  ascertained  from  the  records : 


2  died  the  1st  day. 


6 

"   2d 

14 

"   3d 

2 

"   4th 

5 

"   oth 

2 

"   6th 

2 

"   7th 

1  lived  over  a  week. 


1  died  the    8th  day. 

1     "       "    10th     " 

1     "       "   14th     " 

1  lived  nearly  a  week,  the  exact 

time  not  being  given. 
1  lived  six  weeks. 
3,  time  of  death  not  given. 
7  recovered. 


INTUSSUSCEPTION  IN  THE  LARGE  INTESTINES.  847 

In  2  of  the  3  cases  in  which  the  duration  is  not  stated  the  patient  lived  much 
longer  than  the  usual  period.  One  of  these  2,  a  girl  of  six  years,  having 
eaten  raw  carrots,  was  seized  with  pain  in  the  abdomen,  which  lasted  eight 
months,  when  she  died.  During  the  last  three  months  she  passed  mucus 
and  blood.  In  this  case  the  ciccum  had  descended  to  the  anus,  drawing  with 
it  the  ileum,  which  remained  pervious.  The  symptoms  indicated  the  con- 
tinuance of  the  invagination  for  three  months,  if  not  eight.  The  other 
patient  was  -a  boy  aged  three  years  and  four  months,  who  complained  of  pain 
in  the  abdomen  for  many  months,  and  occasionally  vomited.  During  the  la.st 
six  weeks  of  his  life  all  the  phenomena  of  invagination  were  present.  In 
this  case  also  the  inverted  caput  coli  had  descended  the  entire  length  of  the 
colon,  and  at  the  autopsy  it  lay  in  the  rectum. 

In  West's  Treatise  on  Diseases  of  Children  (5th  ed.,  1866,  p.  504)  it  is 
stated  that  death  in  this  complaint  always  occurs  within  a  week.  The  above 
statistics,  however,  show  that  there  are  exceptions  to  this  statement,  although 
a  large  majority  do  die  within  the  first  seven  days.  In  33  of  the  cases 
embraced  in  my  statistics  death  occurred  within  the  first  week,  and  in  no 
fatal  case  in  which  strangulation  was  complete  was  life  prolonged  beyond  the 
eighth  day.  In  these  cases  of  complete  strangulation  the  average  duration 
was  3.7  days,  and  the  largest  number  of  deaths  occurred  on  the  third  day. 
Death  on  the  first  day  is  rare,  but  it  occurred  in  two  of  the  cases  embraced 
in  my  statistics.  Death  at  so  early  a  period  usually  takes  place  in  convul- 
sions and  coma. 

Prognosis. — Intussusception  is  in  its  nature  so  grave  an  accident  that  the 
physician  called  to  a  case  should  always  explain  its  gravity  to  the  friends. 
But,  while  death  is  the  common  result,  there  are  three  different  modes  of 
termination  in  which  life  is  preserved  :  First,  the  reduction  of  the  incarcerated 
intestine,  with  immediate  relief.  There  can  be  no  doubt  that  it  is  possible  for 
intussusception,  when  recent,  to  be  reduced  by  the  unaided  action  of  the 
bowels,  in  the  same  way  as  the  common,  simple  intussusception  in  the 
jejunum  and  ileum  or  as  hernia  is  reduced,  through  the  vermicular  action 
of  the  intestines ;  for  sometimes,  as  in  Dr.  Coggswell's  ^  case,  the  patients  at 
some  previous  time  have  experienced  the  same  symptoms  as  those  which 
accompanied  the  attack,  and  which  subsiding  they  remained  for  a  time  in 
perfect  health.  This  termination  is  probably  rare  if  the  symptoms  be 
sufficiently  marked  to  necessitate  treatment.  Again,  the  intussusception  may 
be  cured  by  early  and  well-applied  treatment.  The  physician  often  succeeds 
in  reducing  the  displaced  intestine,  even  if  the  intussusception  be  in  the 
upper  part  of  the  colon,  if  he  be  called  sufiiciently  early  and  employ  the 
proper  measures. 

A  second  mode  of  favorable  termination  is  alluded  to  by  certain  foreign 
writers.  The  intussusception  continues  for  a  considerable  period  with  the  cha- 
racteristic symptoms,  and  then,  as  Bouchut  expresses  it,  "  the  vomitings  grad- 
ually cease,  the  intestinal  hemorrhage  disappears,  the  strength  returns,  and 
the  health  becomes  restored  without  the  expulsion  of  fragments  of  the  intes- 
tine." What  changes  the  displaced  intestine  undergoes  in  these  protracted 
cases,  which  gradually  recover  \vithout  sloughing,  have  not  been  clearly  ascer- 
tained, although  they  have  been  the  subject  of  conjecture.  According  to 
Rilliet,  a  large  proportion  of  favorable  cases  terminate  in  this  manner.  It 
does  not  appear,  however,  from  the  statistics  which  I  have  collected  that  this 
is  a  common  mode  of  recovery.  The  clinical  history  of  intussusception  estab- 
lishes the  fact  that  in  a  large  majority  of  protracted  cases  there  is  either  death 
or  the  third  mode  of  favorable  termination — namely,  by  sloughing. 

But  we  cannot  reasonably  expect  recovery  in  young  children  through 
'  Loridon  Lancet,  July,  1853. 


848  INTUSSUSCEPTION. 

sloughing  and  the  expulsion  of  the  intestine,  since  few  have  the  requisite 
strength  for  so  tedious  and  exhaustive  a  process.  The  youngest  child  that 
recovered  in  this  way,  so  far  as  I  have  been  able  to  ascertain,  was  an  infant 
thirteen  months  old,  whose  case  was  reported  by  M.  Marage.  With  the 
exception  of  this  case  the  youngest  was  a  boy  aged  five  years.  The  older 
the  child  the  greater,  of  course,  the  power  of  endurance  and  the  better  the 
prospect  of  recovery.  Of  the  52  cases  whose  records  I  have  collated,  7 
recovered  by  the  sloughing  and  expulsion  of  the  mass.  These  children  were 
of  the  ages  of  five,  six,  six,  nine,  eleven,  twelve,  and  twelve  years.  The  sep- 
aration of  the  invaginated  mass  occurred  in  six  of  these  between  the  sixth 
and  twelfth  days,  with  an  average  of  nine  and  a  half  days.  In  the  remain- 
ing case  the  time  is  not  given.  If,  then,  the  patient  can  be  carried  through 
the  first  week  without  too  much  exhaustion,  discharge  of  the  slough,  reopen- 
ing of  the  bowels,  and  ultimate  recovery  may  possibly  be  the  result. 

But  in  those  cases  in  which  the  intussusception  remains  open,  so  as  to 
allow  the  passage  of  fecal  matter,  recovery  is  improbable  unless  the  displace- 
ment be  diagnosticated  early  and  properly  treated.  If  the  intussusception 
continue,  it  becomes  greater  and  greater  from  the  absence  of  strangulation. 
Without  inflammation  and  with  little  or  no  congestion  of  the  displaced  por- 
tion, and  without  the  severe  symptoms  which  occur  in  ordinary  cases,  the 
patient  wastes  away,  having  irregular  evacuations  and  more  or  less  abdominal 
pain,  and  finally  dies  in  a  state  of  emaciation  and  weakness.  In  the  early 
stage  of  this  form  of  displacement  it  is  not  improbable  that  injections  or 
inflation,  employed  with  sufficient  force,  will  give  relief,  but  if  the  early 
period  pass  without  such  treatment  cure  is  impossible  by  the  ordinary 
methods.  It  is  in  such  instances  especially — to  wit,  those  in  which  the 
displacement  occurs  without  strangulation  or  inflammation,  and  in  which 
fecal  matter  passes  through  the  displaced  mass  more  or  less  freely — that 
laparotomy  is  justifiable,  and  is  likely  to  give  relief  when  injections  and 
inflation  have  been  employed  in  vain.  Jonathan  Hutchinson's  successful 
performance  of  this  operation  in  a  child  of  two  years  who  had  this  kind  of 
displacement  is  known  to  most  readers.' 

The  prognosis  is  most  favorable  when  the  displacement  occurs  in  the 
lower  part  of  the  large  intestine,  for  its  reduction  is  then  comparatively  easy. 
An  interesting  case  of  this  kind  was  observed  and  treated  by  Drs.  O'Dwyer, 
Keid,  and  myself  in  the  New  York  Foundling  Asylum  in  1875.  The  child 
was  a  female  aged  two  years,  and  had  had  previous  good  health.  The 
invaginated  mass  protruded  like  a  prolapse  about  four  inches  outside  of  the 
anus.  It  was  cold,  considerable  hemorrhage  had  occurred  from  it,  and  the 
infant  seemed  in  collapse.  When  the  mass  was  returned  so  far  as  it  could 
be  carried  within  the  pelvis  by  the  index  finger,  the  lower  end  of  it  could 
still  be  felt  like  an  os  uteri.  It  protruded  four  or  five  times  within  twenty- 
four  hours,  but  by  replacement  so  far  as  possible  with  the  fingers  and  the  use 
of  simple  water  injections,  with  the  hips  elevated,  it  was  finally  permanently 
reduced,  and,  with  the  use  of  stimulants,  she  soon  fully  recovered. 

Mode  op  Death. — This  is  diff'erent  in  difi'erent  cases.  It  sometimes 
occurs  from  collapse.  At  a  meeting  of  the  New  York  Pathological  Society, 
held  December  10,  1873,  I  presented  a  specimen,  showing  intussusception 
occurring  about  one  foot  above  the  ileo-csecal  valve  in  an  infant  aged  thirteen 
months.  On  the  day  before  its  death,  its  previous  health  having  been  good, 
it  seemed  ill,  and  vomited  once  or  twice,  but  did  not  appear  to  be  in  pain.  It 
had  two  evacuations  from  the  bowels,  of  the  usual  appearance,  in  the  latter 
part  of  the  day.  On  the  following  morning  it  was  unexpectedly  in  collapse, 
and  died  within  about  twenty-four  hours  from  the  commencement  of  the  sick- 
^  London  Lancet,  November  22,  1873. 


INTUSSUSCEPTION  IN  THE  LARGE  INTESTINES.  84!) 

ness.  At  tlie  post-mortem  examination  the  cranium  was  not  opened,  l)ut  all 
the  organs  of  the  trunk  were  found  normal  except  the  intussusception.  The. 
mass  involved  in  the  displacement  measured  two  and  a  half  inches  in  lentrth 
and  was  slightly  crescentic.  The  mucous  membrane  above  and  below  it  had 
the  normal  appearance,  as  had  that  of  the  external  or  incarcerating  portion  of 
the  mass,  while  that  of  the  incarcerated  part  was  deeply  injected.  Water 
poured  into  the  intestine  above  the  invagination  was  wholly  arrested  by  it.' 
liut  in  the  majority  of  instances  death  occurs  from  asthenia,  which  comes  on 
gradually,  but  increases  rapidly  in  consequence  of  the  pain,  vomiting,  and 
imperfect  nutrition.  Children  dying  in  this  way  may  have  convulsive 
movements  more  or  less  marked,  but  the  prevailing  characteristic  as  death 
approaches  is  extreme  exhaustion.  In  exceptional  instances  the  life  of  the 
.sufferer  is  cut  short  by  convulsions  before  the  stage  of  exhaustion  is  reached. 
Thus  a  child  aged  three  years,  whose  case  was  reported  by  Dr.  Isaac  Thomas,'^ 
and  another,  aged  two  years,  whose  case  was  reported  by  Dr.  Coggswell,'*  died 
in  convulsions  on  the  second  day. 

TreaTiMent. — It  is  unfortunate  in  cases  of  intussusception  that  the  time 
in  which  treatment  can  be  of  most  service  is  likely  to  pass  by  before  the  true 
condition  of  the  intestine  is  detected.  Invagination  being  comparatively  rare, 
the  patient  is  generally  on  the  first  day  treated  for  colic  or  dysentery  or  some 
other  common  affection  of  the  bowels ;  and  it  is  often  not  till  the  second  day, 
when  the  intestine  has  become  incarcerated,  that  the  physician  accurately  diag- 
nosticates the  disease.  The  purgative  medicines  often  given  in  the  commence- 
ment injure  the  patient.  In  fact,  both  reason  and  experience  teach  us  the 
impropriety  of  using  purgatives  in  this  complaint.  Cathartic  remedies  act  as 
a  vis  d  tergo,  and  may  cause  still  further  descent  of  the  inverted  intestine. 
Yet  such  powerful  agents  of  this  class  as  quicksilver  have  been  employed. 
It  was  administered  in  two  doses  of  one  ounce  each  in  one  of  the  cases 
embraced  in  my  statistics,  but  none  of  the  mineral  passed  the  bowels.  At 
the  post-mortem  examination  a  considerable  part  of  it  was  found  in  small 
globules,  coated  with  a  black  layer  consisting  of  the  sulphuret  or  black  oxide 
of  mercury,  in  the  intestine  above  the  intussusception.  It  need  not  be  added 
that  the  case  was  speedily  fatal. 

The  proper  treatment  of  intussusception  consists  in  attempts  to  reduce 
the  displacement  by  pressure  from  below.  The  pressure  may  be  applied 
either  by  licjuid  injections  into  the  rectum  or  by  inflation  of  the  lower  intes- 
tine by  air  or  gas. 

Injections  should  be  made  with  lukewarm  water,  for  cold  or  hot  water 
may  cause  contraction  of  the  muscular  fibres  of  the  intestine  and  increase 
the  constriction.  The  child  should  be  placed  in  bed  or  in  the  nurse's  lap, 
with  the  nates  elevated  45°.  With  the  common  India-rubber — or,  better, 
the  fountain-syringe — and  the  aid  of  an  assistant  the  liquid  should  be  gently 
thrown  into  the  rectum  until  the  abdomen  is  fully  distended.  By  carry- 
ing the  fingers,  firmly  but  gently  applied  upon  the  abdominal  walls,  along  the 
direction  of  the  colon,  the  liquid  is  made  to  press  against  the  lower  end  of 
the  intussusception.  The  same  gentleness  and  perseverance  are  required  in 
kneading  and  pressing  the  abdominal  walls  as  in  the  treatment  of  hernia  by 
taxis.  If  the  invagination  be  in  the  descending  colon,  probably  only  a  small 
quantity  of  the  liquid  can  be  injected,  and  it  may  be  forcibly  returned,  but 
by  repeating  the  injections  a  sufficient  quantity  can  ordinarily  be  introduced 
to  obtain  the  full  effect  of  the  mode  of  treatment.  There  is  also  sometimes 
an  increased  irritability  of  the  rectum,  even  when  the  intussusception  is  at 
the  upper  extremity  of  the  large  intestine,  so  that  tenesmus  and  expulsive 

'  New  York  Medical  Record,  April  1,  1874.  ^  Amer.  Med.  Recorder,  1823. 

^London  Lancet,  July,  1853. 

54 


850  INTUSSUSCEPTIOA\ 

efforts  follow  the  introduction  of  the  instrument.  The  assistant  can  aid  in 
overcoming  this  and  in  retaining  the  water  by  pressing  the  soft  parts  of  the 
nates  around  the  instrument. 

If  the  injection  fail  to  reduce  the  displacement,  it  may  be  repeated  after 
allowing  the  patient  to  rest  for  a  while.  In  the  New  York  Medical  Journal 
for  May,  1875,  is  the  history  of  an  interesting  case  which  was  treated  by  Drs. 
Church  and  Warren  of  this  city,  and  is  reported  by  the  latter.  The  infant 
was  seven  months  old  and  had  the  usual  symptoms,  such  as  frequent  parox- 
ysmal pain  in  the  abdomen,  vomiting,  tenesmus,  scanty  muco-sanguineous 
stools.  On  the  third  day  injections  were  twice  employed  without  result,  but 
on  the  fourth  day  an  injection  of  ten  or  twelve  ounces  reduced  the  displace- 
ment and  the  infant  recovered.  In  a  second  case  treated  by  Dr.  Warren  the 
age  was  nine  months,  and  a  tumor  appeared  a  little  above  the  umbilicus  a  few 
hours  after  the  commencement  of  the  symptoms.  The  following  is  Dr.  War- 
ren's account  of  this  interesting  case,  which  will  give  a  clear  idea  of  the  proper 
mode  of  treatment : 

"  The  patient  was  looking  very  pale  and  prostrated,  the  pulse  was  quick 
and  feeble,  and  the  skin  cold.  I  at  once  determined  to  use  fluid  injections^ 
and,  with  the  little  patient  placed  in  a  semi-prone  position  in  his  mother's  lap, 
with  an  ordinary  Davidson's  syringe  I  commenced  injecting  tepid  soap  and 
water,  but  after  perhaps  a  gill  had  been  thrown  into  the  rectum  it  was  almost 
immediately  rejected,  very  highly  colored  with  blood,  and  mixed  with  it  a  very 
small  quantity  of  mucus  and  fecal  matter ;  the  latter,  by  the  way,  not  hard- 
ened, but  of  the  consistency  of  soft  putty.  In  a  second  attempt  the  fluid 
was  retained  longer,  but  was  after  a  little  while  discharged,  with  more  blood 
and  mucus,  but  with  much  less  tenesmus  and  pain. 

"  When,  soon  after,  I  made  my  third  attempt,  the  child's  chest  was  rested 
upon  the  side  of  its  mother's  lap,  with  the  lower  extremities  elevated  by  an 
assistant,  so  that  the  position  was  at  an  angle  of  about  45°,  anus  upward. 
This  time  I  injected  the  fluid  very  slowly,  in  order  to  avoid,  if  possible,  the 
irritation  caused  generally  by  the  frequent  emptying  and  refilling  of  the 
syringe  (which,  by  the  way,  is  a  very  serious  hindrance  to  the  successful  use 
of  this  syringe,  and  which  renders  it  much  inferior  to  the  fountain  or  hydro- 
static). In  this  manner  I  succeeded  in  injecting,  as  I  estimated  at  the  time, 
perhaps  ten  or  twelve  ounces,  and  during  the  operation  the  child  gradually 
became  more  quiet,  and  had,  when  I  ceased,  fallen  asleep.  Then,  with  the 
direction  that  occasional  doses  of  tinct.  opii  camph.  should  be  administered 
during  the  night,  to  control,  if  possible,  the  peristaltic  action  of  the  intes- 
tines, I  left  him. 

"  On  the  following  morning,  to  my  surprise,  I  found  the  child  sleeping 
quietly  and  naturally,  and  I  was  informed  that  at  about  5  A.  M.  (six  hours 
after  my  visit)  he  had  a  movement  of  the  bowels,  which  was  saved  for  my 
inspection,  and  consisted  simply  of  the  enema,  slightly  colored  with  fecal 
matter.  From  that  time  he  seemed  to  be  entirely  free  from  pain,  and  six  or 
seven  hours  later  had  a  natural  passage,  after  which  recovery  progressed 
rapidly,  and  in  a  few  days  he  was  discharged   well." 

The  following  case  is  interesting  as  showing  success  from  the  use  of 
injections  after  the  lapse  of  two  days  in  a  severe  case  which  had  resisted 
treatment  on  the  first  day.  The  good  result  was  apparently  in  great  part  due 
to  the  manipulation,  which  was  made  so  as  to  press  the  water  against  the 
course  which  intussusceptions  are  known   to  take. 

On  September  10,  1876,  I  visited,  with  Dr.  Gillette,  a  nursing  infant  aged 
nine  months  whose  history  was  as  follows :  It  was  habitually  constipated,  but 
it  continued  in  its  usual  health  till  September  8th,  on  which  day  it  was  carried 
by  its  nurse  to  one  of  the  city  parks.     After  its  return  it  began  to  be  fretful  ^ 


INTUSSUSCEPTION  IN  THE   LARdK  INTESTINES.  80 1 

it  vomited  and  .seeiiied  to  b(!  in  pain.  It  continued  to  vomit  frequently,  espe- 
cially after  nursing  or  taking  drinks,  and  in  the  ensuing  night  passed  two 
scanty  stools  of  mucus  and  blood  without  fecal  matter.  In  the  morning  of 
September  'Jth,  Dr.  G.  was  summoned,  who  found  the  pulse  180  and  tem- 
perature 102°,  and  the  matter  vomited  greenish  like  bile.  In  the  evening  the 
temperature  was  1(>2:|°.  Dr.  (J.  diagnosticated  intussusception,  and  employed 
injections  of  water,  but  they  were  returned  without  bringing  fecal  matter  and 
without  apparent  result.      lie  also  admini.stered  opiates  by  the  mouth. 

September  10th,  temperature  102]°  ;  features  pallid,  beginning  to  have  a 
pinched  or  sunken  appearance,  and  indicative  of  much  suffering;  no  nutri- 
ment is  apparently^  retained,  on  account  of  the  frequent  vomiting,  and  the 
bowels  are  obstinately  constipated.  As  the  symptoms  indicated  rapid  sink- 
ing and  collapse,  consultation  was  called  at  4  P.  M.  It  was  impossible  to 
determine  certainly,  through  the  abdominal  walls,  on  account  of  the  disten- 
sion, whether  there  was  any  tumor,  but  it  was  my  opinion  and  the  opinion  of 
one  of  the  other  phy.sicians  that  a  tumor,  hard  and  inelastic,  could  be  felt 
nearly  in  the  median  line  between  the  umbilicus  and  the  symphysis  pubis. 
At  about  5  P.  M.  the  shoulders  of  the  little  patient  were  lowered  and  the 
nates  elevated,  so  that  the  trunk  formed  an  angle  of  perhaps  45°  with  the 
horizontal,  and  a  large  quantity  of  tepid  water  was  gently  passed  into  the 
intestine  through  Davidson's  syringe,  with  the  vaginal  nozzle  attached.  It 
was  impossible  to  estimate  the  quantity  retained,  since  a  considerable  part  of 
it  escaped,  although  the  anus  was  firmly  pressed  around  the  instrument. 

When  the  abdomen  was  distended  as  fully  as  seemed  justifiable,  the  nates 
being  still  elevated,  and  the  liquid  retained,  so  far  as  possible,  by  firm  pres- 
sure upon  the  anus,  the  abdomen  was  firmly  and  deeply  kneaded  by  the 
hand,  the  movements  being  made  chiefly  from  the  right  lumbar  toward  the 
right  inguinal,  and  from  the  right  inguinal  toward  the  hypogastric  region. 
The  kneading  was  continued  perhaps  eight  or  ten  minutes,  and  the  water, 
which  contained  no  perceptible  amount  of  fecal  matter,  blood,  or  mucus,  was 
allowed  to  escape. 

After  this  operation  the  child  became  quiet,  slept,  and  the  vomiting 
ceased.  At  our  next  visit,  at  7  P.  m.,  although  the  severe  symptoms  had 
in  a  great  part  abated  and  the  countenance  had  lost  that  pinched  and  suffer- 
ing aspect  which  was  so  prominent  before,  it  was  deemed  best,  in  consulta- 
tion, to  repeat  the  injection,  and  this  time  through  a  rectal  tube,  which  was 
introduced  farther  than  the  nozzle  employed  at  the  preceding  visit.  The 
body  was  placed  in  the  same  position  as  before  and  the  abdomen  kneaded  in 
the  .same  manner.  The  water,  when  allowed  to  return,  brought  no  fecal  mat- 
ter, but  the  last  that  flowed  contained  two  shreds,  the  largest  about  one  inch 
in  length  by  two  lines  in  width,  resembling  matted  and  nucleated  epithelial 
cells.  It  was  believed  that  they  were  composed  of  such  cells,  with  perhaps 
some  of  the  mucous  membrane  to  which  they  were  attached,  and  that  they 
were  detached  from  the  invaginated  portion.  An  opiate  mixture  was  now 
prescribed,  to  be  given  sufficiently  often  to  relieve  any  restlessness  and  keep 
the  patient  quiet,  and  a  flaxseed  poultice  was  applied  over  the  abdomen. 
On  the  following  day  the  temperature  was  103y°,  pulse  158,  and  the  abdo- 
men somewhat  distended  ;  but  the  vomiting  had  ceased  and  there  had  been 
two  fecal  evacuations  since  our  last  visit.  The  intussusception  had  been 
relieved,  the  inflammatory  symptoms  soon  abated,  and  the  infants  health  was 
fully  restored. 

Groodhart  reports  a  case  of  cure  by  injecting  a  boracic-acid  solution  after 
the  symptoms  had  continued  seventy-.six  hours.  The  patient's  age  was  eight 
months,  and  the  tumor  could  be  felt  per  rectum.'     Humphreys  relates  two 

^  Lnndon  Lancet,  Feb.  25,  1888. 


852  INTUSSUSCEPTION. 

cases  of  recovery  by  injection  of  water  thirteen  and  forty  hours  after  the 
commencement  of  symptoms  in  infants  of  eight  months  and  two  years/ 
Butler  also  succeeded  by  water  injections  in  reducing  intussusception  of 
thirty-six  hours'  continuance  in  a  child  of  three  years.'"*  But  injections  of 
water  have  not  always  been  successful.  Chaffey  failed  to  reduce  invagination 
of  the  caecum  and  appendix  in  a  "  somewhat  chronic  "  case,  but  inflammatory 
bands  were  found  in  their  vicinity,^  and  Cripps  ruptured  the  intestine  by 
injecting  water  in  a  girl  of  eighteen  months.  The  symptoms  had  continued 
four  or  five  days,  and  the  tumor  projected  from  the  anus. 

Injections,  in  order  to  be  effectual  and  give  promise  of  success,  should  be 
aided  by  gravitation.  The  physician  should  remember  to  elevate  the  nates 
higher  than  the  shoulders,  as  in  the  case  related  above.  Treatment  by  infla- 
tion— which  indeed  ought  to  occur  to  any  intelligent  physician  appreciating 
the  anatomical  condition  of  the  parts  as  deserving  of  trial — was  prominently 
brought  to  the  notice  of  the  profession  in  modern  times  by  Mr.  Samuel 
Mitchell.*  "  I  take  the  liberty,"  he  writes,  "  of  suggesting  to  the  profession, 
through  the  medium  of  your  valuable  periodical,  the  trial  of  inflating  the 
bowels  by  means  of  a  glyster-pipe  attached  to  a  common  pair  of  bellows ;  it 
has  fallen  to  my  lot  to  witness  several  of  these  most  distressing  cases  in  chil- 
dren ;  the  nature  of  the  obstruction  was  foretold  during  life,  and  unfortu- 
nately verified  by  post-mortem  examination.  The  last  case  of  the  kind  which 
came  under  my  care,  about  two  years  since,  presented  all  the  usual  symp- 
toms— intolerable  restlessness,  the  most  obstinate  sickness,  the  singularly  dis- 
tressed state  of  countenance,  and  shrunken  features.  The  usual  remedies 
were  had  recourse  to — viz.  warm  baths,  glysters,  anodyne  frictions  over  the 
abdomen,  etc. — but  without  avail.  As  a  forlorn  hope  I  made  trial  of  infla- 
tion by  the  above  means,  with  the  most  happy  result.  The  sickness  imme- 
diately ceased ;  the  child  within  an  hour  passed  a  natural  stool,  and  in  the 
morning  was   almost  without  ailment." 

This  mode  of  treatment  is  termed  novel  in  the  Lancet,  but  it  is  really  as 
old  as  the  time  of  Hippocrates,  who  speaks  of  throwing  air  into  the  bowels, 
by  which  flatulence  is  imitated  (flatus  immitatur).*  Haller  ^  also  recom- 
mended the  same  treatment :  "  Flatus  etiam  immissus  celerrime  susceptionem 
dispellet."  Dr.  David  Greig '  relates  five  cases  of  successful  treatment  of 
intussusception  by  inflation.  The  first,  an  infant  six  months  old,  previously 
in  good  health,  suddenly  became  very  fretful,  apparently  having  severe 
paroxysmal  pain  in  the  abdomen.  She  had  vomiting,  and  finally  tenesmus, 
with  bloody  evacuations.  Warm-water  enemata  could  not  be  employed,  on 
account,  the  writer  thinks,  of  the  spasmodic  action  of  the  intestines,  and  an . 
abdominal  tumor  could  be  felt  near  the  umbilicus.  Castor  oil  and  a  purga- 
tive powder  and  enemata  of  water  having  been  employed  in  vain,  and  the 
case  becoming  really  critical  on  the  second  day,  inflation  was  resorted  to. 
The  writer  says :  "  The  nozzle  of  a  small  pair  of  bellows  was  introduced  into 
the  anus,  and  air  injected  to  a  considerable  extent.  Contrary  to  our  expecta- 
tion, the  air  passed  readily  into  the  bowel,  and  seemed  to  give  the  child  great 
relief.  After  the  injection  it  lay  very  quiet,  as  if  asleep,  and  evidently  quite 
free  from  pain.  In  about  twenty  minutes  from  the  time  the  air  injection  was 
administered  a  slight  rumbling  noise  was  heard  in  the  child's  abdomen,  fol- 
lowed by  a  crack  so  loud  and  distinct  as  to  alarm  the  attendants  in  the  room, 
who  thought  something  had  burst  in  the  child's  bowels.     The  child,  however, 

1  London  Lancet,  Oct.  27,  1888.  *  Brooklyn  Med.  Jour.,  Feb.,  1888. 

3  London  Lancet,  July  7,  1888.  *  Ibid.,  for  March  17,  1838. 

^  Hippocrates'  Works,  translated  from  the  Greek  by  Grimm,  4  Bd.,  p.  198. 

*  Physiologia  Corporis  Humani,  torn.  vii.  p.  95. 

'  Edinburgh  Medical  Journal,  October,  1864. 


INTUSSUSCEPTION  IN  THE  LARGE  INTESTINES.  853 

continued  as  if  asleep  and  free  from  pain,  and  in  about  half  an  hour  a  large 
feculent  stool,  slightly  mixed  with  blood  and  mucus,  was  passed  without  pain. 
During  the  night  the  child  rested  pretty  well,  had  no  return  of  vomiting,  took 
the  breast  as  usual,  and  in  two  days  was  quite  well." 

Another  child,  nine  months  old,  treated  by  Dr.  Oreig,  presenting  nearly 
the  same  symptoms  and  the  abdominal  tumor,  also  obtained  relief  by  inflation 
after  castor  oil  and  enemata  had  failed  to  produce  any  benefit. 

An  apparatus  for  the  production  and  injection  of  carbonic-acid  gas  has 
been  invented  by  Schultz  &  Warker  of  this  city,  and  is  manufactured  by 
them.  It  consists  essentially  of  two  glass  chambers,  one  over  the  other.  In 
the  lower  one  a  bicarbonate  is  placed,  and  in  the  upper  an  acid  in  a  liquid 
state.  By  the  gradual  admixture  of  the  two,  carbonic  acid  is  set  free.  An 
elastic  tube  conveys  the  gas  from  the  lower  chamber.  This  apparatus  has 
been  used  by  physicians  of  this  city  for  the  reduction  of  intussusception  and 
other  purposes,  and  is  a  useful  invention. 

The  same  firm  and  several  others  in  this  city  prepare  for  the  shops  large 
bottles  of  highly-charged  carbonic-acid  water,  from  which,  when  inverted, 
a  powerful  current  of  the  gas  can  be  obtained.  Two  or  three  of  these  bot- 
tles, with  a  portion  of  the  tube  from  Davidson's  syringe,  which  can  be  readily 
attached  to  the  stem  from  which  the  gas  escapes,  constitute  all  that  is  required 
for  an  ordinary  case. 

The  following  cases,  which  I  have  treated  with  Dr.  Biichler  of  this  city  in 
1871,  show  what  may  be  achieved  by  inflation,  and  also  the  unfavorable 
result  which  must  inevitably  occur  in  certain  cases.  A  German  infant  five 
months  old,  nursing,  began  to  be  fretful,  crying  often,  on  March  7th,  and 
before  night  passed  a  scanty  motion  of  blood.  The  symptoms  continuing,  I 
was  asked  to  examine  the  infant  on  the  10th,  and  learned  the  following  facts : 
It  had  vomited  daily,  had  had  daily  scanty  but  infrequent  stools,  consisting 
chiefly  of  blood,  accompanied  at  first  by  tenesmus,  but  not  within  the  last 
day ;  it  continued  to  nurse,  but  was  becoming  thinner  and  weaker,  and  was 
evidently  in  pain.  The  symptoms  indicating  the  nature  of  the  disease,  the 
abdomen,  which  was  not  distended,  was  examined  for  the  tumor,  which  was 
found  in  the  right  side  in  the  site  of  the  ascending  colon,  apparently  about 
one  and  a  half  to  two  inches  in  length  ;  pulse  124  in  sleep  ;  no  cough.  An 
ineff'ectual  attempt  was  made  to  reduce  the  intussusception  by  a  very  rude 
and  imperfectly  constructed  apparatus  (the  bellows),  when  from  the  lateness 
of  the  hour  further  treatment  was  postponed  till  early  the  following  morning. 
11th.  Tumor  still  detected  in  the  right  lumbar  region;  pulse  120  asleep, 
150  awake.  By  means  of  Schultz  &  Warker's  apparatus  the  intestines  were 
inflated  so  as  to  produce  very  decided  prominence  of  the  abdomen,  and  the 
abdomen  gently  kneaded.  After  some  minutes  the  gas  was  allowed  to  escape, 
when  the  tumor  had  disappeared.  In  a  few  hours  a  natural  evacuation 
occurred  from  the  bowels,  and  the  infant  has  remained  well  since. 

The  second  case  ended  unfavorably,  although  the  symptoms  were  appar- 
ently no  more  grave  than  in  the  case  just  related  and  had  continued  a  shorter 
time.  This  infant  was  also  of  German  parentage.  The  tumor,  firm  and 
elongated,  could  be  distinctly  felt  in  the  left  lumbar  region.  In  this  case  the 
inverted  bottles  of  carbonic-acid  water  were  employed,  and  when,  after  con- 
siderable delay  and  kneading  of  the  abdomen,  the  gas  was  allowed  to  escape 
from  the  intestine,  the  tumor  had  disappeared.  A  few  hours  afterward  con- 
vulsions occurred,  ending  fatally.  At  the  autopsy  the  invaginated  mass, 
which  was  too  firmly  strangulated  to  admit  of  reduction  by  inflation,  was 
found  in  the  epigastric  region,  having  been  carried  up  from  its  ibrmer  posi- 
tion by  the  inflation  of  the  intestine  below.  It  consisted  of  the  terminal 
part  of  the  ileum,  which  had  passed  through  the  ileo-caecal  orifice,  and  had 


854  INTUSSUSCEPTION. 

become  incarcerated  in  the  ascending  colon,  and,  as  is  not  unusual  in  these 
cases,  the  movements  of  the  intestines  had  changed  the  location  of  the  tumor 
in  the  abdomen  from  the  right  to  the  left  side.  In  the  London  Lancet  for 
Feb.  18,  1888.  Cheadle  reports  a  case  of  successful  inflation  in  an  infant  of 
fifteen  months,  whose  symptoms  indicated  intussusception  of  fifteen  hours' 
duration,  and  the  tumor  could  be  felt  per  rectum.  Higginson  also  reduced 
an  intussusception  by  inflation.  The  patient,  an  infant  of  seven  months,  had 
symptoms  of  intusseeption  three  days,  and  the  tumor  could  also  be  felt  per 
rectum.^ 

Whether  air  or  carbonic  acid  be  employed,  it  is  necessary  to  produce  dis- 
tension of  the  intestine  to  its  fullest  extent  below  the  seat  of  the  complaint 
without  endangering  rupture,  and  of  course  the  sooner  it  is  used  the  better 
the  chance  of  success.  In  a  few  days  the  displaced  intestine  has,  in  a  large 
proportion  of  cases,  become  so  firmly  incarcerated,  and  has  descended  so  far, 
that  attempts  to  replace  it,  either  by  injections  or  inflation,  are  unsuccessful ; 
still,  even  at  a  late  period  a  persevering  attempt  should  be  made  if  it  have 
not  previously  been  tried.  During  the  four  years  which  have  elapsed  since 
the  publication  of  the  sixth  edition  of  this  treatise  in  1886,  I  have  treated 
successfully  three — I  think  I  may  say  four — cases  of  intussusception  in  infants 
by  frequent  rectal  injections  of  warm  water  as  large  as  could  be  given,  and 
followed  by  kneading  of  the  abdomen.     The  youngest  of  these  infants  was 

Geo.  H.  Mc ,  male,  aged  four  months,  nursing,  to  whom  I  was  called  on 

Dec.  24,  1886.  He  had  been  very  fretful  since  Dec.  22d,  had  the  last  fecal 
evacuation  on  the  morning  of  Dec.  23d,  and  had  since  passed  stools  of  mucus 
and  blood  without  the  least  fecal  matter.  Enemata  of  warm  water  as  large 
as  possible  were  given  every  hour  to  two  hours  with  the  nates  raised,  and 
were  followed  by  kneading  the  abdomen.  The  fretfulness  was  always  less 
after  these  enemata.  On  Dec.  26th  the  temperatui'e  fell  from  1015°  to  nor- 
mal, and  a  fecal  evacuation,  the  first  in  three  days,  occurred.  From  this  time 
the  infant  was  well.  The  vomiting,  which  had  been  frequent  since  the  22d, 
ceased  on  the  26th.  The  mother  stated  that  the  tenesmus,  which  had  been 
a  distressing  symptom,  was  uniformly  less  after  the  injections.  My  experi- 
ence during  the  last  ten  years  with  cases  of  intussusception  incline  me  more 
and  more  to  the  belief  that  copious  and  frequent  warm-water  injections, 
employed  in  the  manner  described  above,  are  more  likely  to  give  relief  than 
any  other  mode  of  treatment.  But  it  is  proper  that  I  should  state  that  dur- 
ing this  time  I  have  seen  cases  that  were  fatal  in  which  this  and  other  modes 
of  treatment,  including  laparotomy,  were  employed. 

If  the  modes  of  treatment  which  I  have  recommended  above  fail  to  give 
relief  when  perseveringly  and  sufiiciently  employed  in  a  case  of  acute  intus- 
susception, the  patient's  state  is  one  of  extreme  peril  and  the  prognosis  is 
unfavorable.  Yet  recovery  is  possible  in  one  of  two  ways — namely,  first, 
by  incision  through  the  abdominal  walls  (laparotomy),  and  reduction  of  the 
displacement  by  the  fingers  within  the  abdominal  cavity  ;  and  secondly,  by 
sloughing  of  the  invaginated  mass  and  union  by  adhesive  inflammation  of 
the  ends  of  the  intestine  which  have  preserved  their  vitality.  Cripps  relates 
a  remarkable  case  of  spontaneous  cure  in  an  infant  of  seven  months.  It  had 
been  two  weeks  sick,  with  vomiting  and  alvine  discharges  of  blood  and  mucus, 
when  presented  for  examination.  A  portion  of  the  large  intestine,  gan- 
grenous, protruded  from  the  rectum.  This  was  cut  off",  and  portions  of 
sloughy  substance  were  removed  daily  for  a  month  afterward,  when  the  child 
recovered.  It  died  of  scarlet  fever  eight  months  subsequently,  and  the 
autopsy  revealed  the  entire  loss  of  the  large  intestine,  the  small  intestine 
being  united  to  the  anus.^     Atrophy  of  the  imprisoned  part  so  seldom  occurs 

'  London  Lancet,  May  19,  1888.  ^  Brit.  Med.  Jour.,  June  2,  1888. 


INTUSSUSCEPTION  IN  THE  LARGE  INTESTINES.  855 

ill  a  case  which  has  resisted  injections  and  inflation  tliat  it  need  not  be  con- 
sidered in  this  connection  as  a  mode  of  recovery. 

Laparotomy  has  been  successfully  performed  in  a  child  aged  two  years, 
as  T  have  stated  above,  by  Dr.  Jonathan  Hutchinson  of  London.  The  case 
was  one  of  those  exceptional  ones  in  which  great  displacement  had  occurred 
without  strangulation.  It  had  continued,  as  indicated  by  the  symptoms, 
about  one  n)onth,  and  a  portion  of  the  intestine  terminating  in  the  ileo-coecal 
valve  had  protruded  several  inches  from  the  anus.  '•  The  patient  was  anaes- 
thetized by  chloroform,  and  the  abdomen  was  opened  in  the  middle  line  below 
the  umbilicus.  The  intussusception  was  then  easily  found  and  as  easily  re- 
duced. The  after-treatment  consisted  only  in  the  administration  of  a  few  mild 
opiates,  and  the  child  made  rapid  recovery."  ^  In  a  case  of  this  kind  there 
can  be  no  doubt  of  the  propriety  and  necessity  of  laparotomy  as  the  last 
resort,  for,  there  being  no  strangulation,  sloughing  could  not  occur,  and  death 
sooner  or  later  from  exhaustion  must  be  the  result.  Cases  of  this  sort  have 
usually  been  left  to  perish  after  the  ordinary  modes  of  relief  have  failed. 
Thus  as  far  back  as  1784,  M.  Robin  published^  the  case  of  a  child  aged 
three  and  a  half  years  who  died  after  the  lapse  of  three  months  with  a 
cascum  protruding  from  the  anus ;  and  in  the  American  Journal  of  Medical 
Science  for  1849,  Dr.  Worthington  published  a  similar  case,  in  which  a  child 
aged  three  years  and  four  months  lived  a  longer  time.  In  these  days  of 
anaesthetics,  and  with  the  brilliant  success  of  Hutchinson,  a  physician  would, 
in  my  opinion,  be  reprehensible  if  he  allowed  a  child  aged  two  years  or  over 
with  this  form  of  displacement  to  perish  without  strongly  advising  laparotomy 
when  injections  with  water  have  failed. 

But  the  question  arises  whether  in  those  more  frequent  cases  of  intussus- 
ception in  j'oung  children  in  which,  after  displacement  has  continued  a  few 
hours,  there  is  such  firm  constriction  of  the  invaginated  mass  that  the  patient 
sufiers  much  pain  and  constitutional  disturbance,  and  passes  blood  and  mucus 
without  fecal  matter,  laparotomy  is  justifiable.  This  operation,  in  the  case  of 
infants,  has  heretofore  been  regarded  as  so  dangerous  and  so  likely  in  itself 
to  prove  fatal  that  the  profession  have  generally  considered  it  unjustifiable, 
believing  that,  although  death  was  nearly  certain  without  it,  the  perform- 
ance of  it  did  not  increase  the  chances  of  a  favorable  result.  Dr.  J.  B.  Sands 
of  New  York  has  recently  shown  that  laparotomy  is  justifiable  as  a  last  resort 
for  the  relief  of  this  form  of  intussusception,  even  in  the  youngest  infants, 
and  in  the  following  case,  recorded  in  the  Nev:i  York  Medical  Jotirncd,  June, 
1877,  saved  the  patient,  who  doubtless  would  otherwise  have  perished : 

On  March  11,  1877,  an  infant  of  six  months  suddenly  presented  the  cha- 
racteristic symptoms  of  intussusception,  such  as  tenesmus,  abdominal  pain, 
vomiting,  and  bloody  stools.  A  few  hours  later,  when  Dr.  Sands  was  called, 
the  pulse  was  rapid  and  feeble,  with  symptoms  of  collapse.  An  elongated 
tumor  could  be  felt  in  the  abdomen,  extending  from  the  left  iliac  region  to 
the  left  hypochondrium,  inelastic,  tender  on  pressure,  and  dull  on  percussion. 
The  lower  end  of  the  invaginated  mass  could  be  readily  touched  by  the  finger 
introduced  into  the  rectum.  The  usual  methods  to  eff"ect  reduction  were  at 
once  employed  with  partial  success,  for  the  tumor  disappeared  from  the  site 
where  it  had  been  discovered,  and  was  reduced  to  a  small  and  firm  mass  on 
a  level  with  the  umbilicus,  but  it  resisted  any  further  attempts  to  efi'ect  its 
reduction. 

Dr.  Sands  then,  having  etherized  the  patient,  made  an  incision  in  the 
median  line  of  the  abdomen,  extending  downward  about  two  inches  from  a 
point  a  little  below  the  umbilicus.  Through  this  opening,  proceeding  cau- 
tiously and  using  as  little  violence  as  possible,  he  was  able,  after  some  delay, 

^  London  Lancet,  November  22, 1873.  ^  Mem.de  V Acad,  de  Chirurg. 


856  APPENDICITIS,    TYPHLITIS,   PERITYPHLITIS. 

to  reduce  the  displacement.  The  invaginated  mass,  which  was  only  one  and 
a  half  inches  in  length,  consisted  of  the  terminal  portion  of  the  ileum  and 
caecum,  which  had  entered  the  ascending  colon.  The  wound  was  closed  by 
five  silver  sutures,  which  embraced  the  peritoneum,  and  the  patient  made  a 
good  recovery.  The  operation  was  performed  eighteen  hours  after  the  com- 
mencement of  symptoms. 

Dr.  Sands  has  collected  the  statistics  of  20  cases  of  laparotomy  for  intus- 
susception occurring  at  different  ages  in  which  the  result  was  stated.  Of 
these,  7  recovered,  or  1  in  3  ;  but  he  judiciously  remarks,  considering  the 
gravity  of  the  operation,  that  it  is  doubtful  whether  future  statistics  will 
show  so  favorable  a  result  of  laparotomy  for  this  displacement  as  to  justify 
the  frequent  use  of  the  knife.  For  facts  and  statistics  relating  to  this  sub- 
ject the  reader  is  referred  to  an  able  and  elaborate  paper  by  Dr.  Ashhurst.^ 

It  is  obvious  that  the  earlier  the  displacement  is  recognized,  the  greater 
the  probability  of  the  reduction  by  the  judicious  use  of  injections  or  infla- 
tion, and  it  is  seen  from  cases  related  above  that  this  treatment  may  be  suc- 
cessful as  late  as  the  second  or  third  day,  after  previous  attempts  to  reduce 
the  intussusception  by  the  same  means  have  failed,  and  when  there  is  that 
degree  of  strangulation  that  bloody  stools  occur.  But.  as  my  own  expe- 
rience has  shown  me,  there  is  also  inevitably  a  large  proportion  of  cases  in 
which  the  use  of  injections  and  inflation,  however  judiciously  and  persever- 
ingly  made,  totally  fail,  and  it  seems  to  me,  in  the  light  of  present  expe- 
rience, that  when  pressure  from  below  by  water,  air,  or  gas,  which  is  the  only 
eflScient  mode  of  treatment  short  of  the  knife,  has  been  tried  sufiiciently  long 
and  sufiiciently  often  without  result,  it  is  the  duty  of  the  physician  to  seek  sur- 
gical advice  in  reference  to  laparotomy,  as  he  would  in  a  case  of  hernia,  espe- 
cially since,  under  Lister's  antiseptic  method,  the  danger  from  severe  operations 
appears  to  be  considerably  diminished.  It  may  be  added  that  laparotomy 
performed  on  the  first  or  second  day  will  be  much  more  likely  to  save  life  in 
ordinary  cases  than  if  performed  later,  since  the  strangulated  intestine  is 
soon  badly  damaged,  and  a  local  peritonitis  is  likely  to  be  developed  any  time 
after  the  first  forty-eight  hours. 

When  an  intussusception  has  reached  that  stage  in  which  active  inter- 
ference by  injections,  inflation,  or  laparotomy  is  no  longer  proper,  the  physician 
can  only  prescribe  opiates  with  sustaining  measures  and  an  emollient  poultice 
over  the  abdomen,  and  must  await  the  result.  The  diet  should  consist  of 
beef  juice  and  other  concentrated  nutriment  which  leaves  little  residuum. 
Vomiting,  which  is  so  common,  is  best  controlled  by  bismuth  and  opiates ; 
convulsions  require  the  bromide  of  potassium  and  an  enema  of  three  to  five 
grains  of  chloral  hydrate  dissolved  in  a  little  water. 


CHAPTER    XIII. 

APPENDICITIS,  TYPHLITIS,   PERITYPHLITIS. 

The  portions  of  the  intestinal  tract  which  are  involved  in  these  inflam- 
mations are  the  caecum  and  appendix  vermiformis,  which  are  lined  by  mucous 
membrane  continuous  with  that  of  the  colon.  Inflammation  of  the  caecum 
and  of  the  appendix  so  frequently  coexist  that  they  may  be  considered 
together. 

'  American  Journal  of  the  Medical  Sciences,  for  July,  1874. 


ETIOLOGY.  857 

According  to  (lorlach,  a  fold  of  the  mucous  ineuibrane  after  the  age  of 
three  years  ordinarily  forms  a  valve  at  the  upper  end  of  the  appendix,  so  as 
to  prevent  fecal  matter  from  entering  it.  Kansohoff  states  that  this  valve 
prevented  rectal  injections  which  he  employed,  and  which  reached  the  caecum, 
from  entering  the  appendix.  This  anatomical  fact  prevents  the  more  frequent 
occurrence  of  appendicitis  from  the  lodgment  of  foreign  substances.  The 
appendix  is  covered  by  peritoneum  on  all  sides  and  in  its  entire  length,  and 
this  peritoneum  forms  underneath  it  a  mesentery  designated  the  mesenteriolum^ 
which  attaches  it  to  the  posterior  wall  of  the  right  iliac  fossa,  and  from  its 
length  allows  considerable  mobility  of  the  appendix.  If  the  appendix  beeomeS' 
inflamed  and  perforated  by  the  lodgment  in  it  of  a  foreign  substance,  a  local- 
ized peritonitis  inevitably  results.  The  csccum  anteriorly  and  laterally  i& 
also  covered  by  peritoneum.  In  rare  instances  its  posterior  surface  is  attached 
by  loose  connective  tissue  to  the  posterior  wall  of  the  iliac  fossa,  and  is  there- 
fore without  peritoneal  covering.  Ransohoff  states  that  in  63  post-mortem 
examinations  he  found  the  posterior  surface  of  the  caecum  covered  by  peri- 
toneum in  all  but  2  cases.  Therefore,  contrary  to  the  statement  of  Oppolzer, 
in  posterior  inflammation  of  the  caecum  extending  through  all  its  layers  the 
peritoneum  does  not  escape.  Perityphlitis,  as  the  inflammation  is  designated 
when,  whether  it  begins  in  the  caecum  or  appendix,  it  extends  to  their  perito- 
neal covering  and  produces  the  characteristic  exudation,  is  said  to  be  more 
frequent  in  males  than  in  females.  In  Matterstock's  collection  of  cases  51 
were  males  and  21  females,  and  in  Fitz's  cases  80  per  cent,  were  males,  20 
per  cent,  females. 

No  age  is  exempt  from  perityphlitis,  but,  according  to  all  writers  whom  I 
have  consulted,  a  large  majority  of  the  cases  occur  under  the  age  of  thirty 
years.  Matterstock  has  the  records  of  72  cases  under  the  age  of  fifteen 
years,  tabulated  as  follows : 

Cases. 

Under  2  years 2 

From    2  to    5  years,  inclusive 10 

5  "  10      "  "  2o 

"      10  "  15      "  "  • 35 

The  youngest  reported  case,  so  far  as  I  know,  was  one  related  by  Demme, 
A  female  infant,  aged  seven  weeks,  had  been  fed  from  the  age  of  seven  days- 
with  porridge.  In  the  third  week  she  was  fretful.  In  the  seventh  week  she 
was  very  feverish,  was  tympanitic,  and  had  tenderness  especially  marked  in 
the  right  iliac  region.  The  symptoms  indicated  peritonitis,  and  death  occurred 
soon  afterward.  At  the  autopsy  the  lesions  of  difl"use  peritonitis  were  found, 
most  marked  around  the  caecum  and  appendix.  The  appendix  was  distended 
with  fecal  substance,  which,  examined  under  the  microscope,  was  found  to 
consist  of  hardened  masses  of  the  porridge,  from  which,  apparently,  the 
inflammation  had  originated  without  producing  perforation. 

Etiology. — The  most  common  cause  of  the  inflammations  which  we  are 
considering  is  the  lodgment  and  impaction  in  the  appendix  or  caecum,  or  both, 
of  fecal  matter  or  hard,  indigestible  foreign  bodies  which  produce  inflamma- 
tion, and  sometimes  perforation,  by  their  pressure.  In  146  cases  of  perfora- 
tion of  the  appendix  collated  by  Matterstock,  fecal  concretions  were  present 
in  63 ;  foreign  bodies  difi"erent  from  concretions  in  9  ;  neither  fecal  masses 
nor  hard  bodies  in  8 ;  and  in  the  remaining  cases  the  records  do  not  mention 
the  presence  of  any  substance  likely  to  cause  inflammation.  In  49  cases  of 
fatal  perityphlitis  in  children,  perforations  had  occurred  in  37.  The  analysis 
of  152  cases  collated  by  Fitz  gives  a  very  similar  result  to  that  obtained 
from  the   examination   of  Matterstock's  records ;  but  Hagen  ascertained  the 


858  APPENDICITIS,   TYPHLITIS,  PERITYPHLITIS. 

presence  of  fecal  concretions  in  602  per  cent.,  and  hard  bodies  not  concretions 
in  30^  per  cent.,  of  the  cases  of  perforation  of  the  appendix.  We  must  there- 
fore regard  foreign  substances,  either  concretions  or  other  hard  bodies  which 
act  mechanically  by  pressure,  as  the  common  cause  of  appendicitis,  perfora- 
tion of  the  appendix,  and  perityphlitis. 

The  fecal  concretions  found  in  the  appendix  are  single  or  multiple,  and 
of  different  degrees  of  hardness.  The  hardest  masses  sometimes  exhibit  con- 
centric layers,  and  contain  phosphate  of  calcium.  Exceptionally,  the  concre- 
tion has  a  nucleus  of  some  solid  substance  in  the  interior.  The  foreign  bodies 
which  lodge  in  the  appendix  and  cause  ulceration  are  numerous.  In  a  case 
in  my  practice  an  over-baked  bean,  hard  and  black,  perforated  the  appendix 
and  caused  an  abscess,  which  by  rupturing  produced  fatal  peritonitis.  Among 
the  substances  which  have  caused  perforation  and  been  recovered  we  may 
mention  small  buttons,  beads,  grape-seeds,  cherry-stones,  orange-seeds,  raisin- 
seeds,  apple-seeds,  and  seeds  of  other  fruits. 

Perityphlitis  may  also  result  from  traumatism,  as  a  blow  or  kick  upon  the 
right  iliac  region,  and  from  tubercular  or  typhoid  ulcers  of  the  intestine.  The 
exciting  cause  of  the  perforation,  and  of  the  consequent  inflammation,  is 
sometimes  trivial,  and  under  ordinary  circumstances  inadequate,  such  as 
^imetics,  purgatives,  clysters,  vomiting,  sneezing,  defecation,  coughing,  and 
■dancing ;  but  it  is  supposed  that  when  so  trivial  a  cause  produces  so  grave  a 
result  an  ulcer  or  abscess  was  present,  and  in  such  a  state  that  a  slight  injury 
was  sufficient  to  rupture  it. 

Anatobiical  Characters. — The  initial  lesions  take  place  in  most 
instances  in  the  appendix.  Atrophy  or  necrosis  of  its  epithelium  occurs 
from  pressure  of  the  foreign  substance ;  then  the  intestinal  microbes  invade 
the  exposed  subepithelial  tissue,  causing  septic  inflammation.  This  inflam- 
mation extends  through  the  muscular  coat  to  the  subperitoneal  connective 
tissue  and  peritoneum,  causing  a  local  peritonitis,  or  it  ceases  before  reaching 
the  peritoneum,  producing  gangrene  or  ulceration  of  the  underlying  tissues ; 
and  as  they  contract  in  healing,  the  lumen  of  the  appendix  may  be  oblit- 
erated and  its  shape  changed.  Sometimes  the  appendix  is  nearly  or  quite 
obliterated  by  the  inflammatory  process,  its  place  being  occupied  by  cicatri- 
cial tissue,  or  its  proximal  end  may  be  obliterated  while  its  distal  end  remains 
open.  A  retention-cyst  then  results,  which  may  subsequently  be  inflamed, 
and  may  at  some  point  be  destroyed  by  gangrene  or  ulceration,  so  that  the 
retained  fecal  substance  escapes,  causing  peritonitis.  Occasionally  similar 
changes  occur  in  the  caecum.  Thus  Burne  relates  the  case  of  a  girl  of  twelve 
years  who  died  after  two  years'  sickness.  The  walls  of  the  caecum  had  under- 
gone contraction  through  bands  of  connective  tissue,  so  that  its  surface  was 
irregular  and  uneven  and  its  capacity  much  reduced. 

In  the  common  favorable  cases  of  perityphlitis  a  fibrinous  exudation 
occurs  over  the  inflamed  parts,  so  as  to  limit  the  extension  of  the  disease  and 
prevent  the  escape  of  pus  or  fecal  matter.  This  adhesive  peritonitis  around 
the  ulcerated  appendix  is  common.  The  extent  and  gravity  of  the  peritonitis 
depend  on  the  size  of  the  perforation  and  the  quantity  of  pus  or  feculent 
matter  that  escapes.  If  the  substance  which  escapes  from  the  perforation 
be  considerable  and  highly  irritating,  the  perityphlitis  is  of  course  severe  and 
pus  results,  forming  the  perityphlitic  abscess.  But  Balzer  states  that  the 
abscess  is  much  less  frequent  in  children  than  in  adults.  Its  location  depends 
upon  the  place  of  perforation.  It  is  stated  that  in  most  instances  the  centre 
of  the  abscess  is  behind  or  alongside  the  caecum,  and  if  it  extend  upward  its 
walls  consist  of  intestine  and  the  posterior  and  lateral  parietes  of  the  abdo- 
men. If  the  appendix  be  long  and  extend  to  the  brim  of  the  pelvis  minor, 
and  the  perforation  be  near  its  distal  end,  a  somewhat  rare  occurrence,  the 


SYMPTOMS.  859 

abscess  may  press  upon  the  rectum  or  uterus.  The  presence  of  fecal  matter 
with  its  microbes  in  the  pus  renders  it  very  irritating  and  poisonous. 

The  abscess,  left  to  itself,  may  open  in  any  direction.  It  sometimes  dis- 
charges into  the  intestine,  either  into  the  lower  end  of  the  ileum,  the  caicum, 
ascending  colon,  or  rectum,  through  an  opening  that  is  quite  small  in  the 
mucous  membrane,  but  larger  in  the  other  intestinal  coats.  Evacuation  of 
the  pus  per  rectum,  sometimes  tinged  with  blood,  has  been  regarded  as  favor- 
able from  the  time  of  Dupuytren.  It  occurred  in  18  per  cent,  of  the  cases 
collated  by  Fitz,  the  pus  breaking  into  the  intestine  at  some  point  above,  and 
escaping  by  the  rectum.  But  the  result  is  not  always  favorable  when  the 
abscess  breaks  into  the  intestine,  for  after  the  pus  has  been  evacuated  fecal 
matter  may  escape  from  the  intestine  through  the  opening,  carrying  with  it 
microbes  which  may  poison  the  system  and  set  up  septic  fever.  Of  G  cases 
related  by  Demme  in  which  the  abscess  broke  into  the  intestine,  3  subse- 
quently died.  Henoch  states  that  abdominal  abscesses  are  very  prone  to 
escape  at  the  umbilicus,  since  this  is  the  weakest  part  of  the  abdominal  wall. 
Rarely  the  pus  makes  a  passage  into  the  bladder,  and  if  this  occur,  cystitis, 
due  to  the  presence  of  purulent  and  fecal  matter,  may  result.  The  inflam- 
mation has  also,  in  a  case  mentioned  by  Eisenschtitz,  extended  from  the  per- 
forated appendix  to  the  right  ovary,  producing  purulent  inflammation  in  this 
organ.  Extension  of  the  inflammation  from  the  perforated  appendix  to  and 
around  the  contiguous  blood-vessels  may  produce  disastrous  results.  The 
superior  mesenteric  vein,  which  conveys  blood  from  the  cpecum  and  appendix 
to  the  portal  vein,  sometimes  becomes  the  seat  of  thrombosis,  the  circulation 
in  its  branches  being  interrupted  by  the  presence  and  pressure  of  inflamma- 
tory products.  Detached  particles  of  the  thrombi,  conveyed  through  the  por- 
tal vein  to  the  liver,  produce  septic  inflammation  and  abscesses  in  this  organ. 
Matterstock  has  the  records  of  eleven  cases  in  which  the  liver  became  involved 
in  this  manner.  Occasionally  the  abscess  ascends  along  the  colon  and  behind 
the  liver,  becoming  subdiaphragmatic,  and  cases  have  been  reported  in  which 
it  entered  the  right  pleural  cavity.  Tillmann  states  that  in  22  cases  of  fecal 
fistula  extending  into  the  pleural  cavity,  6  originated  from  perforations  in  the 
appendix.  The  abscess  penetrating  the  retro-peritoneal  tissue  may  extend 
to  the  kidney,  so  as  to  become  perinephritic,  or  it  may  descend  along  the 
psoas  and  iliac  muscles,  even  under  or  below  Poupart's  ligament.  Cases  are 
reported  in  which  it  burrowed  under  the  gluteus  maximus  muscle  or  in  the 
perirectal  tissue,  occupying  the  sacral  or  coccygeal  region. 

Evidently,  inasmuch  as  the  appendix  is  invested  by  peritoneum,  its  per- 
foration and  the  escape  of  fecal  substance  or  a  foreign  body,  which  produces 
the  abscess  described  above,  cannot  occur  without  a  localized  peritonitis  behind 
and  below  the  ca3cum,  where  the  appendix  lies.  But  a  more  serious  and 
ordinarily  fatal  result  sometimes  follows — to  wit,  the  occurrence  of  acute  dif- 
fuse peritonitis.  This  may  take  place  immediately  after  the  perforation,  but 
frequently  an  abscess  forms,  perhaps  of  little  extent,  around  the  appendix, 
and  it  may  continue  for  weeks  or  months  without  producing  any  dangerous 
symptoms.  Finally  it  bursts,  and  its  contents  escape  into  the  general  peri- 
toneal cavity,  producing  an  acute  peritonitis,  which  rapidly  extends  over  the 
peritoneal  surface.  A  large  proportion  of  the  cases  of  perforation  of  the 
appendix  if  left  to  themselves  terminate,  after  a  time,  in  this  manner,  in  peri- 
tonitis, which  from  its  extent  and  severity  is  usually  fatal.  This  was  the 
result,  according  to  Volz,  in  31  of  39  cases,  and,  according  to  Cless,  in  7  out 
of  8  cases. 

Symptoms. — The  initial  symptom  of  the  inflammation,  typhlitis,  appen- 
dicitis, and  perityphlitis  is  pain,  more  or  less  severe,  in  the  region  of  the 
appendix  or  csecum.  perhaps  at  first  paroxysmal,  with  intervals  of  comparative 


860  APPENDICITIS,   TYPHLITIS,  PERITYPHLITIS. 

ease,  and  accompanied  by  tenderness.  The  patient  is  apt  to  have  nausea  and 
even  vomiting,  constipation  or  diarrhoea,  flatulence,  and  tenesmus,  so  that 
experienced  physicians  sometimes  diagnosticate  indigestion,  not  aware  of  the 
serious  malady  which  is  impending.  These  symptoms  in  the  initial  period 
frequently  abate  for  a  day  or  two,  and  the  patient  is  able  to  be  about,  but 
they  return  with  equal  or  greater  severity. 

When  the  disease  is  fully  established  the  severe  pain  in  the  CEecal  region 
is  constant,  and  the  patient  takes  to  bed,  unable  to  stand  upright  or  to  walk. 
He  inclines  forward  and  to  the  right,  and  his  right  thigh  is  flexed  to  relieve 
the  tension.  Sometimes  he  refers  the  pain  to  the  epigastrium  or  the  abdo- 
men, and  it  is  increased  by  coughing,  by  full  inspiration,  and  by  extension 
of  the  right  thigh.  The  patient  is  quiet  in  bed  or  he  moves  from  restless- 
ness. Distension  of  the  stomach  with  food  or  drinks  increases  the  pain. 
Vomiting  of  the  ingesta  mixed  with  mucus  and  bile  is  common,  and  eructa- 
tions of  gas  may  occur.  Occasionally  these  symptoms  are  preceded  by  a 
chill,  but  less  frequently  in  children  than  in  adults.  The  following  are  the 
symptoms  commonly  present :  anorexia,  thirst,  fever  with  morning  remissions 
(101°  to  103°  F.),  accelerated  pulse,  features  indicative  of  severe  sickness, 
sometimes  icteric  hue  of  skin  and  conjunctiva,  perhaps  dysuria,  scanty  uri- 
nation or  retention  of  urine,  diarrhoea  or  constipation  ;  abdomen  flat  and  muscles 
tense  at  first,  but  subsequently  abdomen  tympanitic ;  tenderness  on  pressure 
at  first  in  the  right  iliac  region,  but  subsequently  more  general ;  prominence 
of  the  ileo-caecal  region,  at  first  from  gas,  subsequently  from  exudates ;  a 
csecal  tumor,  tender  and  immovable ;  adjacent  loops  of  intestine  distended. 
Such  are  the  symptoms  and  phenomena  that  attend  this  disease.  Pressure 
on  the  crural  plexus  may  cause  numbness,  pain,  or  other  abnormal  sensation 
in  the  right  leg  and  the  external  genital  organs.  Pressure  on  the  iliac 
vein  may  retard  the  return  circulation  from  the  leg  and  cause  oedema  of 
the  limb. 

The  progress  of  this  disease  and  its  gravity  vary  greatly  in  diff'erent 
cases.  In  the  mildest  forms  of  the  inflammation  the  pain,  nausea,  fever,  ileo- 
cascal  tenderness,  and  fulness  gradually  abate,  and  in  two  or  three  weeks  the 
health  is  restored ;  or  the  symptoms  may  continue  longer,  but  finally  yield 
after  the  discharge  per  rectum  of  gas  and  off"ensive  feces.  A  deep-seated 
induration  and  soreness,  gradually  abating,  may  remain  at  the  seat  of  the 
disease  for  months,  and  the  patient  may  complain  of  aching  or  pain  after  a 
full  meal  or  active  exercise.  When  the  abscess  opens  into  the  intestine,  the 
dangerous  symptoms  abate  rapidly,  and  the  patient,  as  a  rule,  quickly  begins 
to  convalesce. 

In  other  cases  the  symptoms  continue,  but  with  some  remission,  due  to 
the  fact  that  the  abscess,  which  does  not  discharge,  becomes  surrounded  by 
condensed  connective  tissue  which  limits  its  extension.  Then,  perhaps  after 
some  unusual  effort  or  a  blow  or  pressure  upon  the  inflamed  part,  an  aggra- 
vation of  symptoms  occurs.  Purulent  or  septic  matter  has  probably  escaped 
at  some  point,  and  peritonitis  may  have  resulted,  or  burrowing  of  pus,  as  has 
been  described  above,  or  septic  inflammation  in  some  important  organ.  The 
sudden  advent  of  alarming  symptoms  when  the  patient  has  been  compara- 
tively comfortable,  severe  and  general  abdominal  pain,  prostration,  rapid 
pulse  (150  to  160),  a  high  temperature  (105°  or  106°),  or  abnormally  low 
for  the  other  symptoms,  painful  respiration,  tenseness  of  the  abdominal  mus- 
cles, followed  by  tympanites  and  distension,  indicate  rupture  of  the  abscess, 
general  peritonitis,  and  rapidly  approaching  death,  unless  early  and  imme- 
diate laparotomy  be  performed  and  the  peritoneal  cavity  be  irrigated  by  a 
warm  antiseptic  lotion.  In  this  alarming  state,  vomiting,  gaseous  eructa- 
tions, constipation,  more  rai'ely  diarrhoea,  retention  of  urine,  clammy  perspi- 


DIAGNOSIS.  861 

rations,  hiccough,  flexed  thighs,  pallor,  and  liiially  collapse,  indicate  the  fatal 
progress  of  the  attack. 

To  add  to  the  gravity  of  the  situation,  septic  inflaniuiations  in  other  parts 
sometimes  start  up,  as  empyema  or  pericarditis,  cystitis,  perhaps  with  per- 
foration of  the  bladder,  inflammation  around  or  within  the  female  genital 
or"-ans  or  in   the  retro-peritoneal  connective  tissue. 

On  the  other  hand,  it  must  be  remembered  that  in  a  considerable  propor- 
tion of  cases  the  abscess  is  so  encapsulated  that  septic  poisoning  and  diffuse 
peritonitis  are  prevented,  and  after  a  time  it  begins  to  point  at  some  place 
where  it  has  approached  the  surface,  and  the  pus  escapes  spontaneously  or 
is  released  by  the  knife,  and  the  patient  immediately  begins  to  recover. 
Prof.  Henoch  has  witnessed  the  discharge  of  pus  through  the  umbilicus,  and 
he  believes  that  this  is  quite  liable  to  occur,  from  the  fact  that  the  abdomi- 
nal wall  is  thin  and  yielding  in  the   umbilical  region. 

Of  the  symptoms  enumerated  above,  pain  is  one  of  the  most  constant,  and 
was  present  in  84  per  cent,  of  the  cases  collated  by  Fitz.  It  is  of  course  less 
severe  if  the  inflammation  is  localized  in  the  ileo-CcBcal  region,  and  of  little 
extent,  than  when  it  occupies  a  wider  area.  Fitz,  in  his  examination  of  the 
records  of  patients,  ascertained  that  the  pain  was  referred  to  the  ileo-caecal 
region  in  48  per  cent,  of  the  cases  of  appendicitis  and  in  60  per  cent,  of 
perityphlitis,  to  the  abdomen  in  36  per  cent,  of  the  cases  of  appendicitis  and 
in  34  per  cent,  of  the  cases  of  perityphlitis.  In  a  few  instances  the  pain 
was  referred  to  the  hypogastric,  umbilical,  or  epigastric  regions,  and  in  rare 
instances  to  the  region  of  the  liver,  left  iliac  fossa,  and  the  right  hip  and 
groin.  Cessation  of  pain  when  the  other  symptoms  are  severe  indicates 
commencing  collapse. 

Vomiting  is  one  of  the  most  common  symptoms.  It  was  absent  in  only 
2  of  the  72  cases  collated  by  Matterstock,  and  was  present  in  Pepper's  13 
cases.  It  appears  to  be  more  common  in  children  than  in  adults.  Diarrhoea 
was  present  in  33.3  per  cent,  of  Matterstock's  cases,  and  constipation  in  46.6 
per  cent.,  alternating  constipation  and  diarrhoea  in  15.5  per  cent.,  and  nor- 
mal stools  in  4.5  per  cent,  of  the  cases.  According  to  Pott,  diarrhoea  is 
more  common  than  constipation  in  children,^  and  in  fatal  cases  approaching 
termination  severe  colliquative  diaiThoea  sometimes  occurs. 

More  or  less  fulness  and  induration  can  usually  be  detected  in  the  ileo- 
caecal  region  at  an  early  as  well  as  late  stage  of  the  disease,  but  a  distinct 
tumor  is  only  occasionally  perceptible.  According  to  Pepper,  in  19  children 
with  this  disease  a  tumor  could  be  detected  in  only  3  instances.  A  dull  per- 
cussion sound  in  the  right  ileo-caecal  region  is  common,  but  occasionally,  even 
when  there  is  considerable  inflammatory  induration,  loops  of  intestine  dis- 
tended with  gas  lie  over  the  seat  of  inflammation,  so  that  the  percussion 
sound  is  resonant.  The  temperature  usually  ranges  from  100°  to  103°  or 
104°.  It  is  sometimes  remittent.  In  a  case  treated  by  the  late  Dr.  H.  B. 
iSands  the  temperature  fell  from  101.6°  before  laparotomy  to  98.5°  imme- 
diately after  the  operation,  and  it  remained  below  100°  during  convalescence. 
A  sudden  rise  in  temperature  indicates  extension  of  inflammation  or  perhaps 
the  occurrence  of  septic  inflammation  in  organs  not  previously  involved.  A 
sudden  fall  of  temperature  when  other  symptoms  are  grave,  like  cessation  of 
pain,  indicates  collapse. 

Diagnosis. — Recurring  pain  or  tenderness  in  the  cajcal  region  at  inter- 
vals of  a  few  weeks  should  excite  suspicion  of  the  presence  of  a  foreign  sub- 
stance in  the  appendix.  Dr.  C.  E.  With'^  found  that  such  recurring  attacks 
preceded  the  severe  disease  for  weeks,  months,  or  even  years  in  certain  cases, 

^  Jahrbuch  fiir  Kmderhell.,  N.  F.  xiv. 

'^  Peritonitis  Appendicularis,  etc.,  Kjobenhavn,  1879. 


862  APPENDICITIS,   TYPHLITIS,  PERITYPHLITIS. 

and  in  the  large  number  of  cases  which  he  collated  Matterstock  ascertained 
that  these  occasional  attacks  of  pain  and  tenderness  preceded  the  disease  in  8 
per  cent,  of  the  children  affected.  Sometimes  the  accumulation  of  fecal  mat- 
ter in  the  caecum  can  be  determined  by  palpation,  since  it  produces  a  "  doughy  " 
feel.  The  diagnosis  of  this  inflammation  from  invagination  is  not  difficult,  since 
the  latter  occurs  chiefly  in  infancy,  is  attended  by  a  tumor  more  centrally  located 
in  the  abdomen  than  the  ileo-ceecal  induration  which  we  are  considering,  and 
is  attended  often  by  bloody  stools  and  fecal  vomiting.  Dr.  V.  P.  Gibney* 
states  that  four  children  with  perityphlitis  had  been  brought  to  his  orthopae- 
dic hospital  in  the  belief  that  they  had  hip  disease,  and  had  been  treated  for 
it ;  but  a  more  careful  examination  of  such  cases,  especially  under  ether, 
shows  that  the  hip-joint  is  not  affected.  The  swelling  in  hip-joint  disease  is 
lower  down  than  the  perityphlitic  induration.  Besides,  perityphlitis  does  not 
produce  the  change  in  the  appearance  of  the  hip  when  examined  from 
behind,  or  in  the  position  of  the  foot,  which  we  observe  in  hip  disease.  N. 
Senn^  recommends  rectal  injection  of  hydrogen  gas  as  a  means  of  determin- 
ing the  presence  of  perforation  of  the  caecum  or  appendix,  since  in  case  of  per- 
foration the  gas  enters  the  peritoneal  cavity,  and  laparotomy  without  delay  is 
indicated.  The  diagnosis  from  a  psoas  abscess  may  be  made  by  attention  to 
the  following  facts :  This  abscess  occurs  gradually,  without  symptoms  refer- 
able to  the  intestines  or  peritoneum,  and  without  the  ileo-cascal  induration  of 
perityphlitis.  Moreover,  the  abscess  usually  descends  along  the  psoas  mus- 
cle and  forms  a  swelling  under  Poupart's  ligament,  or  it  extends  along  the 
thigh  under  the  fascia. 

Prognosis. — This  varies  greatly  in  different  cases.  If  the  inflammation 
be  of  little  extent  and  encapsulated,  and  sepsis  do  not  occur,  the  prognosis  i& 
good.  On  the  other  hand,  if  the  perforation  of  the  caecum  or  appendix  be 
of  considerable  size,  with  considerable  escape  of  feculent  matter,  loaded  as  it 
is  with  microbes,  the  severe  inflammation  which  results  in  the  peritoneum  or 
retro-peritoneal  tissue,  with  perhaps  consecutive  septic  inflammation  in  adja- 
cent organs  or  tissues,  to  which  septic  matter  has  been  conveyed  by  the  lym- 
phatics or  blood-vessels,  a  fatal  termination  is  almost  certain.  It  is  evident 
that  the  statistics  relating  to  the  result,  as  ascertained  by  different  writers, 
vary  according  to  the  average  severity  of  the  cases  whose  records  they  con- 
sult. The  following  statistics  have  been  published,  showing  the  mode  of 
termination  of  appendicitis,  typhlitis,  and  perityphlitis,  considered  as  one 
disease  : 

Authors.  Deaths.  Recoveries. 

Volz 39 10 

Bamberger 18 55 

W.  T.  Bull 33 34 

Matterstock 49 21 

With 12 18 

Demme 27 9 

According  to  Matterstock,  age  influences  the  result  in  a  measure,  since  of 
12  patients  under  the  age  of  six  years,  11  died;  of  24  patients  between  the 
ages  of  six  and  ten  years,  15  died;  and  of  34  patients  between  the  ages  of 
ten  and  fifteen  years,  23  died.  A  difiuse  peritonitis,  whether  resulting  imme- 
diately from  the  perforation  or  from  rupture  of  an  abscess  which  has  been 
previously  encapsulated  and  indolent,  is  usually  fatal.  Evacuation  of  the 
abscess  into  the  caecum  or  rectum  justifies  a  favorable  prognosis,  though 
some  die  in  which  this  occurs.  Evacuation  of  pus  through  the  abdominal 
walls,  if  it  take  place  at  an  early  date,  is  also  regarded  as  favorable.  Lapa- 
rotomy, which  consists  in  evacuation  of  the  pus  through  the  abdominal  walls^ 

'  Amer.  Jour,  of  Med.  ScL,  1881.         '  Jour,  nf  the  Amer.  Med.  Assoc.,  June  23, 


TREATMENT.  863 

if  performed  at  the  proper  time  and  with  antiseptic  precautions,  increases  the 
chances  of  recovery.  According  to  Noyes,'  in  100  such  operations  the  mor- 
tality was  only  15.  But  according  to  Bull,  the  result  is  not  so  favorable  if 
the  abscesses  burrow  their  way  to  the  surface  and  open  without  surgical 
assistance,   for  of  28  such  abscesses,   11    were  fatal. 

How  long  patients  may  live  in  fatal  cases  after  the  occurrence  of  severe 
symptoms  has  been  investigated  by  Fitz,  who  found  that  in  176  cases  84  per 
cent,  died  in  the  first  five  days,  more  than  half  in  the  first  week,  31  per  cent, 
in  the  second  week,  and  4  per  cent,  in  the  third  week.  In  those  mild  cases 
in  which  the  inflammation  in  the  Ci«cal  region  is  of  slight  extent  and  the 
patient  is  soon  convalescent,  a  sudden  aggravation  of  symptoms  sometimes 
occurs  from  breaking  loose  of  the  inflammatory  products  or  septic  absorp- 
tion, and  the  case  ends  fatally. 

Treatment — ProplujJndic. — Children  should  have  plain  and  easily- 
digested  diet,  from  which  seeds  or  other  indigestible  substances  are 
removed  so  far  as  possible.  They  should  be  instructed  to  reject  the 
seeds  of  the  ordinary  fruits  which  they  are  allowed  to  eat,  since  seed.s 
are  the  off'ending  substances  which  cause  appendicitis  and  perforation  in 
so  large  a  proportion  of  cases.  Daily  fecal  evacuations  should  be  pro- 
cured, so  as  to  prevent  fecal  accumulation  in  the  caecum.  If  there  be 
complaint  of  colicky  pain  in  the  abdomen  while  the  bowels  move  reg- 
ularly, or  if  there  be  occasional  pain  or  aching  in  the  caecal  region,  a 
careful  examination  should  be  made  in  order  to  ascertain  if  there  be 
tenderness  or  induration  at  the  point  complained  of,  and  if  so  a  quiet 
life  with  open  bowels  should  be  enjoined.  By  such  measures  the  threat- 
ening symptoms  may  pass  off. 

Curative. — Prof.  Henoch  of  the  University  of  Berlin,  whose  opinions 
relating  to  the  diseases  of  children  always  claim  attention,  if  not  acceptance, 
on  account  of  his  large  experience,  says  that  whether  the  inflammation  occurs 
from  over-distension  of  the  caecum  by  fecal  masses  or  from  concretions  in 
the  appendix,  the  symptoms  are  the  same  as  in  later  life — to  wit,  pain  in  the 
cascal  region,  which  is  likely  to  extend  over  "  a  large  part  of  the  peritoneum  : 
the  frequent  formation  of  a  tum'or  by  the  exudation,  which  not  infrequentlv 
terminates  in  suppuration  ;  the  repeated  relapses,  etc."  Henoch  states  that 
he  keeps  the  intestines  perfectly  quiet  by  opium,  and  only  gives  castor  oil  or 
calomel  when  prolonged  constipation  and  palpation  indicate  the  presence  of 
a  large  fecal  accumulation  in  the  ctecum  ;  otherwise,  he  abstains  from  purga- 
tives, applies  a  few  leeches,  without  after-bleeding  if  there  be  much  tender- 
ness, gives  an  emulsion  of  oil  (emulsio  oleosa),  with  the  aqueous  extract  of 
opium  every  two  hours,  and  uses  constantly  the  ice-bag  over  the  caecum. 
When  with  this  treatment  the  pain  and  tenderness  cease,  he  states  that  defe- 
cation usually  occurs  spontaneously  or  is  produced  by  a  simple  enema  or  a 
dose  of  oil.  The  following  remark  might  be  thought  to  be  an  exaggeration 
were  it  not  for  the  well-known  accuracy  and  high  professional  standing  of 
Prof.  Henoch  :  "  When  this  treatment  was  begun  early  enough  recovery 
ensued  in  almost  all  cases,  and  if  a  swelling  had  been  formed  by  the  exuda- 
tion, its  transition  into  suppuration  was  prevented  even  in  children  who  in 
the  course  of  a  few  years  had  been  repeatedly  admitted  to  the  hospital  on 
account  of  relapses."  The  treatment  detailed  above,  employed  and  recom- 
mended by  Prof.  Henoch,  is  in  my  opinion  the  best  that  can  be  prescribed 
for  typhlitis,  appendicitis,  and  perityphlitis  before  suppuration  has  occurred. 
The  use  of  laxatives,  even  of  laxative  enemata,  should  be  postponed  until 
the  tenderness  and  other  inflammatory  symptoms  have  to  a  considerable 
extent  abated  by  the  use  of  the  ice-bag,  and  opium  in  sufiicient  doses  to  allay 

'  Trans.  Rhode.  Island  Med.  Soc,  1882. 


864  APPENDICITIS,   TYPHLITIS,  PERITYPHLITIS. 

restlessness  and  procure  sleep.  If,  when  the  inflammation  has  been  subdued, 
we  ascertain  by  palpation  the  presence  of  fecal  masses  in  the  caecum,  a  large 
•clyster  of  warm  water,  containing  one  ounce  of  glycerin  and  one  of  sweet 
oil,  may  be  prescribed,  or  perhaps,  as  recommended  by  Henoch,  a  dose  per 
orem  of  castor  oil  or  calomel  may  be  given.  Even  in  the  commencement  of 
the  treatment,  if  there  be  the  history  of  constipation,  and  on  palpation  the 
caecum  appears  to  be  distended  with  fecal  matter,  it  is  proper  to  employ  a 
large  clyster  of  warm  water,  containing  one  ounce  of  glycerin  and  one  of 
sweet  oil,  in  order  to  remove  a  chief  cause  of  irritation.  The  diet  should 
consist  of  liquids  that  leave  little  residuum,  as  the  beef  peptones  and  pep- 
tonized milk.  Carbonized  water  may  be  allowed  to  relieve  the  thirst  or 
nausea.  If  the  case  result  favorably,  the  child  should  lead  a  quiet  life, 
avoiding  violent  exercise  during  and  after  convalescence,  for  relapse  is  not 
infrequent. 

If  the  inflammation  continue  and  suppuration  occur,  a  perityphlitic 
abscess  forms,  which  requires  incision  if  the  diagnosis  be  clearly  made.  In 
America  the  advantages  of  early  liberation  of  the  pus  in  ileo-csecal  abscesses 
was  brought  to  the  notice  of  the  profession  by  the  late  Prof.  Willard  Parker, 
whose  first  case  of  successful  operation  occurred  in  1843.  Since  this  time 
the  treatment  of  perityphlitic  abscesses  by  incision  has  been  practised  in 
numerous  instances,  so  that  Dr.  R.  F.  Noyes  in  1882  was  able  to  collate  the 
records  of  119  cases,  only  about  16  per  cent,  of  which  were  fatal. ^ 

Dr.  Sands  strongly  objected  to  the  use  of  the  exploring  needle  at  an  early 
stage  of  the  inflammation,  employed  for  the  purpose  of  determining  the 
presence  or  absence  of  pus,  since  it  might  penetrate  the  healthy  peritoneal 
cavity  and  pierce  the  intestine  or  pus-cavity,  and  when  withdrawn  the  foul 
substance  adherent  to  it  would  probably  infect  the  peritoneum  and  cause  a 
diffuse  peritonitis.  G.  Buck,  Wier,  Noyes,  and  Bull  advise,  if  the  presence 
of  pus  be  determined  by  the  needle,  to  leave  it  in  situ,  that  it  may  serve  as  a 
guide  in  making  the  incision.  Morton  states  that  the  aspirator  needle  should 
never  be  used,  and  Ransohoff  also  objects  to  it.  Dr.  Lange  ^  in  making  the 
incision  and  entering  the  peritoneal  cavity,  finding  that  the  tumor  was  covei'ed 
by  omentum,  closed  the  opening  and  made  th'e  cut  farther  to  the  right,  where 
the  peritoneum  was  adherent  to  the  tumor,  and  the  patient  recovered. 

Sands  recommends  making  a  vertical  incision  over  the  caBcum,  as  afford- 
ing the  readiest  approach  to  the  diseased  parts.  Noyes,  Parker,  Hancock, 
and  others  make  the  incision,  four  inches  in  length  and  even  longer,  in  a  line 
parallel  with  the  outer  half  of  Poupart's  ligament.  Hadden  and  Bontecou 
make  a  curved  incision  along  the  crest  of  the  ileum,  and  others,  as  Gibney 
and  Parker,  make  the  incision  at  the  most  prominent  part  of  the  tumor,  and 
nearer  the  median  line  than  most  other  operators. 

Laparotomy,  or  the  opening  of  the  abdominal  cavity  for  the  purpose  of 
evacuating  the  perityphlitic  abscess,  has  been  performed  a  considerable  num- 
ber of  times  during  the  last  ten  years,  and  cases  have  been  published  show- 
ing very  favorable  results.  But  it  must  be  borne  in  mind  that  favorable 
cases  are  much  more  likely  to  be  reported  than  the  unfavorable.  Dr.  Sands 
reported  the  following  case  in  1888 :  A  boy,  sick  two  days,  had  a  pulse  of 
130,  temperature  101.6°,  respiration  32.  An  incision  carefully  made 
revealed  the  parietal  peritoneum  thickened  and  opaque,  and  the  hypodermic 
needle  introduced  drew  pus.  A  free  incision  was  then  made,  and  a  little  gas 
and  one  ounce  of  fetid  pus  escaped.  The  caecum  and  loops  of  the  small 
intestines  were  covered  with  pus.  The  peritonitis,  not  being  restricted  by' 
adhesions,  was  diffuse.  Three  fecal  concretions  escaped  from  a  perforation 
in  the  appendix.     The  abdominal  cavity  was  irrigated  by  warm  water,  and 

1  Tram,  of  Rhode  Island  Med.  Soc.,  1882.  ''  N.  Y.  Med.  Jour.,  Mar.  3,  1888. 


TREATMENT.  865 

thou  by  half  a  pint  of  corrosive-sublimate  solution,  1  part  to  1000.  "J'lie 
wound  was  partially  closed  by  interrupted  silk  sutures,  the  part  not  closed 
being  packed  by  iodoform  gauze  extending  to  the  loops  of  small  intestine. 
The  drainage-tube  was  not  used.  The  patient  immediately  began  to  improve 
and  recovered.'  Ilomans  relates  the  case  of  a  boy  of  eleven  years  who  had 
had  pain  in  the  ileo-ciccal  region  five  days,  and  had  been  in  bed  three 
days.  lie  had  dulness  and  tenderness  on  percussion  in  the  right  iliac  region, 
without  swelling ;  pulse  120,  temperature  102.4°.  The  incision,  made  liali' 
an  inch  anterior  to  the  crest  of  the  ileum,  revealed  healthy  loops  of  intestine, 
but  below  and  behind  them  were  deeper  loo))S  agglutinated  by  the  inflamma- 
tion. On  separating  the  adhesions  a  cavity  was  reached,  from  which  two 
ounces  of  fetid  pus  escaped,  which,  so  far  as  pos.sible,  was  removed  without 
flowing  over  the  healthy  peritoneal  surface.  Double  rubber  tubes  were 
introduced  and  the  wound  was  closed  around  them.  This  case  occurred 
before  antiseptic  measures  were  so  generally  employed  as  at  the  present 
time,  but  the  patient  progressively  improved,  and  was  out  of  bed  after  three 
weeks,  the  discharge  from  the  tubes  being  abundant  during  two  weeks. 

Such  cases  show  what  may  be  accomplished  by  surgical  treatment  of  the 
perforated  appendix  and  perityphlitic  abscess,  even  in  cases  in  which  diffuse 
peritonitis  has  resulted ;  but  of  course  when  peritonitis  not  limited  by  adhe- 
sions occurs,  death  will  inevitably  result  in  a  considerable  proportion  of  cases 
under  any  treatment. 

Removal  of  the  perforated  and  diseased  appendix,  when  it  can  be  readily 
brought  into  view,  has  been  recommended  and  performed  by  Sands,  Morton, 
Hoffmann,  and  others,  and  it  is  generally  advised  by  the  writers  of  the 
various  monographs  on  this  disease,  since  it  is  a  source  of  irritation,  and  by 
the  subsequent  escape  of  fecal  matter  might  cause  a  renewal  of  the  inflam- 
mation. But  in  a  large  proportion  of  cases  the  appendix  lies  at  the  bottom 
of  the  cavity  surrounded  by  adhesions,  so  that  it  cannot  be  removed  without 
considerable  cutting  and  tearing  of  the  parts  which  surround  it,  and  perhaps 
producing  an  opening  through  which  inflammatory  products  may  escape  into 
the  peritoneal  cavity.  Attempts  to  remove  it  under  such  circumstances 
would  not  be  justifiable.  If  it  be  accessible,  the  cautious  and  experienced 
surgeon  will  understand  in  what  way  its  removal  can  be  best  accom- 
plished. 

1  N.  Y.  Med.  Jour.,  Feb.  25,  1888. 
55 


SECTIOE"  IT. 
DISEASES   OF  THE   GENITO-URINARY  ORGANS. 


Uric-Acid  Infarctions. 

Infarctions  of  uric  acid  or  the  urates  are  very  common  in  new-born 
infants.  They  are  seen,  if  an  opportunity  of  examining  the  kidneys  occurs, 
as  yellowish-red  lines  in  the  tubules  or  lying  in  the  pelvis  of  the  kidney, 
forming  small  yellowish  granules.  As  they  are  washed  away  by  the  urine^ 
we  often  find  them  upon  the  diaper.  The  irritation  produced  by  these  infarc- 
tions sometimes  causes  painful  micturition.  Children  a  few  months  old  often 
fret  or  cry  from  pain  during  urination  in  consequence  of  the  irritating  action 
of  the  uric  acid,  while  in  the  intervals  between  the  passing  of  water  they 
may  or  may  not  be  free  from  suffering.  Perhaps  they  pass  only  a  few  drops 
of  urine  with  straining,  and  in  it  we  find  crystals  of  uric  acid  or  the  urates. 
Urine  highly  acid  from  the  presence  of  this  substance  causes  a  burning  pain 
in  the  urethra,  and  sometimes  redness  not  only  of  the  urethra,  but  even  of 
the  labia  over  which  the  urine  flows.  Although  infants  perhaps  suffer  most 
from  this  cause,  the  same  condition  not  infrequently  occurs  in  older  children. 
Their  urine,  previously  normal,  becomes  unduly  acid  from  some  error  in  feed- 
ing or  in  the  digestive  process,  and  uric-acid  crystals  or  concretions  form. 
An  exaggerated  secretion  of  mucus  occurs  from  the  surface  of  the  bladder 
or  from  the  urinary  canal  in  consequence  of  the  irritation  produced  by  the 
acid,  and  sometimes  pus-cells  are  also  seen  under  the  microscope  mixed  with 
the  mucus. 

The  state  of  the  urine  described  above  should  be  at  once  rectified,  for  it 
furnishes  the  conditions  in  whieh  calculi  form  either  in  the  pelvis  of  the  kid- 
ney or  in  the  bladder.  Urine  unduly  acid  and  irritating  probably  at  first 
causes  catarrh  of  the  delicate  membrane  lining  the  tubules  and  pelvis  of  the 
kidneys,  and  if  the  irritation  be  sufficiently  severe  the  catarrh  extends  along 
the  ureters  to  the  bladder,  causing  a  degree  of  cystitis.  Now,  a  catarrah  of 
the  pelvis  of  the  kidney  or  the  bladder  greatly  increases  the  tendency  to  the 
formation  of  calculi,  since  the  crystals  become  imbedded  in  the  mucus,  which 
serves  to  agglutinate  them.  Uric  acid,  when  so  abundant  in  the  urine  as  to 
cause  symptoms,  should  be  at  once  treated  and  the  acid  neutralized  by  an 
alkali.  The  liquor  potassse,  employed  as  recommended  in  our  remarks  on 
the  treatment  of  Enuresis,  is  the  best  alkali  for  this  purpose.  For  an  infant 
of  one  year,  two  drops  sufficiently  diluted  in  mucilage  will  be  sufficient, 
repeated  in  three  or  four  hours. 


Enuresis. 

Enuresis,  or  incontinence  of  urine,  is  a  common  and  troublesome  infirmity 
in  children.     It  occurs  both  in  boys  and  girls,  but  is  more  common  in   the 

866 


ENURESIS.  867 

former  than  in  the  latter.  In  many  children  it  dates  back  to  infancy,  but 
others  have  a  respite  from  it  in  the  years  immediately  succeeding  infancy 
until  the  sixth  or  seventh  year,  when  it  returns.  It  may  be  diurnal  as  well 
as  nocturnal,  interfering  seriously  with  the  comfort  of  the  child  and  render- 
ing his  schooling  inconvenient ;  but  the  annoyance  which  it  causes  is  com- 
monly most  at  night,  and  it  is  f(jr  nocturnal  enuresis  that  the  physician  is 
most  frequently  consulted.  The  child  may  pass  his  urine  in  bed  every  night, 
or  even  more  than  once  each  night,  or  there  may  be  occasional  nights  of 
immunity. 

The  bladder  consists  of  three  concentric  coats :  1 .  On  the  outside  the 
peritoneal,  which  covers  the  pcjsterior,  the  superior  part  of  the  lateral,  and 
the  anterior  aspects  of  the  organ ;  2.  The  muscular,  which  chiefly  concerns 
us  at  present,  and  which  consists  of  two  layers — the  one  external,  the  fibres 
of  which  have  a  general  longitudinal  direction  ;  the  other  internal,  whose 
fibres  are  circular.  The  circular  fibres  become  more  abundant,  producing 
greater  thickness  of  this  layer,  at  the  urethral  orifice,  and  they  extend  a  dis- 
tance over  the  urethra.  This  increase  in  the  number  of  circular  muscular 
fibres  at  the  urethral  orifice  constitutes  the  sphincter  vesicae.  The  fibres  in 
the  muscular  coat  of  the  bladder  are  unstriped,  and  are  not  under  the  control 
of  the  will. 

A  second  sphincter,  which  aids  materially  in  the  retention  of  urine,  is 
formed  by  the  compressor  urethrae.  This  muscle,  arising  by  aponeurotic 
fibres  from  the  ramus  of  the  pubes,  surrounds  the  whole  membranous  por- 
tion of  the  urethra,  extending  from  the  prostate  to  the  bulbous  portion.  The 
compressor  urethras  is  a  striped  muscle,  and  its  action  is  therefore  controlled 
by  the  will.  Certain  accessory  muscles  influence  the  retention  as  well  as  the 
expulsion  of  urine — to  wit,  the  levator  ani,  acceleratores  uringe,  and  the  abdom- 
inal muscles. 

Nerves. — The  muscular  coat  of  the  bladder  receives  its  nerves  from  the 
hypogastric  plexus,  which  belongs  to  the  sympathetic  system,  although  fila- 
ments enter  the  plexus  from  the  spinal  system.  The  innervation  of  the  blad- 
der is  therefore  twofold,  that  derived  from  the  sympathetic  system  predom- 
inating over  that  from  the  spinal  system,  as  shown  by  the  relative  number  of 
filaments  from  the  two  sources.  According  to  Belfield,  the  spinal  centre  of 
the  motor  nerves  of  the  bladder  is  in  the  vicinity  of  the  third  lumbar  verte- 
bra ;  but  Budge,  in  his  experiments  on  rabbits,  locates  it  in  this  animal  in 
the  vicinity  of  the  fourth  lumbar  vertebra.  The  spinal  centre  of  the  nerv- 
ous supply  of  the  bladder,  says  Coulton,  "  is  connected  with  the  brain  by  a 
strand  of  fibres  which  may  be  traced  from  the  cerebral  peduncle  along  the 
anterior  columns  of  the  spinal  cord."  The  neck  of  the  bladder,  including 
the  sphincter  vesicae,  derives  nervous  fibres  directly  from  the  anterior  or 
motor  roots  of  the  third,  fourth,  and  fifth  sacral  nerves ;  and  it  is  more 
abundantly  supplied  with  nervous  filaments  than  is  the  muscular  coat  of  the 
organ.  That  the  sphincter  vesicas  is  under  the  control  of  the  will  is  there- 
fore apparent  from  the  anatomical  characters,  since  a  strand  of  fibres  con- 
nects the  peduncles  with  the  motor  centre  of  the  bladder  in  the  spine,  and 
this  centre  connects  with  the  sphincter  through  the  spinal  nerves.  In  nor- 
mal urination  the  sphincter  is  relaxed  by  the  volition  of  the  individual,  while 
the  muscular  coat  of  the  organ,  being  under  the  control  of  the  sympathetic 
system  and  involuntary  in  its  action,  expels  the  urine  as  soon  as  the  sphinc- 
ter is  open. 

The  pudic  nerve  aLso  sustains  an  important  I'clation  to  the  function  of  the 
bladder.  Arising  from  the  sacral  plexus,  it  is  distributed  "  to  the  base  of  the 
bladder,  the  prostate,  the  integument  of  the  penis,  scrotum,  and  perineum, 
the  urethral  muscles  and  mucous  membrane,  and  the  sphincter  of  the  anus ; 


868  DISEASES  OF  THE  QENITO-U BINARY  ORGANS. 

in  the  female,  the  uterus,  vagina,  and  vulva  are  supplied  by  branches  of  the 
same  nerve."  Knowledge  of  the  distribution  of  the  pudic  nerve  enables  us 
to  understand  the  manner  in  which  disease  or  abnormal  conditions  of  the 
genital  organs  and  anus  disturb  the  functions  of  the  bladder.  Irritation 
of  the  inferior  branches  of  this  nerve  affects  the  action  of  the  superior 
branches,  or  those  which  supply  the  base  of  the  bladder  and  the  urethral 
muscles,  so  as  to  produce  in  certain  patients  dysuria  or  incontinence,  or 
both. 

Etiology. — In  all  cases  the  urine  should  be  examined,  since  the  cause 
of  the  enuresis  is  often  discovered  in  the  deviations  in  it  from  the  normal 
state  which  are  apparent  on  inspection.  The  chief  causes  may  be  grouped 
as  follows,  but  often  two  or  more  of  them  are  present  in  the  same  case : 

1.  Too  great  acidity  of  the  urine.  The  urine  in  its  normal  state  is  acid 
from  the  presence  of  the  acid  phosphate  of  sodium  (Robin),  but  in  certain 
conditions  the  acidity  becomes  so  great  that  the  urine  is  unduly  stimulating 
to  the  surface  of  the  bladder.  Now,  stimulating  or  irritating  urine  causes 
the  bladder  to  contract,  just  as  an  irritating  substance  in  the  intestines 
increases  the  peristaltic  and  vermicular  movements  of  this  tube.  Exces- 
sive acidity  of  the  urine  is  commonly  due  to  the  presence  of  uric  acid, 
resulting  from  decomposition  of  the  urates ;  but  in  certain  conditions  lactic 
and  hippuric  acids,  resulting  from  faulty  digestion,  appear  in  the  urine 
(Robin)  ;  urine  unduly  acid  renders  its  retention  difficult,  except  in  mod- 
erate quantity,  so  that  enuresis  results. 

2.  Increased  quantity  of  urine.  This  sometimes  occurs  from  the  free 
use  of  liquids,  as  of  water  or  milk.  Renal  disease,  attended  by  an  exag- 
gerated excretion  of  urine,  sometimes  produces  enuresis.  Henoch  ^  says : 
"  I  would  advise  you  never  to  omit  an  examination  of  the  urine,  because 
cases  of  diabetes  mellitus  and  chronic  nephritis  are  known  which  were  first 
manifested  by   nocturnal  incontinence." 

3.  A  vesical  calculus.  This  is  an  infrequent  cause,  but  when  present  it 
is  likely  to  produce  both  diurnal  and  nocturnal  enuresis.  If  micturition  be 
frequent  and  painful  by  day  and  by  night,  if  the  urine  contain  a  large 
amount  of  mucus  or  muco-pus  so  as  to  render  it  turbid,  and  if  the  dysuria 
and  frequent  urination  be  not  soon  relieved  by  treatment,  a  calculus  is  prob- 
ably present.  In  such  cases  the  bladder  should,  of  course,  be  sounded  by 
the  proper  instrument  to  render  diagnosis  certain. 

4.  The  muscular  coat  of  the  bladder  may  have  an  exaggerated  contractile 
power  in  itself,  and  not  imparted  to  it  by  any  extraneous  stimulating  agency. 
The  surrounding  conditions  may  be  normal,  while  the  bladder  is  hypersensi- 
tive, so  as  to  contract  with  undue  energy  by  ordinary  stimulation.  The  fault 
is  in  the  bladder  itself,  whose  functional  activity  is  in  excess  ;  this  appears  to 
be  the  most  common  cause  of  enuresis  in  children.  It  is  the  condition  of  the 
bladder  which  Trousseau  had  in  mind  when  he  wrote :  "  I  repeat  that  the 
nocturnal  incontinence  of  urine  is  a  neurosis,  and  I  now  add  that  it  is  a  neur- 
osis manifesting  itself  by  excessive  irritability  of  the  bladder ;  in  fact,  the 
immediate  cause  of  incontinence  is  this  excess  of  irritability  in  the  muscular 
fibres  of  the  bladder."  As  Bretonneau  pointed  out,  children  with  enuresis 
from  this  cause  habitually  pass  urine  in  a  full  and  rapid  stream,  and  therefore 
in  less  time  than  other  children,  showing  that  the  contractile  power  of  the 
muscular  coat  is  in  excess.  From  the  fact  that  belladonna  relieves  so  many 
patients,  we  infer  that  irritability  of  the  muscular  coat  is  a  common  cause 
of  enuresis  in  children,  since  this  agent  acts  by  diminishing  muscular  con- 
tractility. 

5.  Weakness  of  the  muscular  fibres  which  constitute  the  sphincter  of  the 

^  Diseases  of  Children,  p.  257. 


ENURESIS.  869 

bladder.  I)iiiiiiii.slied  tonicity  of  the  sphincter  muscles  does  not  occur,  or  it 
occurs  very  rarely  in  those  who  have  had  previous  good  health  and  are  robust. 
Ordinarily,  children  affected  by  enuresis  from  this  cause  are  in  habitual  ill- 
health.  They  have  had  long  and  prostrating  sickness,  which  has  diminished 
muscular  tonicity,  or  they  have  local  disease  in  the  spine  or  in  the  course  of 
spinal  nerves,  which  has  impaired  the  innervation  of  the  sphincter.  Some- 
times incontinence  of  feces  is  also  present,  and  examination  of  the  sphincter 
ani  by  introducing  the  finger  shows  that  its  contractile  power  is  insufficient. 
We  infer  the  presence  of  atony  of  the  sphincter  vesicjc  i'rom  the  atony  thus 
easily  discovered  of  the  sphincter  ani.  As  an  example  of  enuresis  from  atony 
of  the  sphincter  vesicjc,  we  may  mention  the  case  of  a  boy  of  thirteen  years 
who  had  "  a  flat,  doughy  tumor"  at  the  lower  end  of  the  dorsal  vertebrae,  in 
the  middle  of  which  a  deficiency  in  the  bony  arch  which  covers  the  spinal 
cord  was  detected  by  the  fingers,  showing  that  the  tumor  was  a  spina  bifida 
containing  a  considerable  amount  of  adipose  and  granulation  tissue.  The 
congenital  deficiency  in  the  spinal  column,  and  consequent  injury  of  the  spi- 
nal cord,  had  produced  incontinence  of  both  urine  and  feces. 

6.  We  have  already,  in  speaking  of  the  distribution  of  the  pudic  nerve, 
alluded  to  the  fact  that  enuresis  in  children  is  not  infrequently  produced 
through  reflex  action  by  disease  or  an  abnormal  condition  external  to  the 
bladder  in  parts  which  receive  their  nerves  from  the  same  source  as  the 
bladder.  Henoch  says  :  "  Occasionally  congenital  phimosis,  stricture  of  the 
urethra,  irritation  of  ascarides,  fissure  of  the  anus,  onanism,  or  vulvitis  can 
be  detected,  upon  the  removal  of  which  the  enuresis  ceases."  Trousseau 
relates  the  case  of  a  young  man  of  seventeen  years  who  from  childhood  had 
been  in  the  habit  of  wetting  the  bed  two  or  three  times  every  night.  After 
unsuccessful  trial  of  belladonna,  strychnia,  and  mastich,  it  occurred  to  Trous- 
seau that  the  infirmity  might  be  due  to  congenital  phimosis,  and  accordingly 
Professor  Jobert  circumcised  him.  With  the  exception  of  three  consecutive 
nights  he  was  entirely  relieved  of  enuresis  during  his  subsequent  stay  of 
nine  months  in  the  hospital.  In  dispensary  practice  in  New  York  City  we 
find  preputial  adhesions,  with  the  accumulation  of  smegma  between  the  glans 
and  foreskin,  and  more  or  less  balanitis — a  common  cause  of  disturbed  func- 
tion of  the  bladder.  The  dysuria  and  enuresis  cease  when  the  adhesions  are 
divided  by  the  probe,  the  smegma  removed,  and  the  preputial  inflammation 
or  irritation  has  abated. 

7.  A  psychical  cause,  to  which  Bartholow  alludes.  The  patient  dreams 
that  he  is  in  a  convenient  place  for  urination,  the  desire  of  which  is  impressed 
on  his  thoughts,  and  awakens  to  find  that  he  has  urinated  in  bed.  Since  the 
action  of  the  bladder  is  largely  under  the  control  of  the  will,  a  strong  will  or 
determination,  if  the  patient  be  not  too  sound  a  sleeper,  does  exercise  a  con- 
trolling action  over  the  bladder  even  during  sleep.  We  sometimes  observe  this 
eff"ect  of  will-power  in  the  fact  that  the  patient  breaks  the  habit  of  enuresis 
through  a  sense  of  shame  or  by  a  determination  to  avoid  the  disgrace.  Thus 
one  writer  mentions  the  case  of  a  girl  in  whom  severe  flogging  by  her  mother 
put  a  stop  to  the  habit,  and  patients  sleeping  away  from  home,  as  when  visit- 
ing among  friends  or  at  a  boarding-school,  sometimes  break  the  habit  through 
an  eff"ort  of  the  will.  The  sense  of  profound  shame  which  the  infirmity  pro- 
duces thus  enables  certain  patients  to  control  the  action  of  the  bladder  even 
in  sleep.  The  state  of  the  mind  should  therefore  be  considered  as  an  element 
both  in  the  causation  and  cure  of  the  infirmity. 

8.  Malformation  of  the  bladder  or  its  appendages.  These  are  of  various 
kinds.  Some  of  them  are  of  such  a  nature  that  cure  of  the  enuresis  is  dif- 
ficult or  impossible.  Thus,  Thomas  U.  Madden,  M.  D.,  F.  R.  S.  C.  E.,  relates 
the  case  of  a  young  lady  who  had  been  treated  by  diff"erent  physicians  in' 


870  DISEASES  OF  THE  OENITO-URINARY  ORGANS. 

various  localities  with  belladonna,  iron,  vesication  of  sacrum,  and  the  other 
usual  remedies,  without  the  least  benefit.  The  dribbling  of  urine  was  con- 
stant day  and  night,  so  that  she  was  debarred  from  school  and  ridiculed  and 
avoided  by  her  associates.  She  was  placed  under  chloroform,  and  her  blad- 
der was  found  to  have  the  power  to  retain  a  considerable  amount  of  urine. 
Pursuing  the  examination,  Dr.  Madden  found  that  the  urine  dribbled  from  a 
small  orifice  about  half  an  inch  above  the  meatus  urinarius  and  covered  by 
rugge  of  the  mucous  membrane.  A  No.  1  catheter  was  introduced  its  en- 
tire length  through  the  opening,  so  that,  in  the  opinion  of  Dr.  Madden,  there 
was  malposition  and  elongation  of  the  right  ureter,  which,  instead  of  empty- 
ing into  the  bladder,  discharged  the  secretion  of  the  right  kidney  upon  the 
vulva.  In  malformations  like  the  above,  as  well  as  in  ectopia  vesicae,  recto- 
vesical or  vesico-vaginal  fistula,  the  result  of  abnormal  foetal  development, 
the  urine  obviously  dribbles  constantly  and  from  the  moment  of  birth.  In 
perpetual  lifelong  dribbling  a  malformation  or  congenital  defect  should  be  sus- 
pected, and  is  probably  the  cause. 

Prognosis. —  The  prognosis  depends  on  the  cause  or  causes  of  the  enure- 
sis. Most  of  the  causes  are  of  such  a  nature  that  they  can  be  removed,  and 
the  majority  of  patients  can  therefore  be  cured  by  appropriate  remedies. 
Enuresis  due  to  irritating  properties  in  the  urine,  to  irritation  or  inflamma- 
tion in  the  genital  organs  or  rectum,  and  that  due  to  exaggerated  tonicity  of 
the  muscular  coat  of  the  bladder,  can  be  for  the  most  part  readily  cured 
by  appropriate  measures,  while  that  resulting  from  structural  disease  of  the 
spinal  cord  or  from  malformations  in  the  urinary  tract  is  least  amenable 
to  treatment. 

It  is  the  common  belief  that  those  epochs  in  life  which  produce  a  decided 
change  in  the  individual,  as  puberty  or  marriage,  are  likely  to  effect  a  cure 
in  cases  previously  obstinate.  This  opinion  is  to  a  certain  extent  founded 
on  fact.  The  development  of  the  sexual  organs  at  puberty  seems  to  render 
the  bladder  less  irritable  and  more  retentive  in  some  patients.  Cases  are  also 
related,  as  one  by  Trousseau,  in  which  incontinence  ceased  with  marriage 
and  pregnancy.  But  treatment  in  the  ordinary  form  of  enuresis  should  not 
be  deferred  in  the  hope  that  time  and  physical  changes  will  effect  a  cure, 
for  this  belief  is  likely  to  be  illusory. 

Treatment. — The  physician  asked  to  prescribe  for  a  case  of  enuresis 
should  carefully  examine  the  patient  in  order  to  ascertain  the  cause.  Since 
the  most  common  cause  is  irritability  of  the  bladder,  whether  inherent  in 
the  bladder  itself  or  imparted  to  it  by  the  stimulating  properties  of  the  urine, 
the  urine  should  be  rendered  as  bland  and  unirritating  as  possible.  It  should 
be  made,  so  far  as  possible,  as  bland  and  unirritating  as  tepid  water.  This 
is  best  accomplished  by  rendering  it  neutral.  Excessive  acidity  of  the  urine, 
so  common  a  cause  of  enuresis,  is  promptly  removed  by  the  liquor  potassae 
administered  in  doses  of  a  few  drops  largely  diluted.  I  have  found  it  a  safe 
and  efficient  remedy  in  the  treatment  of  this  infirmity  when  the  bladder  is 
unduly  irritable.  If,  therefore,  in  the  examination  of  a  case  we  discover  no 
cause  of  the  incontinence  except  an  exaggerated  contractile  power  of  the 
bladder,  and  the  urine  is  acid,  from  three  to  five  drops  of  the  liquor  potassae 
should  be  given  three  or  four  times  daily  in  a  wineglassful  of  gum-water 
until  litmus-paper  shows  that  the  urine  is  neutral,  and  its  neutral  state 
should  be  maintained. 

In  belladonna  we  possess  an  agent  which  diminishes  the  functional  activ- 
ity of  the  bladder  when  the  latter  is  in  excess.  It  diminishes  the  contrac- 
tile power  of  the  muscular  fibres,  and  its  use  is  therefore  indicated  in  the 
class  of  cases  which  we  are  now  considering.  In  this  country  the  tincture 
of  belladonna  is  more  commonly  employed  than  the  extract,  which  is  used 


ENURESIS.  871 

ill  Europe,  especially  in  continental  Europe,  and  if  obtained  from  a  good 
laboratory  its  action  is  as  certain  as  that  of  the  extract,  while  its  dose  can  be 
better  regulated.  Five  drops  of  the  tincture  may  be  given  every  evening 
or,  if  the  enuresis  be  diurnal  as  well  as  nocturnal,  every  morning  and  even- 
ing, to  a  child  of  five  years,  and  the  dose  be  increased  by  one  drop  every 
second  day  if  improvement  do  not  occur  and  physiological  eifects  are  not 
produced,  until  the  dose  is  doubled  or  even  trebled.  If  the  enuresis  be 
relieved,  or  if,  without  its  relief,  physiological  effects  be  observed,  as  dry- 
ness of  the  fauces,  cutaneous  efflorescence,  or  dilatation  of  the  pupils,  the 
dose  should  not  be  increased.  When  belladonna  produces  the  desired  effect, 
it  is  no  doubt  best  to  continue  its  use  for  some  weeks  in  the  dose  which  is 
found  to  be  eff'ectual,  and  then  to  diminish  the  number  of  drops  gradually. 

Trousseau,  who,  as  we  have  seen,  considered  enuresis  in  most  cases  a 
neurosis,  highly  extolled  the  treatment  by  belladonna,  believing  it  the  most 
eifectual  of  all  methods  of  cure.  He  prescribed  the  extract  of  belladonna, 
gr.  ^,  or  the  sulphate  of  atropia,  gr.  yi^,  but  he  did  not  state  the  age  of  his 
patients.  The  dose  was  increased  if  necessary,  and  whatever  dose  he  found 
to  give  relief  he  administered  once  daily  for  three,  four,  or  five  months,  after 
which  it  was  gradually  diminished,  but  it  was  not  discontinued  until  after 
the  lapse  of  two  to  ten  months.  By  this  treatment  Trousseau  states  that  a 
majority  of  his  cases  were  signally  benefited,  and  not  a  few  were  entirely 
relieved.  The  following  case,  which  recently  occurred  in  my  practice,  indi- 
cates the  mode  of  treatment  in  enuresis  when  it  results  from  the  cause  which 

we  are   now  considering :  L ,  aged  eleven  years,   male,  had  diurnal   and 

nocturnal  enuresis,  which  seriously  interfered  with  his  comfort  and  rendered 
him  an  object  of  aversion  and  ridicule  among  his  schoolmates.  He  had  pre- 
viously taken  belladonna  and  other  remedies  without  improvement.  His 
urine  was  found  highly  acid.  Five  drops  of  liquor  potassae  were  ordered  to 
be  given  three  or  four  times  daily,  and  the  tincture  of  belladonna,  to  which 
he  was  accustomed,  was  administered  in  nine-drop  doses  three  times  daily,  to 
be  increased,  if  need  be,  to  fourteen  or  fifteen  drops.  The  liquor  potassa?, 
in  the  dose  mentioned,  immediately  rendered  the  urine  neutral,  and  the  enu- 
resis from  that  time  ceased.  The  treatment  recommended  above,  of  render- 
ing the  urine  as  little  irritating  as  possible  by  neutralizing  it,  aided  by  bella- 
donna, which  diminished  the  contractility  of  the  muscular  fibres,  cured  the 
infirmity,  which  had  been  most  troublesome  and  tedious. 

If  the  enuresis  be  due  to  an  abnormally  large  secretion  of  urine,  the 
cause  may  be  such  that  something  can  be  done  to  relieve  the  patient.  The 
liquid  ingesta  in  the  latter  part  of  the  day  should  be  restricted.  If  it  be 
found  that  the  increased  flow  is  due  to  diabetes  or  chronic  nephritis,  the  enu- 
resis, though  an  unpleasant  symptom,  is  comparatively  unimportant,  and  the 
grave  disease  which  causes  it  requires  chief  attention.  The  quantity  of 
urine  may  be  diminished  in  diabetes  mellitus  by  the  use  of  proper  food,  and 
in  diabetes  insipidus  by  ergot. 

Enuresis  due  to  a  vesical  calculus  is  associated  with  symptoms,  as  we 
have  stated  above,  which  indicate  the  presence  of  stone,  such  as  painful 
micturition,  which  may  awaken  the  patient  at  night,  and  thus  prevent  the 
accident  of  which  we  are  treating.  Urination  more  frequent  and  painful  in 
the  daytime  than  at  night,  occasional  interruption  in  the  stream  of  urine 
from  the  impediment,  pus,  perhaps  blood  and  an  increased  amount  of  mucus, 
in  the  urine,  indicate  the  presence  of  a  stone.  Fortunately,  the  calculus  is 
easily  detected  by  sounding,  and  by  the  present  improved  instruments  it  can 
be  crushed  and  removed,  or  it  can  be  removed  by  lithotomy,  which  in  the 
opinion  of  some  is  less  dangerous,  and  is  preferable  to  crushing  when  the 
patient  is  a  child. 


872  DISEASES  OF  THE  GENITO-URTNARY  ORGANS. 

As  we  have  stated  above,  the  physician  should  always  examine  parts  con- 
tiguous to  the  bladder,  as  the  genital  organs  and  rectum,  in  order  to  ascer- 
tain if  there  be  any  source  of  irritation  in  them  which  may  produce  irrita- 
bility of  the  bladder  by  reflex  action.  In  some  instances,  as  we  have  seen, 
enuresis  rebellious  to  ordinary  treatment  ceases  when  the  irritation  in  parts 
contiguous  to  the  bladder  is  removed.  Phimosis,  preputial  adhesions,  the 
accumulation  of  smegma  between  the  foreskin  and  glans,  with  more  or  less 
balanitis  produced  by  the  foul  products,  and  vulvitis,  or  ascarides,  should,  if 
present,  receive  treatment,  and  with  the  removal  of  the  irritating  cause  the 
enuresis  will  probably  cease. 

Cases  in  which  preputial  irritation  produces  an  irritable  state  of  the  blad- 
der are  not  infrequent  among  the  poor  of  New  York,  whose  habits  are  fre- 
quently degraded  and  filthy,  and  the  treatment  consists  in  dividing  adhesions 
of  the  glans  to  the  foreskin,  cleaning  away  the  smegma,  and  using  a  sooth- 
ing ointment.  The  foreskin  can,  with  few  exceptions,  be  sufficiently  stretched 
for  this  purpose,  so  that  incision  (or  circumcision,  which  is  frequently  per- 
formed in  these  cases)  is  unnecessary. 

If  the  enuresis  be  due  to  atony  of  the  sphincter,  a  remedy  is  required 
which  acts  very  differently  from  belladonna.  If  weakness  of  the  sphincter 
be  the  cause,  the  indication  is  obviously  to  increase  its  tonicity,  and  the  two 
medicines  which  have  been  most  successfully  employed  for  this  purpose  are 
nux  vomica  (or  its  active  principle  strychnia)  and  ergot.  We  have  stated 
that  the  sphincter  is  more  abundantly  supplied  with  nerves  than  is  the  mus- 
cular coat  of  the  bladder,  so  that  those  agents  which  restore  innervation,  and 
thereby  increase  muscular  tonicity,  act  upon  the  sphincter  more  powerfully 
than  upon  the  muscular  coat.  Ergot  appears  to  exert  a  similar  action^ 
though  perhaps  less  in  degree,  upon  the  sphincters  of  the  bladder  and  anus, 
to  that  which  it  exerts  upon   the  uterine  muscular  fibres. 

We  can  obtain  a  clearer  idea  of  the  effect  of  therapeutic  agents  upon 
paresis  of  the  sphincter  vesicae  by  observing  their  action  in  paresis  of  the 
sphincter  ani,  for  these  two  sphincters  suffer  a  loss  of  power  from  the  same 
causes,  and  recover  it  by  the  use  of  the  same  agents. 

In  a  very  instructive  paper  on  incontinence  of  feces,  published  by  Dr. 
George  B.  Fowler  in  the  American  Journal  of  Obstetrics  for  October,  1882, 
two  cases  are  detailed,  showing  unmistakably  the  beneficial  action  of  ergot  in 
increasing  the  tonicity  of  the  sphincter  ani ;  and  the  same  treatment  is  indi- 
cated for  urinary  incontinence  when  it  arises  from  a  similar  cause.  A  child 
of  seven  years,  in  the  practice  of  Dr.  Fowler,  had  been  closely  confined  to 
his  studies,  with  probably  some  deterioration  of  his  health,  when  fecal  incon- 
tinence commenced.  The  tonicity  of  the  sphincter  ani  on  examination  with 
the  finger  did  not  seem  much  impaired.  Nevertheless,  it  was  so  increased  by 
ten-drop  doses  of  the  fluid  extract  of  ergot  that  the  incontinence  was  relieved. 
The  second  patient,  an  anaemic  girl  of  thirteen  years,  had  been  under  treat- 
ment with  iron  and  other  tonics  without  benefit  to  the  fecal  incontinence. 
Her  flesh  was  flabby  and  surface  cool,  and.  which  is  interesting  to  remark  as 
throwing  light  on  the  condition  of  the  vesical  sphincter  when  it  lacks  toni- 
city, a  lack  of  resistance  in  the  anal  outlet  was  very  apparent  to  the  touch. 
A  mixture  containing  15  minims  of  the  fluid  extract  of  ergot  and  grain  jl-^ 
of  strychnia  was  given  three  times  daily.  At  the  end  of  the  first  week  she 
had  only  two  recurrences  of  the  trouble,  and  in  three  weeks  was  cured. 
Four  months  afterward,  although  she  had  been  taking  quinine  and  iron  after 
the  discontinuance  of  the  ergot,  a  partial  relapse  occurred,  and  a  suppository 
of  five  grains  of  ergotin,  with  butter  of  cocoa,  was  employed  morning  and 
evening.  Immediate  relief  followed,  the  tonicity  of  the  sphincter  was 
restored,   and   the   suppositories   were   discontinued   after   two  weeks.      The 


ENURESIS.  873 

beneficial  effects  of  ergotin  in  weakness  of  the  sphincters  is  shown  Vjy  these 
cases.  Enuresis  from  weakness  of  the  spliincter  vesica;  could  not  have  been 
better  treated  than  by  the  same  remedies  which  relieved  the  fecal  inconti- 
nence in   these  two  patients. 

A  considerable  number  of  medicines  which  are  now  seldom  used  have 
been  employed  with  more  or  less  success  for  enuresis.  According  to 
Bouchut,  M.  Kibes  was  the  first  who  prescribed  nux  vomica.  The 
patient  was  a  soldier  who  had  both  urinary  and  fecal  incontinence,  and 
was  cured  of  the  weakness  of  the  bladder  in  five  days.  Nux  vomica  is 
employed  instead  of  strychnine,  as  its  use  involves  less  danger.  Mon- 
diere  prescribed  this  agent  in  combination  with  the  black  oxide  of  iron 
in   the   following   formula : 

R.   Extracti  nucis  voniicfie,         gr.  vj  ; 
Ferri  oxidi  magnetici,  ,5J. 

Ft.  pil.  No.  xxiv.     Take  one  pill  three  times  daily. 

Although  we  accept  the  statement  of  Bouchut  that  strychnia  is  an 
"  extremely  dangerous  "  remedy  for  enuresis  if  the  patient  be  under  the 
age  of  four  or  five  years,  yet  over  that  age  it  can  be  safely  prescribed  as 
an  adjuvant  to  the  ergot  in  proper  dose  and  with  proper  precautions.  A 
small  dose,  repeated  after  three  hours,  is  obviously  safer  than  a  larger  dose 
at  longer  intervals. 

Among  the  remedies  not  yet  mentioned  which  have  been  successfully 
employed  in  certain  cases,  the  tincture  of  cantharides  requires  notice.  In 
large  doses  this  drug  causes  strangury,  but  in  small  doses  it  produces 
such  irritation  or  stimulation  of  the  surface  of  the  urethra  as  to  increase 
the  contraction  of  the  sphincter  and  awaken  the  patient  when  the  urine 
presses  upon  the  urethral  orifice,  which  is  rendered  sensitive  by  this  agent. 
Cantharides  is  an  unpleasant  remedy,  and  it  is  not  much  employed  of  late 
years ;  probably  the  benefit  from  its  use  is  not  usually  permanent.  A  child 
of  five  years  can  take  four  or  five  drops,  largely  diluted  with  water,  three 
times  daily,  and  the  dose  should  be  gradually  inci'eased  until  there  is  some 
evidence  of  its  effect  on   the   outlet  of  the  bladder. 

Cubebs,  recommended  by  M.  Dieters,  the  various  vegetable  tonics  and 
astringents,  iron,  creasote,  and  many  other  remedies,  have  fallen  into  dis- 
repute and  are  now  seldom  used.  Sometimes  certain  combinations  of  rem- 
edies give  prompt  and  entire  relief.  Eustace  Smith  says :  "  I  have  lately 
cured  a  little  girl,  aged  four  years,  who  had  resisted  all  other  treatment,  with 
the  following  draught,  given  three  times  daily  : 


"  R.  Thict.  bellad., 

.^.i; 

Potas.  bromidi. 

gr.  x; 

Infus.  digitalis, 

."i.i ; 

A  quae, 

ad  5SS.     Misce. 

Ft.  haustus." 

The  tincture  of  belladonna  of  the  British  Pharmacopoeia  has  about  half 
the  strength  of  that  employed  in  the  United  States ;  but  even  with  this 
allowance  I  would  not  dare  to  prescribe  so  large  a  dose  of  this  agent^ 
except  that  smaller  doses  were  first  used  and  tolerance  of  the  remedy 
demonstrated.  Of  the  tincture  of  belladonna  of  the  U.  S.  Pharmacopoeia 
ten  minims  would  be  a  large  dose. 

Local  treatment  has  been  attended  by  a  degree  of  success.  The  neck  of 
the  bladder  and  the  urethra  have  been  cauterized  by  the  nitrate  of  silver 
applied  by  the  porte-caustique  of  Lallcmand,  with  some  relief  of  the  enure- 
sis, at  least  so  long  as  the  soreness  remained.  Baths  and  douches  of  cold 
water  have  also  been  used  by  many  physicians,  some   of  whom,  as  Under- 


874  DISEASES  OF  THE  OENITO-UBINABY  ORGANS. 

wood,  Baudelocque,  Guersant,  and  Dupuytren,  state  that  they  have  obtained 
good  results.  This  treatment  is  most  beneficial  in  those  cases  in  which  the 
sphincter  is  relaxed. 

Finally,  in  certain  patients  the  advice  of  Trousseau  may  be  followed,  that 
the  patient  in  the  daytime  resist  the  inclination  to  pass  urine  so  long  as  it 
does  not  greatly  increase  his  or  her  discomfort ;  by  this  means  greater  toler- 
ance of  the  presence  of  urine  in  the  bladder  is  produced. 

Calculi;  Dysuria;  Cryptorchia. 

We  have  seen,  in  our  remarks  on  Uric-Acid  Infarctions,  how  calculi  may 
form  in  the  pelvis  of  the  kidney,  first  as  small  concretions,  and  how,  descend- 
ing to  the  bladder,  they  may  become  nuclei  which  gradually  increase  by 
accretions  to  their  surfaces,  or  they  may  form  primarily  in  the  bladder.  A 
vesical  calculus  is  not  very  infrequent,  even  in  the  young  child.  Its  pres- 
ence is  manifested  by  dysuria  and  increase  of  mucus,  and  the  occurrence  of 
pus  and  sometimes  of  blood-cells  in  the  urine.  Occasionally  the  flow  of 
urine  is  obstructed  by  the  presence  of  the  calculus,  and  the  consequent 
tenesmus  causes  prolapsus  ani.  Prolapsus  ani  and  dysuria  are  important 
symptoms  of  stone  in  the  bladder.  Sometimes  the  bladder  becomes  greatly 
distended  with  urine,  and  there  may  be  trickling  of  it,  with  oedema  and  sore- 
ness of  the  prepuce  and  adjacent  parts.  Now  and  then  a  calculus  lodges  in 
the  urethra,  producing  more  or  less  retention  of  urine,  with  cedema  of  the 
prepuce  and  adjacent  parts.  The  treatment  for  calculus  must  be  entirely 
surgical.  Lithotrity  as  now  performed  with  improved  instruments  is  devoid 
of  danger  and  successful.  If  a  stone  lodge  in  the  urethra,  it  is  usually  near 
its  outer  extremity,  where  the  canal  is  narrowest,  and  it  can  be  removed  by  a 
pair  of  small  forceps. 

Dysuria  occurs  from  various  causes.  It  not  only  results  from  calculus, 
but  also  from  urine  concentrated  and  acid.  We  have  stated  above  that  urine 
containing  uric  acid  and  the  urates,  if  they  are  abundant,  is  highly  irritating, 
and  while  this  acid  and  its  salts  increase  the  frequency  of  micturition,  they 
are  likely  to  render  it  painful.  They  sometimes  cause  colicky  pain  from 
spasmodic  contraction  of  the  muscular  fibres  in  the  urinary  tract,  and  even 
transient  albuminuria  has  been  noticed.  Dysuria  from  this  cause  is  best 
treated  by  alkaline   and  mucilaginous  drinks. 

Dysuria  not  infrequently  arises  from  a  morbid  state  of  the  external  gen- 
itals, and  they  should  always  be  examined  when  micturition  is  painful  or 
obstructed  to  ascertain  their  condition.  In  the  first  two  or  three  years  of 
life  the  prepuce  is  usually  adherent  to  the  glans  through  epidermal  cells, 
which  appear  to  arise  from  the  rete  Malpighii,  and  instead  of  becoming  horny 
remain  soft  and  filled  with  protoplasm.  This  adhesion  is  so  common  that  it 
must  be  considered  normal,  especially  as  it  does  not  give  rise  to  symptoms. 
But  occasionally,  even  in  young  boys,  a  pathological  state  sometimes  occurs 
which  gives  rise  to  symptoms,  among  which  is  dysuria.  Phimosis  may  be 
present,  retarding  the  flow  of  urine,  some  of  which  is  retained  under  the 
foreskin,  where,  decomposing,  it  excites  balanitis,  causes  adhesions,  and  renders 
urination  painful.  Circumcision  gives  relief  to  the  local  disease  and  the 
dysuria.  In  the  Out-door  Department  at  Bellevue  Hospital,  where  a  con- 
siderable number  of  cases  of  this  kind  have  been  brought  for  treatment,  it 
has  rarely  been  necessary  to  circumcise  or  slit  the  prepuce.  Instead  of  this, 
the  adhesions  are  divided  by  a  probe,  the  prepuce  stretched  and  drawn  back 
so  as  to  expose  the  glans,  and  the  parts  thoroughly  smeared  with  a  simple 
ointment ;  if  there  be  much  inflammation  and  swelling,  it  may  be  necessary 
to  etherize  the  patient  for  the  operation. 

In  young  girls  the  labia  minora  are  often  adherent,  apparently  through  a 


VUL  VITLS.  875 

catarrhal  inflammation.  They  can,  for  the  most  part,  be  readily  separated  by 
traction,  when  minute  drops  of  blood  appear  upon  the  exposed  surfaces,  show- 
in}^  that  a  vascular  connection  has  already  occurred.  Henoch'  says:  "  In  a 
lew  cases  this  adhesion  appears  to  me  to  be  the  cause  of  dysuria,  which  dis- 
appeared after  the  separation  of  the  labia  from  one  another  ;  in  others  exam- 
ination showed  inflammatory  redness  of  the  introitus  and  meatus,  with 
increased  secretion  of  mucus,  which  renders  the  excretion  of  urine  pain- 
ful." Separating  the  adherent  parts  and  covering  the  surface  with  simple 
ointment  to  prevent  readhesion  sufiice  to  efi'ect  a  cure  of  the  dysuria  when  it 
depends  upon  this  cause. 

In  the  first  months  of  foetal  life  the  testes  lie  in  the  abdominal  cavity  in 
front  of  and  a  little  below  the  kidneys,  behind  the  peritoneum,  and  attached 
to  the  base  of  the  scrotum  by  a  long  cord,  the  gubernaculum  testes.  Between 
the  fifth  and  sixth  months  the  testes  descend  to  the  iliac  fossa,  with  corre- 
sponding shortening  of  the  gubernaculum.  At  the  end  of  the  eighth  month 
it  has  descended  into  the  scrotum,  surrounded  by  a  pouch  of  the  peritoneum, 
which  becomes  detached  from  the  peritoneum  "just  before  birth"  (Gray), 
forming  a  closed  sac,  the  tunica  vaginalis.  It  is  estimated  that  in  one  case 
in  five  the  descent  of  the  testicle  is  delayed  from  a  few  months  to  a  year 
after  birth.  Astley  Cooper  states  that  the  descent  docs  not  occur  in  some 
cases  until  between  the  thirteenth  and  seventeenth  years.  When  there  is 
this  late  descent  intestine  is  apt  to  follow  the  testicle,  causing  inguinal 
hernia.  In  about  one  case  in  one  thousand,  it  is  estimated,  the  testicle 
does  not  descend,  but  remains  in  the  abdominal  cavity,  either  on  account  of 
adhesions  to  the  abdominal  viscera,  the  small  size  of  the  ring,  or  some  defect 
in  the  gubernaculum.  Occasionally,  a  retained  testicle  has  the  normal  struc- 
ture and  development,  but,  as  a  rule,  it  is  imperfect  and  small,  like  the  tes- 
ticle of  the  infant,  and  it  is  prone  to  fatty  or  fibrous  degeneration.  If  both 
testicles  are  retained,  impotence  may  result  on  account  of  the  non-develop- 
ment or  degeneration.  No  treatment  is  required  for  the  retained  testicle, 
unless  it  become  inflamed  when  lying  in  the  inguinal  canal,  when  it  should 
be  treated  by  poultices  and  other  soothing  remedies. 

Vulvitis. 

Inflammation  of  the  vulva  is  common  in  girls  under  the  age  of  five  years. 
Like  most  other  inflammations,  it  varies  in  severity  in  different  cases,  from  a 
■mild  and  transient  attack  to  one  attended  by  tumefaction  and  excoriation  or 
ulceration  of  the  labia,  pain,  and  abundant  discharge.  Ordinarily,  when  the 
physician  is  consulted,  the  disease  has  continued  a  few  days,  and  he  finds  the 
vulva  moist  from  a  muco-purulent  discharge,  which  dries  into  light  yellow 
crusts  and  produces  greenish  or  yellowish  stains  on  the  under-clothes.  The 
vulva  and  lower  part  of  the  vagina  are  sensitive  and  red,  and  the  acrid  secre- 
tions sometimes  cause  redness  of  the  skin  over  which  they  flow.  Frequently 
the  labia  are  swollen  and  tender,  the  patient  may  complain  of  soreness  from 
friction  in  walking,  and  sometimes  dysuria  occurs  from  extension  of  the 
inflammation  into  the  urethra.  In  severe  cases  ulcerations  or  erosions  upon 
the  labia  result,  increasing  the  distress  of  the  patient. 

Vulvitis  is  sometimes  aphthous.  Small  rounded  elevations  appear  upon 
the  vulva  and  ulcerate,  and  the  adjacent  surface  is  red  and  more  or  less 
swollen.  The  ulcers  are  sensitive  and  painful,  but  under  ordinary  circum- 
stances they  progressively  heal.  Rarely,  in  those  who  are  markedly  cachec- 
tic the  ulcers  become  gangrenous  and  recovery  is  tedious  and  uncertain. 

Etiology. — The  most  common  cause  of  vulvitis  appears  to  be  uncleanli- 

i  Disease>i  of  Children,  1882. 


876  DISEASES  OF  THE  GENITO-UEINABY  ORGANS. 

ness,  and  hence  its  frequency  in  the  families  of  the  poor  and  degraded  in 
cities.  The  collection  of  dirt  and  sebaceous  matter  upon  the  vulva,  and  the 
irritation  to  which  it  gives  rise,  which  prompts  the  patient  to  rub  or  scratch 
the  parts,  cause  inflammation.  Struma  strongly  predisposes  to  this  inflamma- 
tion, so  that  slight  irritating  causes  develop  it  in  those  who  possess  this  diath- 
esis. A  considerable  proportion  of  those  who  have  vulvitis  have  or  have 
had  other  manifestations  of  scrofula  and  present  the  strumous  aspect,  so  that 
it  seems  proper  to  consider  the  inflammation  of  the  vulva  occurring  under  such 
circumstances  as  possessing  a  strumous  character  or  as  a  local  manifestation  of 
the  strumous  diathesis.  We  therefore,  with  Dr.  West,  regard  struma  as  an 
important  predisposing  cause  of  vulvitis  in  the  child.  Ascarides  in  the  rectum 
have  long  been  recognized  as  a  cause,  producing  this  efi"ect  by  the  intense 
itching  which  prompts  the  patient  to  rub  the  parts  and  thereby  inflame  them. 
It  is  said  that  ascarides  sometimes  crawl  to  the  vulva,  and  produce  inflamma- 
tion by  their  presence  upon  the  sensitive  surface.  A  last  and  most  important 
cause  is  infection  by  gonorrhoeal  pus.  Every  physician  who  sees  cases  in  the 
dispensaries  or  tenement-houses  of  our  large  cities  meets  cases,  even  girls  of 
three  or  four  years,  in  whom  vulvitis  has  this  cause.  Sometimes  the  gonor- 
rhoea is  communicated  criminally  ;  in  other  instances  it  is  contracted  from 
the  infected  seat  of  a  privy  or  from  soiled  towels  or  linen.  A  young  man 
whom  I  attended  was  under  treatment  for  gonorrhoea,  when  his  two  nieces 
of  about  four  and  six  years  were  infected  by  the  same  disease,  probably  from 
soiled  towels.  The  anatomical  characters  do  not  enable  us  to  discriminate 
between  gonorrhoeal  and  non-specific  vulvitis,  but  the  diff'erential  diagnosis 
may  be  made  by  observing  the  gonorrhoeal  microbe  in  the  secretions  of  the 
one  and  its  absence  in  those  of  the  other.  In  both  forms  of  vulvitis  the 
muco-purulent  secretion  and  the  inflammatory  lesions  are  identical.  The 
danger  of  infecting  the  conjunctiva  and  producing  purulent  ophthalmia  from 
inoculation  with  the  secretion  of  vulvitis  is  well  known.  On  the  other  hand, 
it  is  believed  by  some  that  vulvitis  is  occasionally  caused  by  inoculating  the 
vulva  with  the  muco-pus  of  ophthalmia. 

Treatment. — The  parts  should  be  frequently  bathed  with  tepid  water  or 
mucilaginous  water  to  ensure  complete  cleanliness.  This,  with  the  use  of  a 
mild  astringent  employed  with  a  syringe,  sufiices  in  most  instances  to  produce 
immediate  improvement,  and  in  a  few  days  to  effect  a  cure.  Vaginal  injec- 
tions of  tannin  or  alum  (5  :  100).  sulphate  of  zinc  (2  :  100),  or  nitrate  of 
silver  (1  :  100)  have  been  employed  with  good  result  in  this  disease.  I 
have  obtained  benefit  from  the  following  mixture,  and  more  frequently  rec- 
ommend it  than  any  other  : 

R.  Zinci  sulphat.,  .9ss; 

Plumbi  acetat.,  9j ; 

Tinct.  opii, 

Tinct.  catechu,  da.  fjiij  ; 

Aquae,  ad  f^iv.     Misce. 

To  be  injected  warm  four  or  five  times  daily  through  a  small  glass  or  gutta- 
percha syringe.  The  same  should  be  applied  with  a  camel's-hair  pencil  to 
the  external  parts.     The  following  are  also  useful  formulae : 

R.  Ext.  opii  aq.,  3J  ; 

Liq.  phimbi  subacetat.  dil.,  ffiv.     Misce. 

R.  Pulv.  zinci  oxid.,  ^j  ; 

Acidi  tannic,  J^j ; 

Mucil.  acacise,  f.^ss ; 

Aq.  rosse,  f5iiiss.     Misce. 

If  ascarides  be  present,  a  cold  rectal  enema  of  lime-water  or  salt  and 
water  should  be  used  daily.  Benefit  may  be  obtained  from  rectal  enemata  of 
simple  cold  water  even  when  ascarides  are  not  present. 


SECTION   Y. 

SKIN   DISEASES. 


CHAPTER    I. 

ERYTHEMATOUS  DISEASES. 

Under  this  head  are  included  erythema,  roseola,  and  urticaria.  They 
consist  in  active  congestion — inflammatory,  it  is  believed — of  the  skin,  which 
soon  declines,  with  or  without  slight  furfuraceous  desquamation.  The  color 
of  the  aff"ected  cuticle  is  bright  red  in  erythema,  rosy  in  roseola,  and  pale  red 
in  urticaria.  Febrile  symptoms  often  precede  for  a  few  hours  the  occurrence 
of  the  eruption,  and  they  abate  as  it  appears. 

Erythema. 

The  eruption  of  erythema  occurs  in  patches  of  different  sizes,  the  largest 
ordinarily  not  exceeding  four  or  five  inches  in  diameter,  and  most  of  them  have 
considerably  smaller  dimensions,  their  margins  being  in  some  instances  dif- 
fused, and  in  others  circumscribed  and  well  defined.  The  patches  are  slightly 
swollen  from  engorgement  of  the  capillaries  of  the  skin  and  slight  serous 
effusion,  and  are  accompanied  by  a  sensation  of  heat  and  itching. 

Erythema  is  idiopathic  or  symptomatic.  The  idiopathic  form  is  subdivided 
into  erythema  simplex,  intertrigo,  and  laeve.  Erythema  simplex  is  produced 
by  external  agencies  of  an  irritating  nature,  as  heat,  cold,  friction,  chemical 
and  mechanical  irritants,  applied  to  the  skin.  A  common  example  of  this 
form  of  the  disease  is  the  efflorescence  about  the  anus  in  cases  of  infantile 
diarrhcea,  due  to  the  acidity  of  the  evacuations.  Erythema  intertrigo  is  pro- 
duced by  the  friction  of  opposing  surfaces  of  the  skin,  and  it  therefore  occurs 
mainly  in  the  folds  of  the  neck,  about  the  groins,  and  behind  the  ears.  This 
inflammation  is  sometimes  slight,  disappearing  in  two  or  three  days  with 
proper  treatment ;  in  other  cases  the  epidermis  becomes  denuded,  the  surface 
is  tender  and  moist,  and  even  superficial  excoriations  occur.  In  severe  cases 
the  ulcers  extend  more  deeply  and  give  rise  to  considerable  purulent  discharge, 
the  skin  and  even  subcutaneous  connective  tissue  being  more  or  less  infil- 
trated and  indurated.  The  confinement  of  the  perspiration,  and  the  moist- 
ure which  is  exuded  between  the  folds  of  the  skin,  increase  the  inflammation. 
The  effused  lif(uid  does  not  in  ordinary  cases  stiffen  linen,  as  in  eczema.  Ery- 
thema Ifeve  is  the  name  applied  to  the  inflammatory  hypera?niia  of  the  skin 
which  often  occurs  over  cedematous  parts.  Its  most  common  seat  is  about 
the  ankles  and  upon  the  legs.  In  children  it  is  most  frequently  observed  in 
the  cedema  which  results  from  scarlatinous  nephritis  and  from  heart  disease. 

Si/mptomatic  erythema,  which  occurs  from  a  general  or  constitutional 
cause  of  a  pyi'exial  character,  has  several  subdivisions.     The  simplest  and 

87r 


878  ERYTHEMATOUS  DISEASES. 

mildest  form  of  it  is  erythema  fugax,' which  comes  and  goes  quickly.  The 
erythema  which  appears  upon  the  features  in  acute  meningitis  is  a  typical 
example.  It  is  common  in  various  inflammatory  and  febrile  afi"ections.  If 
the  erythematous  patch  be  circular,  with  normal  skin  in  its  centre,  it  is 
sometimes  designated  erythema  circinatum  and,  if  the  margin  be  well  defined, 
marginatum.  Erythema  papulatum,  tuberculatum,  and  nodosum  are  applied 
to  the  same  form  of  the  disease,  one  or  the  other  term  being  employed  accord- 
ing to  the  stage  or  size  of  the  eruption.  In  erythema  papulatum  the  eruption 
begins  as  small  red  spots,  which  soon  become  papular  and  attain  a  size  vary- 
ing from  that  of  a  pin's  head  to  a  split  pea.  It  occurs  especially  on  the  neck, 
breast,  arm,  and  back  of  the  hand,  and  fades  away,  with  slight  desquama- 
tion, in  about  three  weeks.  In  erythema  tuberculatum  and  nodosum  the 
eruptions  have  a  greater  diameter  and  are  usually  more  prominent.  In 
the  latter  variety  they  often  have  a  diameter  of  two  or  more  inches,  and 
occur  most  frequently  upon  the  anterior  aspect  of  the  leg.  These  three  forms 
of  erythema,  which  may  be  described  as  one,  occur  chiefly  in  young  people. 
Erythema  tuberculatum  is  most  common  in  servants,  especially  those  recently 
from  the  country.  The  tumefaction  is  due  to  the  efi"usion  of  serum  in  the 
corium,  and,  when  the  eruption  has  considerable  prominence,  also  in  the  sub- 
cutaneous connective  tissue.  The  color  is  at  first  a  bright  red,  then  dark  red 
or  purple,  and  it  fades  away  like  the  discoloration  of  a  bruise  as  the  eruption 
declines.  Rheumatism  is  often,  and  diarrhoea  occasionally,  associated  with 
these  forms  of  erythema,  and  rheumatic  pains  are  occasionally  present,  as 
well  as  more  or  less  fever. 

Prognosis. — This,  as  regards  the  erythema,  is  always  good.  An  unfavoi'- 
able  result  in  any  case  is  due  to  cachexia  or  some  coexisting  disease.  The 
duration  of  the  milder  cases  is  only  a  few  hours,  while  cases  of  a  more  severe 
type,  as  erythema  nodosum,  last  two  or  three  weeks. 

Diagnosis. — The  ordinary  forms  of  erythema  are  distinguished  from  ery- 
sipelas by  the  absence  of  any  very  decided  burning  pain  and  tumefaction  of 
the  integument  and  tendency  to  spread,  and  by  less  marked  constitutional 
symptoms.  In  those  cases  of  erythema  in  which  there  are  infiltration  and 
swelling  of  the  skin  and  subcutaneous  connective  tissue,  the  patches  are  dis- 
tinguished from  those  of  erysipelas  by  being  multiple,  of  small  size,  less  hot 
and  painful,  not  extending,  and  presenting  as  they  disappear  the  phenomena 
of  a  bruise.  In  urticaria  the  wheals,  that  come  and  go  suddenly  with  a  pecu- 
liar stinging  sensation,  and  the  irritability  of  the  skin  in  consequence  of  which 
these  wheals  are  produced  by  slight  friction,  diff"er  so  much  from  the  symp- 
toms and  appearances  of  erythema  that  the  difi'erential  diagnosis  of  the  two  is 
easy.  In  roseola  the  eruption  ordinarily  occurs  over  a  large  part,  if  not  the 
entire  surface,  in  points  and  small  patches  with  healthy  skin  between,  and 
pi-esenting  a  rosy  instead  of  a  bright-red  color — characters  which  sufficiently 
distinguish  it  from  erythema.  Erythema  when  extensive  is  sometimes  mis- 
taken for  the  scarlatinous  eruption,  but  the  redness  of  the  fauces,  graver 
constitutional  symptoms,  vomiting,  persistence  of  the  eruption,  etc.  serve  to 
distinguish  the  latter  from  the  former  aff'ection.  In  cases  of  doubt  it  is 
proper  to  defer  the  diagnosis  for  a  day  or  two,  when  if  the  rash  be  erythe- 
matous it  will  fade.  Erythema  sometimes  occurs  in  the  initial  stage  of  vari- 
ola, when,  on  account  of  the  grave  general  symptoms,  it  may  be  mistaken  for 
scarlatina.  I  have  more  than  once  known  this  mistake  to  be  made  in  the 
hurried  visits  of  the  physicians  in  former  times,  when  smallpox  was  more 
common  than  at  present.  A  more  careful  examination  would  prevent  this 
error.  There  is  little  danger  of  confounding  erythema  with  measles  or  the 
various  papular,  vesicular,  or  pustular  skin  diseases. 

Treatment. — Erythema    fugax    requires    no    special    treatment,   except 


ROSEOLA.  879 

occasional  dusting  tlic  surface  witli  lycopodium  or  powdered  starch.  Those 
forms  of  erythema  which  are  due  to  mechanical  or  chemical  irritants  soon 
disappear  when  the  cause  is  removed.  In  erythema  around  the  anus,  pro- 
duced by  the  irritation  of  the  urinary  and  alvine  evacuations,  the  diaper 
should  be  changed  as  soon  as  soiled,  and  if  the  stools  be  frequent  and  acid 
the  alkaline  treatment  proper  for  the  diarrhoea  is  useful  also  for  the  erythema. 
In  ordinary  erythema,  as  well  as  in  erythema  intertrigo,  the  following  pre- 
scriptions for  external  use  will  be  found  beneficial : 

li.  Ziuci  oxidi,  5ss; 

Pulv.  calaminse  prspp.,  .^iv  ; 

(JlyceriniP,  ^^^\ 

Li(j.  caleis,  3vij.     Misce. 

^'' 

R.  Lycopodii,  ^sh; 

Pulv.  bismuthi  subnit.,         o'^^^-     Misce. 

R.  Pulv.  zinci  oxidi,  J^^5 

Lycopodii,  giss.     Misce. 

To  be  frequently  dusted  upon  the  inflamed  surface. 

R.  Acidi  salicylici,  gr.  v ; 

Bismuthi  snbnitratis,  ^ij ; 

Corn  starch,  .^iss ; 

Ung.  aqufe  rosfv,  ^.     Misce. 

In  obstinate  cases  the  application  three  or  four  times  daily  of  diluted 
lotio  nigra  will  frequently  be  followed  by  immediate  improvement. 

Potassium  chlorate  internally,  to  correct  the  acidity  of  the  transpiration 
from  the  skin  in  protracted  and  obstinate  cases,  and  in  certain  instances  cod- 
liver  oil  and  the  syrup  of  iodide  of  iron,  are  called  for.  If  the  derangement 
of  the  system  upon  which  the  erythema  depends  appears  to  be  of  a  rheu- 
matic character,  the  sodium  salicylate  or  alkalies  may  be  required.  Ery- 
thema papulatum,  tuberculatum,  and  nodosum  occur  most  frequently  in 
reduced  states  of  the  system,  and  therefore  need  tonics. 

Roseola. 

The  term  "  roseola  "  is  applied  to  rose-colored  spots  or  patches  of  greater 
or  less  extent,  accompanied  by  a  degree  of  febrile  reaction  and  often  by  red- 
ness, with  little  or  no  swelling  of  the  faucial  surface.  It  is  attended  by  a 
sensation  of  warmth  and  slight  itching.  The  following  groups  and  sub- 
divisions embrace  the  recognized  varieties  of  this  disease  : 

EOSEOLA. 

Idiopathic.  Symptomatic. 

Infantilis.  Variolosa. 

jEstiva.  Vaccinia. 

Autumnalis.  Miliaris. 

Annulata.  Rheumatica. 

Punctata.  Arthritica. 

Cholerica. 

Febris  continuse. 

Syphilitica. 

The  color  of  the  eruption  gradually  fades  from  a  rose-red  to  a  duller  hue, 
and  often  disappears  in  two  or  three  days.  In  other  instances  the  eruption 
lasts  a  week  or  more.     Roseola  may  occur  in  any  season,  but  it  is  most  com- 


880  ERYTHEMATOUS  DISEASES. 

mon,  especially  the  idiopathic  form,  in  the  warm  months.  Those  varieties  of 
the  idiopathic  disease  which  are  designated  infantilis,  asstiva,  and  autumnalis 
are  the  most  common  in  early  life.  They  are  in  reality  identical  or  nearly  so, 
and  may  be  described  as  one  disease. 

Symptoms. — Roseola  infantilis,  sestiva,  or  autumnalis  may  be  partial, 
appearing  upon  the  arms  and  legs,  or  general.  It  is  often  preceded  by  fever, 
languor,  and,  in  those  old  enough  to  describe  their  sensations,  by  pain  in  head, 
back,  and  limbs.  There  is  a  great  difference,  however,  in  different  cases  as 
regards  the  severity  of  the  prodromic  symptoms.  They  may  be  absent  or 
so  slight  as  scarcely  to  be  appreciable.  Occasionally  vomiting,  diarrhoea, 
or  other  symptoms  of  derangement  of  the  digestive  apparatus  immediately 
precede  the  eruption. 

The  eruption  of  roseola,  when  general,  usually  commences  upon  or  about 
the  neck  and  face,  and  in  the  course  of  twenty -four  to  thirty-six  hours  appears 
upon  the  rest  of  the  Surface.  It  bears  considerable  resemblance  to  that  of 
measles.  The  patches  are  irregular  in  shape,  a  quarter  to  half  an  inch  in 
diameter,  and,  though  of  a  rose  color  at  first,  they  soon  present  a  dusky  hue 
as  they  begin  to  fade  ;  by  pressure  the  redness  disappears.  In  the  majority 
of  cases  the  eruption  has  nearly  faded  by  the  fifth  day.  The  redness  of  the 
faueial  surface,  together  with  the  itching  or  tingling,  disappears  with  the  sub- 
sidence of  the  rash. 

Roseola  annulata  is  a  rare  disease.  It  commences  with  constitutional 
symptoms,  which  are  slight  or  pretty  severe,  and  which  cease  when  the  erup- 
tion appears ;  this  occurs  in  the  form  of  red  circular  spots,  which  enlarge  to 
the  diameter  of  an  inch  or  thereabout,  and  assume  the  shape  of  rings  enclosing 
healthy  skin.  The  rash  fades  in  a  few  days,  often  leaving  a  bruised  appear- 
ance. The  ordinary  location  of  this  form  of  erythema  is  upon  the  abdomen 
and  about  the  thighs.  In  roseola  punctata  the  eruption  is  of  small  size,  and 
it  occurs  upon  a  large  part  of  the  surface. 

Symptomatic  roseola,  which  appears  in  the  course  of  various  diseases, 
need  only  be  alluded  to.  The  diseases  in  which  it  is  developed  are,  with  the 
exception  of  syphilis,  chiefly  of  an  acute  febrile  or  inflammatory  character. 
This  eruption  is  often  really,  as  stated  by  Tilbury  Fox,  a  rose-colored  ery- 
thema, but  in  other  instances  it  presents  the  typical  form  and  appearance  of 
roseola.  Thus  I  have  known  it  to  occur  about  the  eighth  or  ninth  day  of 
vaccinia  in  rose-colored  spots  over  the  whole  surface,  and  producing  much 
anxiety  on  the  part  of  parents  lest  impure  virus  had  been  employed. 

Causes. — These  are  in  a  measure  obscure.  The  delicacy  of  the  skin  in 
infancy  and  the  active  cutaneous  circulation  no  doubt  predispose  to  roseola 
and  erythema,  and  hence  the  frequency  of  their  occurrence  in  acute  febrile 
and  inflammatory  affections.  Summer  weather,  with  the  derangements  of 
system  which  it  produces,  has  been  in  my  experience  the  most  frequent  cause 
of  idiopathic  roseola  in  young  children  in  this  city.  In  certain  summers,  as 
in  that  of  1 868,  a  large  proportion  of  the  infants  have  been  affected  by  it, 
and  I  have  been  led  to  consider  it  a  favorable  prognostic  sign  as  regards  the 
diarrhoeal  affections  which  are  so  common  in  the  warm  months. 

Prognosis. — Roseola  is  always  a  mild  and  favorable  disease. 

Diagnosis. — Roseola  is  distinguished  from  measles  by  the  absence  of 
catarrhal  symptoms,  a  less  degree  of  fever,  less  uniformity  in  the  size  of  the 
eruption,  and  the  absence  of  the  history  of  contagion.  Roseola  is  distin- 
guished from  erythema  by  the  smaller  size  of  the  eruption  and  its  rosy  or 
dusky-red  color.  The  boundary-line,  however,  between  the  two  diseases  is 
not  well  defined,  and  certain  forms  of  roseola  may  be  described  as  erythema. 
The  general  but  punctiform  efflorescence,  increase  of  temperature,  acceleration 
of  pulse,  and  the  peculiar  appearance  of  the  tongue  and  fauces,  serve  to  dis- 


URTICARIA.  881 

tinguish  scarlet  fever  from  roseola.  There  is  little  danger  of  confounding 
roseola  with  urticaria,  since  the  wheals  of  the  latter  appear  in  no  other 
disease. 

Treatment. — This  is  simple.  If  roseola  occur  in  connection  with  gastro- 
intestinal derangement  or  disease,  the  remedies  which  relieve  the  latter  exert 
a  curative  effect  upon  the  former.  In  all  cases  the  state  of  the  system  should 
be  inquired  into,  and  any  departure  from  a  state  of  health  corrected.  Roseola 
needs  no  further  constitutional  treatment.  If  there  be  itching  or  tingling  of 
the  surface,  a  lukewarm  lotion,  containing  equal  parts  of  liq.  ammon.  acetat. 
and  mistura  camphorae,  has  been  recommended,  or  a  lotion  containing  a 
drachm  of  hydrocyanic  acid  to  a  pint  of  an  emulsion  of  bitter  almonds,  used 
warm.  The  purpose  of  such  lotions  is  simply  to  relieve  the  unpleasant  sen- 
sation. Cold  applications  or  others  which  would  repel  the  eruption  should  be 
avoided ;  such  an  effect  might  be  injurious.  In  case  of  acidity  of  stomach 
alkaline  remedies  are  useful,  and  in  certain  cases  tonic  treatment  is  indicated. 

Urticaria. 

The  name  by  which  this  disease  is  designated  is  derived  from  the  term 
urd'ca,  the  nettle,  the  sting  of  which  produces  this  form  of  eruption.  The 
eruption  occurs  suddenly  in  wheals  or  pomphi,  attended  by  tingling  and 
burning,  and  suddenly  disappearing.  Urticaria  is  often  accompanied  by  no 
very  decided  general  symptoms,  but  in  some  patients  more  or  less  fever 
and  lassitude  occur,  with  perhaps  epigastric  pain  and  headache.  The  wheals 
may  occur  over  the  whole  body,  but  more  frequently  are  confined  to  a  por- 
tion of  it.  Their  shape  may  be  round,  oval,  irregular,  or  band-like,  and  their 
length  varies  from  a  few  lines  to  several  inches.  In  one  affected  by  urticaria 
the  wheals  can  be  readily  produced  by  scratching  or  rubbing  the  surface. 
The  eruption  is  thus  clearly  described  by  a  recent  writer :  "  At  first  a  bright 
flush  appears ;  the  centre  of  this  becomes  slightly  elevated  and  pales,  hence 
appears  of  lighter  color ;  the  tint  may  be  rosy,  but  more  generally  it  is 
whitish."  The  margin  of  the  wheal,  the  diameter  of  which  varies,  always 
remains  red.  This  eruption  appears  to  be  produced  by  active  congestion  of 
the  cutaneous  capillaries,  some  serous  effusion,  and  spasm  of  the  muscular 
fibres  of  the  skin.  The  effusion  of  serum  in  certain  localities  is  quite  appar- 
ent from  the  oedema  which  occurs.  The  subsidence  of  the  eruption  is  with- 
out desquamation.  Urticaria  is  ordinarily  an  acute  disease.  It  is  some- 
times chronic  in  the  adult,  but  rarely  so  in  children.  Several  varieties  of 
it  are  described  by  dermatologists,  according  to  the  cause,  appearance,  and 
duration. 

Cause.s. — These  are  external  and  internal.  Various  irritants  apart  from 
the  nettle  applied  to  the  surface  produce  the  wheals,  as  the  bites  of  certain 
insects  and  sometimes  turpentine.  The  following  are  the  principal  internal 
causes,  as  summarized  by  Hillier:  1st,  profound  and  sudden  mental  emotion ; 
2d,  certain  articles  of  diet,  as  shell-fish,  pork,  sausage,  cheese,  etc.;  3d,  cer- 
tain medicinal  substances,  as  copaiba,  valerian,  and  turpentine  ;  4th,  intes- 
tinal worms,  though  it  is  probable  that  these  seldom  operate  as  a  cause : 
5th,  uterine  ailments,  as  hysteria. 

Prognosis  ;  Diagnosis. — The  prognosis  is  good,  though  the  chronic 
form  is  sometimes  tedious  and  troublesome.  The  occurrence  of  the  wheals 
and  the  possibility  of  producing  them  by  friction  serve  to  distinguish  this 
disease  from  all  others. 

Treatment. — In  urticaria  due  to  recent  ingesta  of  an  irritating  or 
indigestible  character  an  emetic  of  ipecacuanha  is  useful,  followed  by  a 
saline,  and  better  also  an  alkaline  aperient,  as  Rochelle  salts.  An  aperient 
of  this  kind  is  useful  ordinarily  in  acute  cases  attended  by  febrile  reaction. 

56 


882  PAPULAR  DISEASES. 

The  diet  for  several  days  should  lie  simple  and  such  as  is  readily  digested,  as 
fresh  beef,  bread,  or  other  farinaceous  food,  and  milk.  Occasionally  the 
wheals  appear  periodically,  when  a  few  doses  of  quinine  effect  a  prompt  cure. 
After  the  above  measures  have  been  employed  the  subsequent  treatment, 
whether  tonic  or  otherwise,  depends  on  the  condition  of  the  patient.  Little 
benefit  accrues  from  local  measures.  Sponging  the  surface  with  cool  water 
to  which  a  little  vinegar  is  added  relieves,  in  a  measure,  the  heat  and  ting- 
ling of  the  wheals. 


CHAPTER     II. 

PAPULAE   DISEASES. 

Strophulus. 

The  three  papulge — namely,  lichen,  prurigo,  and  strophulus — which  are 
characterized  by  small  and  firm  elevations  upon  the  skin,  occur  in  children ; 
but  the  two  former  are  not  common,  and  as  they  do  not  differ  in  any  essen- 
tial particular  from  the  same  diseases  in  the  adult,  they  will  not  be  treated 
of  in  this  connection.  Strophulus,  on  the  other  hand,  is  a  disease  peculiar 
to  children.  It  is  known  as  the  red  gum  or  white  gum  according  to  its 
appearance,  and  also  as  the  tooth  rash.  The  eruption  appears  usually  on 
parts  which  are  exposed,  as  the  face,  neck,  and  extremities,  the  papules  being 
in  some  patients  of  the  size  of,  or  even  smaller  than,  a  pin's  head,  while  in 
other  cases  they  are  as  large  as  a  millet-seed. 

The  varieties  of  strophulus  described  by  dermatologists  are : 

S.  intertinctus,  S.  candidus, 

"    confertus,  "    volaticus, 

"    albidus,  "   pruriginosus. 

The  following  are  the  characters  of  these  varieties :  S.  intertinctus,  pap- 
ules bright  red,  and  occurring  chiefly  upon  the  cheeks,  forearm,  and  back  of 
hand ;  often  intertinctiired  with  blushes  of  erythema ;  it  lasts  from  two  to 
four  weeks  and  is  most  common  in  young  infants.  S.  confertus,  papules 
numerous  and  closely  aggregated,  paler,  continuing  longer  than  in  strophu- 
lus intertinctus,  and  likely  to  recur,  appearing  about  the  time  of  dentition, 
and  most  frequently  upon  the  arm.  Sometimes  certain  of  the  patches 
become  chronic,  slowly  disappearing  and  leaving  the  skin  rough  and  dry. 
S.  volaticus  appears  usually  upon  the  arms  and  cheeks  in  patches  of  about  a 
dozen  (fewer  or  more)  papules,  which  soon  disappear.  These  patches  reap- 
pear at  intervals  for  two  or  three  weeks,  and  are  attended  by  heat  and  itch- 
ing, though  not  intense.  S.  albidus,  so  called,  should  really  be  placed  among 
the  diseases  of  the  sebaceous  glands  and  described  under  another  name.  It 
appears  in  the  form  of  small  white  elevations  as  large  as  a  pin's  head,  com- 
monly upon  the  face  and  neck,  and  produced  by  distension  of  the  sebaceous 
glands  with  the  secreted  product.  The  term  strophulus  candidus  is  applied 
to  large  white  papules  which  appear  upon  the  sides  of  the  trunk,  shoulders, 
and  arms  of  infants  of  one  year  or  thereabouts,  and  disappear  in  about  one 
week.  They  are  liable  to  be  associated  with  the  papules  of  strophulus  con- 
fertus. S.  pruriginosus  is  really  a  form  of  lichen,  occurring  chiefly  above 
the  age  of  one  and  under  that  of  eight  or  nine  years.     The  papules,  whicK 


ECZEMA.  883 

are  small  and  discrete,  usually  appear  over  a  large  extent  of  surface,  ordi- 
narily n{)on  the  back,  front  (jf  the  chest,  the  face  and  arms,  and  as  they  are 
scratched  from  the  itching!,-,  minute  dark  [)oints  of  blood  collect  and  dry  upon 
their  apices.  This  form  of  strophulus  is  more  protracted  than  the  others, 
and,  in  conseciuence  of  the  irritation  produced  by  the  scratching,  pustules 
of  ecthyma  often  occur  among  the  papules.  The  apparent  cau.se  of  stroph- 
ulus pruriginosus  is  a  mode  of  life  which  imj)overishes  and  vitiates  the 
blood,  such  as  uncleanliness  and  residence  in  damp,  dark,  overheated,  and 
overcrowded  apartments.  Atmospheric  heat  also  operates  as  a  cause  of  this 
form  of  strophulus,  and  it  is  not  an  infrequent  disease  in  cities  during  sum- 
mer months. 

The  various  eruptions  included  under  the  term  "  strophulus  "  have  such 
different  anatomical  characters  that  a  proper  classification  would  locate  some 
of  them  in  other  groups  of  skin  diseases.  One  form  of  it,  as  we  have  seen, 
is  produced  by  distension  of  the  sebaceous  glands;  in  other,  and  the  majority 
of  cases,  as  appears  from  the  recent  observations  of  Mr.  Fox,  its  seat  is  the 
sweat-glands,  and  in  others  still  the  papillary  layer  of  the  skin,  as  in  lichen, 
the  papules  being  produced  by  an  exudation. 

Treatment. — Personal  cleanliness,  with  frequent  change  of  linen  and 
daily  ablution  without  the  use  of  soap,  should  be  enjoined.  Local  irritants, 
which  might  aggravate  or  cause  the  disease,  should,  so  far  as  practicable,  be 
removed.  Alkalies  in  cases  of  acidity  of  the  primse  vix,  and  occasionally 
mild  aperients,  are  required :  the  food  should  be  bland  but  nutritious,  and  if 
the  child  be  nursing  it  may  be  necessary  to  attend  to  the  health  of  the  wet- 
nurse.  Favorable  hygienic  conditions,  important  for  the  successful  treatment 
of  all  forms  of  strophulus,  are  especially  required  in  strophulus  pruriginosus. 
Nutritious  diet,  fresh  air,  quinine,  iron,  cod-liver  oil,  etc.  should  be  prescribed 
for  those  affected  by  it.  In  strophulus  albidus  the  small  round,  whitish, 
sebaceous  elevations  should  be  opened  by  the  point  of  a  lancet  and  their 
contents  pressed  out  between  tlie  thumb-nails  or  by  pressure  with  a  watch- 
key. 


CHAPTER    III. 

ECZEMA. 

This  is  one  of  the  most  common  maladies  of  the  skin.  It  constituted 
one-third  of  Devergie's  cases  and  one-sixth  of  Hillier's.  In  the  commence- 
ment of  the  eczematous  eruption  the  skin  presents  a  superficial  redness,  and 
upon  this  inflamed  area  numerous  minute  and  closely  aggregated  papules, 
vesicles,  or,  more  rarely,  pustules,  appear.  These  are  very  fragile,  so  that 
they  soon  rupture,  the  epidermis  is  broken  and  destroyed,  and  the  surface  is 
moistened  by  an  effusion  which  appears  to  be  serum,  and  cannot  be  distin- 
guished from  it  by  the  microscope.  This  liquid  when  dry  stiffens  linen.  As 
it  dries  thin  crusts  form  of  a  light-yellow  color  upon  most  parts  of  the  sur- 
face, but  they  are  thicker  and  of  a  deeper  yellow  color  upon  the  scalp  than 
elsewhere.  The  crusts  consist  mainly  of  pus,  epithelial  cells,  and  granular 
matter. 

Anatomy. — Biesiadecki  has  described  the  formation  of  the  eczematous 
eruption.  According  to  him,  the  papules  are  produced  from  the  papillae, 
which  increase  in  size  by  cell-formation  in  their  interior.     The  connective- 


884  ECZEMA. 

tissue  corpuscles  enlarge,  and  are  unusually  "  rich  in  fluid,"  and  their  num- 
ber increases.  Under  the  microscope  spindle-shaped  corpuscles  are  observed, 
filling  the  papillae,  and  extending  up  from  them  into  the  rete  Malpighii, 
crowding  apart  the  cells  of  this  layer  and  reaching  and  elevating  the  epi- 
dermis. The  epithelial  cells  in  the  immediate  vicinity  of  the  papillae  also 
become  swollen.     This  cell-growth  produces  the  eczematous  papule. 

If  the  cell-formation  continues  within  a  papilla,  certain  of  the  cells  are 
ruptured,  and  as  they  are  very  moist  a  liquid  is  efi"used  which  raises  the  epi- 
dermis over  the  summit  of  the  papilla.  This  produces  the  eczematous  ves- 
icle. Occasionally  pus  mixes  with  this  liquid,  and  the  eruption  is  then  ves- 
ico-pustular. 

In  acute  eczema  the  upper  part  of  the  true  skin  is  infiltrated  and  swollen, 
while  the  lower  part  is  commonly  unaffected,  except  in  the  most  severe  cases. 
The  older  the  eczema  the  greater  the  extent  of  the  infiltration,  so  that  in 
chronic  eczema  the  whole  thickness  of  the  skin  is  more  likely  to  be  involved 
than  in  acute  forms  of  the  malady.  The  discharge  of  the  eczematous  sur- 
face is  irritating,  and  healthy  skin  with  which  it  may  come  in  contact  is  often 
reddened  by  it  and  made  eczematous  from  its  irritating  effect.  This  eczema, 
occurring  upon  a  part  of  the  surface  which  is  in  contact  with  an  opposite 
surface  of  sound  skin,  commonly  affects  the  latter,  and,  as  Neumann  has 
stated,  a  nurse  by  carrying  an  infant  having  eczema  upon  its  nates  may  con- 
tract the  same  disease  upon  her  arm,  although  there  is  no  contagious  prin- 
ciple in  this  malady. 

Etiology. — Eczema  is  often  produced  by  irritating  substances  applied  to 
the  skin.  Croton  oil,  certain  soaps,  the  finger-nails  in  scratching,  a  hat,  truss, 
or  belt  by  pressure,  may  produce  it.  Those  having  a  tender  and  delicate  skin 
are  more  liable  to  it  than  others.  The  constitutional  causes  are  often  obscure. 
It  is  sometimes  obviously  due  to  indigestion  or  a  diet  which  disagrees,  for  we 
see  it  occur  in  nursing  infants  as  a  result  of  sickness  of  the  mother.  Anae- 
mia and  scrofula  are  occasional  catises.  Among  the  city  poor  eczema  is  com- 
mon, and  many  of  the  children  who  have  it  are  scrofulous,  but  a  large  pro- 
portion show  no  evidence  of  struma,  and  in  the  better  classes  of  society  a 
majority  do  not. 

Varieties  ;  Symptoms  ;  Course. — Eczema  is  sometimes  designated 
according  to  its  location,  as  E.  faciei,  capitis,  etc.  Another  designation, 
which  has  more  scientific  value,  is  according  to  the  form  and  stage  of 
the  eruption,  by  which  we  have  the  following  recognized  varieties — to 
wit,  Eczema  papulosum,  vesiculosum,  pustulosum,  rubrum,  impetiginosum, 
and  squamosum.  A  simpler  and  still  more  convenient  classification  is  into 
eczema  simplex,  rubrum,  impetiginosum,  and  squamosum. 

Eczema  of  the  scalp  is  common  in  infancy,  occurring  as  an  eczema  rubrum 
or  impetiginosum.  The  eczematous  exudation,  mingling  with  the  secretion 
of  the  sebaceous  glands,  which  are  numerous  upon  the  scalp,  forms  a  thick 
yellow  crust.  It  is  likely  to  extend  beyond  the  hairy  portion  to  the  forehead 
and  around  the  ears.  This  extension  aids  in  establishing  the  diagnosis  between 
eczema  and  certain  other  cutaneous  eruptions  of  the  scalp.  Eczema  of  the 
external  ear  is  sometimes  primary,  but  in  other  instances  it  is  consecutive  to 
that  of  the  scalp,  and  due  to  extension  of  the  latter.  Its  common  seat  is  in 
the  angle  behind  the  ear  and  upon  the  lobe  of  the  ear,  whence  it  often  extends 
along  the  auditory  meatus,  narrowing  its  calibre,  and  impairing  the  hearing 
temporarily  or  even  for  years.  Eczema  upon  the  forehead  commonly  occurs 
in  children  from  extension  of  the  eruption  from  the  scalp.  The  cheeks,  lips, 
and  chin  are  often  also  afi'ected  by  eczema,  which  in  this  situation  is  com- 
monly eczema  rubrum,  and  is  attended  by  redness,  swelling,  and  troublesome 
itching.    The  swollen  and  red  appearance,  with  the  crusts  and  marks  produced 


DIAGNOSIS.  885 

by  scratching,  often  greatly  disfigures  the  countenance.  In  children,  when 
eczema  occurs  upon  other  parts,  it  is  usually  associated  with  that  of  the 
scalp,  face,  or  ears,  that  in  the  latter  situations  being  the  most  severe  and 
obstinate. 

Eczema  siniphx  is  common  in  the  summer  months,  being  produced  by  the 
heat  of  the  atmosphere,  aided  perhaps  by  other  causes.  The  patient  may 
appear  well,  or  be  somewhat  indisposed,  having  febrile  symptoms,  and  scjon 
an  erytlusmatous  patch  of  greater  or  less  extent  appears,  upon  which  a  cluster 
of  the  characteristic  papules  or  vesicles  soon  occurs.  These  break,  forming 
slight  crusts,  which  are  detached  and  the  eczema  declines,  or  it  may  continue 
longer,  with  successive  crops  of  the  eruption. 

In  eczema  ruf/rnni,  since  it  is  a  more  severe  form  of  the  disease,  the  fever 
and  the  local  symptoms  are  greater  than  in  the  preceding  variety,  and  the 
eczematous  patch  presents  the  appearance  of  a  more  intense  inflammation. 
The  papules  or  vesicles  are  often  so  minute  as  to  be  with  difficulty  recognized. 
They  are  soon  broken,  when  they  foi'm  with  the  secretion  and  exudation  from 
the  surface  yellowish  or  brownish-yellow  scabs.  The  discharge  is  more  irri- 
tating, as  it  is  more  abundant,  than  in  eczema  simplex,  and  the  adjacent  skin 
is  usually  more  inflamed  from  its  contact. 

Eczema  vmpetu/itiodes  is  common  in  young  debilitated  children,  in  whom, 
in  consequence  of  the  cachexia,  inflammations,  of  whatever  character,  are 
liable  to  be  suppurative.  This  form  of  eczema  presents  at  first  the  symptoins 
and  features  of  eczema  rubrum,  bvit  the  transparent  liquid  of  the  vesicles 
soon  becomes  opaque,  fi'om  the  generation  and  admixture  of  pus-corpuscles. 
The  crusts  which  form  from  the  rupture  and  desiccation  of  the  vesiculo- 
pustular  eruptions  are  thick  and  greenish-yellow,  and  in  infants  the  sebaceous 
glands,  which  are  involved  in  the  inflammation,  pour  out  an  abundant  secre- 
tion, increasing  the  thickness  of  the  crusts.  This  form  of  eczema  is  most 
common  in  infancy,  and  its  usual  seat  is  upon  the  scalp. 

Diagnosis. — Eczema  presents  in  different  instances  so  diff"erent  an  appear- 
ance that  it  is  not  always  readily  diagnosticated.  It  will  aid  in  its  diagnosis 
to  recollect  that  it  is  in  its  nature  a  catarrh,  aff"ecting  primarily  and  chiefly 
the  upper  portion  of  the  derma  and  the  Malpighian  layer,  and  although  it 
may  now  present  a  dry  or  scaly  appearance  (E.  squamosum),  yet  its  history 
will  show  that  there  has  been  a  discharge  or  moisture.  In  a  large  proportion 
of  cases  the  physician  is  not  able  to  detect  papules  or  vesicles,  since  they  are 
fragile  and  transient,  breaking  in  the  first  thirty-six  hours  and  not  reappear- 
ing. Still,  when  they  are  absent  we  sometimes  observe  ai'ound  the  mai'gin  of 
the  patch  an  appearance  which  indicates  that  they  have  been  there.  Their 
minuteness  is  occasionally  such  that  they  may  escape  notice  on  a  cursory 
inspection  when  they  are  present  and  well  defined.  Acute  eczema,  aflPecting 
a  considerable  extent  of  surface,  is  often  attended  by  febrile  symptoms,  and 
may  be  mistaken  for  one  of  the  eruptive  fevers,  but  the  absence  of  certain 
distinctive  appearances  which  characterize  these  fevers,  and  the  speedy 
appearance  of  the  eruption  and  moisture,  establish  the  diagnosis.  Eczema 
can  be  readily  diagnosticated  from  ordinary  erythema,  which  is  a  superficial 
inflammation  without  moisture.  The  location  of  erythema  intertrigo  serves 
for  its  diagnosis,  as  it  is  evidently  produced  by  the  attrition  of  opposite  sur- 
faces of  the  skin.  Moreover,  it  lacks  the  elevated  papillae,  and  the  discharge 
does  not  stiff"en  like  that  of  eczema.  Lichen,  when  acute,  presents  some 
resemblance  to  eczema,  but  it  is  dry  and  papular,  the  papules,  though  .small, 
being  detected  by  the  finger  as  well  as  sight.  The  large  and  irregular  phlyc- 
tenula),  intense  inflammation  and  oedema,  and  mode  of  extension  of  erysipelas  ; 
large,  scattered,  and  non-inflammatory  vesicles  of  sudamina  ;  scattered  and 
acuminate  vesicles,   without  surrounding  inflammation,  of   scabies, — are   so 


886  ECZEMA. 

different  from  the  eczematous  eruption  that  the  differential  diagnosis  from 
those  diseases  is  I'eadily  made.  Herpes  circinatus  can  be  distinguished  from 
eczema  by  the  circular  shape,  larger  size,  and  greater  permanence  of  the  ves- 
icles, and  the  delicate,  branny  scales,  which  consist  rather  of  epithelial  cells 
than  the  product  of  exudation,  as  in  eczema. 

Treatment. — In  the  treatment  of  this  troublesome  complaint  local  meas- 
ures are  more  inportant  than  internal  medication,  but  the  latter  is  often  use- 
ful, and  indeed  necessary,  in  order  to  prevent  relapses.  In  the  infant  eczema 
usually  begins  as  an  erythema,  soon  followed  by  papules  and  vesicles,  and  as 
the  patient  scratches  the  itching  surface,  pustules  appear,  and  the  eczematous 
surface  presents  a  red  and  angry  appearance,  from  which  surface  a  thin  and 
highly  irritating  watery  secretion,  mixed  perhaps  with  serum,  exudes.  Thick- 
ening and  infiltration  of  the  skin  occurs,  and  the  itching  is  so  severe  that  the 
patient  cannot  refrain  from  scratching  or  rubbing,  unless  under  restraint.  The 
itching  and  the  consequent  restlessness  often  deprive  not  only  the  child,  but 
the  mother  or  nurse,  of  the  needed  sleep.  The  cure  of  the  disease  is  there- 
fore a  matter  of  great  importance,  or,  if  not  a  complete  cure,  a  mitigation  of 
the  suffering.  The  popular  belief,  which  is  also  held  by  some  physicians, 
that  the  cure  of  eczema  or  its  sudden  disappearance  may  endanger  the  safety 
of  the  child,  causing  even  convulsions,  is  without  foundation.  Dangerous 
sequelje,  if  they  occur,  must  be  attributed  to  other  causes  and  be  regarded 
as  coincidences.  Hebra,  the  most  distinguished  dermatologist  of  the  age  in 
which  he  lived,  stated,  after  having  treated  twenty-five  thousand  cases  of 
eczema,  that  he  had  never  observed  any  ill-effects  from  its  cure. 

In  the  treatment  of  eczema  it  is  a  matter  of  the  greatest  importance  to 
prevent  the  infant — for  infants  are  the  chief  sufferers — from  scratching  the 
inflamed  surface.  The  method  employed  by  Prof.  White  of  Harvard  Uni- 
versity has,  I  believe,  been  commonly  approved  and  recommended  by  modern 
dermatologists.  He  applies  a  skull-cap  of  old  cotton  or  linen,  closely  fitting, 
over  the  calvarium,  and  a  mask  of  the  same  material  covering  the  face,  with 
apertures  for  the  eyes,  nose,  and  ears,  gathered  in  under  the  chin  and  over- 
lapping two  inches  at  the  back  of  the  head  and  neck.  The  cap  and  the 
mask  protect  the  scalp  and  face  when  eczematous  from  the  rubbing  and 
scratching  of  the  child.  In  a  mild  case  this  covering  may  perhaps  be  dis- 
pensed with,  or  be  used  only  when  the  child  is  not  watched ;  but  in  severe 
cases  it  is  best  to  wear  it  constantly.  The  object  is  to  prevent  entirely  irri- 
tation of  the  inflamed  surface  by  rubbing  or  scratching,  which  invariably 
aggravates  the  eczema. 

Dr.  White  also  recommends  restraint  of  the  hands  of  the  infant.  For 
this  purpose  he  takes  a  small  pillow-case  with  a  hole  in  the  end  sufficient  to 
allow  its  head  to  pass  through.  The  pillow-case  is  then  drawn  down  over 
the  body  and  limbs  of  the  child,  and  its  front  and  back  surfaces  are  united 
by  stitches  or  safety-pins  between  the  body  and  arms  on  the  two  sides.  This 
prevents  the  infant  from  lifting  the  hands  to  the  face  or  scalp.  The  restraint 
from  such  treatment  may  seem  cruel  to  the  parents,  but  the  child  soon 
becomes  accustomed  to  it,  and  suffers  less  in  the  end  from  not  being  able 
to  scratch  the  inflamed  surface,  which  always  aggravates  the  disease. 
Whatever  ointment  is  used  can  be  conveniently  applied  under  the  cap  or 
mask. 

Before  considering  the  details  of  treatment  it  is  well  to  bear  in  mind  the 
following  facts,  which  will  aid  in  the  selection  of  remedies :  Acute  eczema 
requires  soothing  remedies,  and  should  not,  as  a  rule,  be  treated  with  soap 
and  water.  Crusts  forming  over  vesicles  should  not  be  removed,  unless 
accompanied  by  itching  or  purulent  or  decomposing  secretions  underneath. 
If  so,  they  should  be  removed  at  once  by  soothing  lotions  or  cataplasms.     If, 


TREATMENT.  887 

vesicles  form  rapidly  and  are  accompanied  by  severe  itching,  they  may  be 
broken,  so  that  the  secretion  is  released,  which  may  diminish  the  pruritus. 
In  using  mercurial  and  lead  preparations  care  should  be  taken  not  to  apply 
them  over  an  extensive  area,  since  they  are  absorbed  and  might  produce  sys- 
temic eflects  of  a  toxic  nature. 

Rimoval  of  Crusts. — The  crusts  which  in  many  cases  form  upon  eczema- 
tous  surfaces,  and  under  which  irritating  secretions  are  confined,  increase  the 
itcliing  and  restlessness  of  the  child  and  interfere  with  the  action  of  local 
remedies.  Oleaginous  substances  should  be  used  for  their  removal,  as  sweet 
oil  or  cold  cream,  and  they  should  be  applied  in  such  quantity  that  they  soak 
thoroughly  into  the  crusts.  On  smooth  surfaces,  as  the  face,  a  mild  ointment 
like  simple  cerate,  thickly  spread  on  surgeon's  lint,  may  be  applied  over  the 
crusts,  which  will  to  a  great  extent  be  detached  and  removed  with  the  plaster. 
Salicylic  acid  has  also  come  into  use  as  a  solvent  of  crusts.  The  following 
ointment,  rubbed  in  hourly  or  applied  thickly  spread  on  surgeon's  lint,  renders 
the  surface  clean  in  a  few  days : 

U.  Acidi  salicylici,        ,^j ; 

Vaseline,  5iss.     Misce. 

The  first  indication  has  now  been  accomplished,  that  of  denuding  the  sur- 
face of  crusts.     The  next  indication  is  to  cure  the  disease. 

In  commencing  the  treatment  of  acute  eczema  the  lotio  nigra  of  the 
Pharmacopoeia,  consisting  of  calomel  and  lime-water,  may  sometimes  be 
advantageously  employed,  applied  by  a  large  camel's-hair  pencil  or  soft 
cloth,  and  followed  perhaps  by  diluted  oxide-of-zinc  ointment  or  vaseline. 
The  black  wash  should  be  well  shaken  before  being  used. 

Hebra's  diachylon  ointment  is  also  soothing  and  useful  for  acute  eczema, 
if  properly  made  ;  but,  unfortunately,  much  of  that  in  the  shops  is  incor- 
rectly prepared  and  is  unsuitable.     The  following  is  the  correct  formula : 

R.  Olei  olivfe  opt.,        f^v; 
Pulv.  lithargyri,     .^i-^ij ; 
Aquse,  q.  s.     Misce. 

The  oil  is  mixed  with  a  third  of  a  pint  of  water,  and  heated  in  a  steam-bath 
to  boiling.  The  litharge,  finely  powdered,  is  then  sifted  in  with  constant 
stirring.  The  boiling  is  continued  until  the  fine  particles  of  litharge  dis- 
appear. During  the  boiling  a  little  water  is  added  from  time  to  time  to  keep 
up  the  original  amount,  and  water  remains  in  the  vessel  when  it  is  removed 
from  the  fire.  The  mixture  is  then  constantly  stirred  until  cool.  The  oint- 
ment should  be  made  of  the  best  oil  and  litharge,  and  when  properly  made  it 
resembles  butter  in  consistence,  and  to  a  certain  extent  in  color,  having  a 
light-yellow  hue.  It  should  be  freshly  made  when  needed,  and  renewed 
every  week. 

Another  good  ointment  for  acute  eczema  is  the  following,  prepared  orig- 
inally by  McCall  Anderson  : 


.  Pnlv.  bismutlii  oxidi, 

•3' ; 

Acidi  oleici, 

o.); 

Cerse  alb.T, 

3iij ; 

Vaselini, 

.5ix; 

Olei  rosiv, 

"l"j- 

Misce. 

This  also  resembles  butter  in  appearance,  and  may  be   applied   several  times 
daily. 

A  considerable  number  of  other  soothintr  ointments  have  been  used  and 


888  ECZEMA. 

recomia ended  by  dermatologists  for  acute  eczema.  One  drachm  of  carbonate 
of  zinc  or  subnitrate  of  bismuth  to  one  ounce  of  rose-water  ointment  may 
be  employed,  but  it  possesses  no  advantage  over  the  ointments  mentioned 
above,  except  that  it  is  easier  of  preparation  and  more  uniform  ;  and  the 
same  may  be  said  of  the  ointment  of  the  oxide  of  zinc,  which  has  been  more 
used  in  acute  eczema  than  any  other  ointment.  Hebra's  or  Anderson's  oint- 
ment, if  carefully  prepared  according  to  the  formula  given  above,  is  probably 
not  surpassed  by  any  other  ointment  for  its  soothing  or  curative  action. 

Ointments  have,  I  think,  given  more  satisfaction  than  dusting  powders  in 
acute  eczema,  but  in  the  commencement  of  eczema  papulosum  or  vesiculo- 
sum,  common  powdered  starch,  talc  (magnesium  silicate),  semen  lycopodii, 
or  rice-starch  (amylum  oryzse),  dusted  upon  the  inflamed  surface  does  afford 
some  relief. 

The  following  formula  is  essentially  that  recommended  by  Kaposi,  the 
glycerin  being  omitted : 

R.  Amyli  oryzse,  ^iij  ; 

Talc,  venet., 
Flor.  zinci, 
Pulv.  iridis  Florenti,  da.  3JX-     Misce. 

Camphor  may  be  added  to  relieve  itching  in  the  proportion  of  2  per  cent. 

Van  Harlingen  states  that  in  eczema  intertrigo  and  in  other  forms  of 
eczema  attended  by  much  burning  and  itching,  but  without  discharge,  the  fol- 
lowing prescription  gives  great  relief: 

R.  Pulv.  camphorse,  3j  ; 

PuW.  arayli, 
Pulv.  zinci  oxidi,  da.  ,^ss.     Misce. 

To  be  dusted  upon  the  surface  or  upon  the  soft  side  of  surgeon's  lint,  and 
the  lint  to  be  applied  upon  the  inflamed  part.  It  should  not  be  used  upon  a 
raw  surface.  Carbonate  of  zinc  and  subnitrate  of  bismuth  are  also  useful 
dusting-powders  for  such  cases. 

Itching  is  the  symptom  which  produces  the  chief  suffering  and  restless- 
ness of  the  patient :  2  per  cent,  of  camphor  added  to  ointments  or  washes 
gives  some  relief  to  this  symptom.  A  mixture  of  2  per  cent,  of  acetic  acid 
in  water,  or  J  to  a  2  per  cent,  solution  of  aluminium  acetate  in  water,  it  i& 
said  also  relieves  the  pruritus.  Carbolic  acid,  properly  diluted,  is  one  of  the 
most  effectual  agents  to  relieve  the  itching.  But,  as  we  have  stated  above^ 
applications  containing  water  frequently  applied  are  likely  to  aggravate  acute 
eczema.  If  the  above  remedies  fail  to  give  relief,  and  the  pruritus  makes  the 
child  restless,  the  following  formula  may  be  tried : 

R.  Acidi  carbolici,  gr.  xv ; 

Spts.  vini  Gallici,  S^^~3'^y  > 

Spts.  lavendul., 

Eau  de  cologne,  da.  ^vjX-     Misce. 

This  can  be  applied  by  a  camel's-hair  pencil.  The  addition  to  it  of  cocaine 
might  render  it  more  effectual  in  relieving  the  itching.  The  following  lotion 
has  also  been  considerably  used  in  New  York,  and  has  been  recommended  by 
dermatologists : 

R.  Acidi  hydrocyan.  dil.,  ^ij  ; 

Bismuthi  snbnitrat.,  .^ij  ; 

Aquae  destillat.,  5viij.     Misce. 
Ft.  lot. 


TREATMENT.  889 

By  the  above  treatment  the  inflammation  usually  abates,  but  the  ecze- 
matous  patch  may  be  still  hyperaemic,  infiltrated,  and  descjuamating,  and 
additional  measures  are  required  to  restore  it  to  the  normal  state.  Moder- 
ately stimulating  applications  are  now  needed,  and  tar  is  the  best  agent  for 
this  purpose.  Tar  should  never  be  applied  in  moist  eczema.  Its  use  should 
be  reserved  for  dry  and  desquamating  eczema.  The  various  tars  which  have 
been  used  with  success  in  eczema  are  the  pix  lifjuida  or  pine  tar,  the  oleum 
fu^^i  or  beech  tar,  the  oleum  rusci  or  birch  tar,  and  the  oleum  cadinum. 
obtained  from  the  Juniperis  oxycfdriis.  Tar  penetrates  all  the  layers  of  the 
skin,  for  when  used  externally  it  has  been  found  in  the  urine.  In  a  few 
patients  it  has  been  stated  that  its  employment  has  been  followed  by  rigors, 
fever,  headache,  and  vomiting.  If  such  symptoms  arise,  it  should  of  course 
be  discontinued.     The  following  formulae  may  be  employed: 

R.  Ung.  picis  liquidae,  .^j  ; 

Alcoholis,  Sij-     Misce. 

R.  Olei  rusci  Tel  cadini,  f^j  ; 

Alcoholis,  fSii-iij-     Misce. 

R.  Olei  rusci  vel  cadini,  f  5J ; 

Alcoholis, 
^theris,  da.  f5iss.     Misce. 

The  alcoholic  solutions  of  tar  should  be  applied  by  a  small  bristle  brush 

(Heitzman). 

R.  Picis  liquidae,  .^j ; 

Adipis,  Jj.     Misce. 

R.  Picis  liquidre,  .^j  ; 

Ung.  zinci  oxidi,  ^.     Misce.     (Van  Harlingen.) 

Van  Harlingen  states  that  sulphur  may  be  used  with  the  tar,  often  with 
the  best  results.     He  employs  the  following  formula : 

R.  Sulphur,  praecipitat., 

Picis  liquidae,  da.  ^ss ; 

Ung.  zinci  oxidi,  ^j.     Misce. 

He  adds  that,  like  other  tarry  preparations,  it  should  be  used  in  small  quan- 
tity and  rubbed  thoroughly  into  the  skin. 

In  chronic  eczema,  in  which  the  inflammation  is  mild  and  the  surface 
scaly  and  dry,  more  stimulating  applications  are  required  than  those  recom- 
mended above.  For  such  cases  the  following  prescriptions  will  be  found 
useful : 

R.  Unguenti  hydrarg.  ammoniat.,  3y  j 

Unguenti  zinci  oxidi, 
Unguenti  aquae  rosse,  da.  ^. 

^""^ 

R.  Pulv.  hydrarg.  chlor-mitis,  gr.  v; 

Ung.  zinci  oxidi,  3J.     Misce. 

Apply  three  or  four  times  daily  to  the  inflamed  surface. 

Constitutional  Treatment. — No  one  line  of  treatment  is  suitable  for  every 
patient.  Among  the  city  poor  strumous  cases  are  common,  and  cases  also  in 
which,  without  any  pronounced  diathetic  state,  the  cause  is  apparently  a 
reduced  state  of  the  system  from  innutritions  diet  and  other  antihygienic 
conditions.  Such  cases  require  better  diet  and  a  mode  of  life  more  in  accord- 
ance with  sanitary  requirements.  On  the  other  hand,  I  have  observed  cases 
of  eczema  which  seemed  to  be  produced  or  rendered  more  intractable  by  a 
plethoric  state  of  the  system,  especially  in  the  nursing  infant,  when  the  milk 
of  the  mother  or  wet-nurse  was  unusually  rich  or  abundant.  While,  there- 
fore, ill-nourished  and  weakly  children  require  better  regimen,  with  perhaps 


890 


SCABIES. 


vegetable  and  ferruginous  tonics,  the  plethoric  require  reducing  treatment, 
though  of  a  gentle  kind.  Their  food  should  be  plain  and  unstimulating. 
Indigestible  articles,  as  pastries,  cheese,  and  rich  sauces,  should  be  avoided, 
especially  when  symptoms  of  indigestion  are  present.  Indigestion  or  other 
aberration  of  the  system  from  the  healthy  standard  should  be  promptly  cor- 
rected. Saline  aperients  are  useful  in  case  of  constipation  and  of  a  plethoric 
habit.  The  saline  diuretics,  as  the  acetate  and  citrate  of  potassium,  are  often 
beneficial  in  acutQ  eczema  with  febrile  symptoms,  especially  if  the  urine  be 
rather  scanty.    The  following  formula  is  recommended  by  Dr.  A.  R.  Robinson  : 

R.  Potassii  acetatis, 
Spts.  setheris  nitrosi, 
Syrupi  aurantii, 
A  quae  carui,  q.  s.  ad 

One  teaspoonful  three  times  daily  to  a  child  of  one  year. 

In  acute  as  well  as  chronic  eczema  any  departure  from  the  healthy  stand- 
ard, whether  in  the  digestive  organs,  the  kidneys,  or  other  part  of  the  system, 
should  be  corrected  so  far  as  possible,  since  *eczema  is  more  readily  cured 
when  the  functions  of  the  internal  organs  are  normally  performed. 


3iss; 
5"j- 


Scabies. 

The  diseases  of  the  skin  previously  considered  are  non-contagious. 
Scabies,  on  the  other  hand,  is  one  of  the  most  contagious  diseases  by  con- 
tact. It  is  produced  by  an  animal  parasite,  known  as  the  itch-mite,  or  Acarus 
scabiei.  The  inflammation  is  caused  by  the  female  only,  which  burrows, 
making  for  itself  a  canal  or  cuniculus,  in  which  its  eggs  are  deposited.  The 
male  does  not  burrow,  but  conceals  itself  under  the  scales  or  crusts  which 
result  from  the  inflammation  produced  by  its  partner,  or  it  burrows  only 
sufiiciently  to  produce  a  covering  and  shelter.  From  observations  made  by 
Eichstedt,  Gudden,  and  others  the  female  has  been  found  within  half  an  hour 
after  being  placed  upon  the  skin  to  have  concealed  herself  in  the  epidermis, 


Fig.  48. 


Fig.  49. 


Fig.  50. 


Fig.  51. 


0 
0 


Fig.  48.  The  itch  animalcule,  Acarus  scabiei,  viewed  upon  the  back,  showing  its  figure  and 
the  arrangement  of  its  spines  and  filaments.  The  female,  which  is  somewhat  larger  than  the 
male,  has  a  length  of  one-eightieth  to  one-sixtieth  of  an  inch. 

Pig.  49.    The  foot  and  last  joints  of  the  leg  of  the  itch  animalcule. 

Fig.  50.  The  male  itch  animalcule,  viewed  upon  the  under  surface,  showing  its  legs  and 
lobulated  feet. 

Fig.  51.    Ova  of  the  itch  animalcule. 

and  the  burrow  which  she  constructs  is  arched  and  tortuous  and  four  or  five 
lines  in  length,  shorter  or  longer.  The  acarus  has  the  shape  of  a  tortoise. 
It  can,  when  fully  grown,  be  detected  by  the  eye  as  a  minute  whitish  point. 


DIA  GNOSIS— TREA  TMENT.  891 

The  young  acarus  has  six,  tlie  mature  eight,  articulated  legs,  with  suckers 
upo:!-  ^ae  two  anterior  pairs  and  hairs  on  the  posterior.  The  head,  which  can 
be  elongated  or  reti'acted,  is  provided  with  two  jaws.  The  upper  surface 
is  covered  with  spines  directed  backward  so  as  to  prevent  retrogression  in  the 
burrow.  She  leaves  behind  her  in  the  cuniculus,  as  she  advances,  her  moulted 
skin,  excreta,  and  eggs,  which  hatch  on  the  eleventh  day.  The  mother-acarus 
is  always  found  at  the  remote  end  of  the  burrow,  where  it  can  be  seen  by  the 
unassisted  eye  as  a  minute  whitish  or  sometimes  brownish  speck,  and  from 
which  it  can  be  lifted  by  the  point  of  a  needle,  to  which  it  clings.  The 
cuniculi  can  also  be  seen  by  the  naked  eye,  looking,  says  Niemeyer,  like  the 
"  scars  of  needle-scratches,"  and  containing  the  young  acari  in  various  stages 
of  growth. 

The  acarus  by  its  burrowing  produces  an  irritation  and  troublesome  itch- 
ing, which  is  the  chief  cause  of  the  suffering  of  the  patient.  At  the  point 
■where  the  acarus  penetrates  the  cuticle  the  inflammation  gives  rise  to  a  single, 
small,  and  acuminate  vesicular  or  papular  eruption,  the  cuniculus  extending 
away  from  it.  We  often  find  ecthymatous  pustules  and  abrasions  intermin- 
gled with  the  vesicles,  the  result  of  frequent  scratching.  The  itching  is  most 
intense  and  the  acarus  most  active  at  night,  when  the  patient  is  warm  in  bed. 
Scabies  most  frequently  appears,  especially  in  adults,  first  upon  the  hands, 
between  the  fingers,  where  the  skin  is  thin,  and  it  extends  thence  along  the  fore- 
arm and  over  the  thighs  and  abdomen.  In  children  it  not  infrequently  occurs 
upon  the  buttocks,  thighs,  feet,  etc.,  while  the  hands  and  forearms  escape. 

Diagnosis. — Correct  diagnosis  is  important,  because  the  treatment 
required  is  different  from  that  in  any  other  exanthem,  and  because  the  sus- 
picion of  having  this  disease  always  renders  one  solicitous  to  know  the  exact 
nature  of  the  eruption.  Scabies  can  be  diagnosticated  from  those  diseases 
for  which  it  may  be  mistaken  by  the  following  characters :  its  occurrence 
where  the  cuticle  is  thin  and  delicate,  as  between  the  fingers,  along  the  ante- 
rior aspect  of  the  forearm,  upon  the  abdomen,  thighs,  and  inside  of  the  feet ; 
small  size,  acuminate  shape,  and  isolated  position  of  vesicles ;  the  intermin- 
gling with  the  vesicles  of  other  forms  of  eruption,  as  papules  and  pustules, 
and  the  presence  of  linear  scars  and  abrasions  produced  by  the  scratching; 
itching  most  intense  at  night ;  absence  of  fever  ;  absence  of  the  disease  from 
posterior  aspect  of  body  and  arms  and  from  head  and  face.  Scabies  may  be 
distinguished  by  the  vesicular  character  of  the  eruption  from  all  other  exan- 
thematic  aiFections  except  eczema,  sudamina,  and  herpes.  Eczema  is  most 
■common  on  the  scalp  and  face,  where  scabies  does  not  occur,  and  unlike 
scabies  its  vesicles  are  round  and  thickly  aggregated  in  clusters ;  in  eczema 
there  is  a  smarting  or  prickling  sensation  very  diff"erent  from  the  intense  itch- 
ing of  scabies.  In  herpes  the  vesicles  are  large,  rounded,  and  in  clusters, 
and  attended  by  a  burning  or  pricking  sensation,  with  but  little  itching.  The 
eruption  in  sudamina  is  vesicular  and  discrete,  as  in  scabies,  but  it  is  globular 
and  accompanied  by  no  itching  or  other  local  symptoms. 

Treatment. — As  scabies  is  due  to  a  species  of  acarus  which  burrows  in 
the  epidermis,  it  can  only  be  treated  successfully  by  measures  which  destroy 
this  animalcule.  If  it  be  destroyed,  the  disease  gets  well  of  itself.  Sulphur 
has  been  employed  for  a  long  period  for  this  purpose,  since  sulphurous  acid, 
which  is  evolved  from  the  sulphur,  is  destructive  to  the  animalcule.  The 
unguentum  sulphuris,  if  thoroughly  applied,  will  rarely  fail  to  eradicate  sca- 
bies. The  internal  use  of  sulphur  aids  the  external  treatment,  since  a  portion 
of  the  gas  which  is  generated  escapes  through  the  pores  of  the  skin.  The 
chief  objection  to  the  employment  of  sulphur  is  its  exceedingly  unpleasant 
odor,  which  is  noticeable,  however  disguised  by  perfume.  Sulphur  or  any 
other  substance  employed  externally  has  more  effect  if  it  be  preceded  by  a 


892  SCABIES. 

bath,  which  softens  the  epidermis,  and  therefore  favors  the  entrance  of  the 
remedy  into  the  r  ires  of  the  skin  and  the  cuniculi. 

Helmeri'^^'s  ointment  is  very  efiectual  in  the  treatment  of  scabies.  It 
consists  oi  two  parts  of  sulphur,  one  of  carbonate  of  potassium,  and  eight 
of  lard.  "  M.  Hardy  afterward  perfected  the  method,  so  as  radically  to  cure 
the  disease  in  two  hours.  He  proceeded  in  the  following  manner  :  The  patient 
first  undergoes  a  friction  of  his  whole  body  for  half  an  hour  with  soft  soap, 
in  order  to  cleanse  the  skin  and  break  up  the  burrows ;  a  warm  bath  of  an 
hour's  duration  follows,  during  which  the  skin  is  thoroughly  rubbed,  in  order 
to  complete  the  destruction  of  the  burrows ;  after  which  frictions  for  half  an 
hour  and  upon  the  whole  surface  are  practised  with  Helmerich's  ointment. 
This  completes  the  cure.  Out  of  400  patients  subjected  to  this  treatment 
only  4  returned  to  the  hospital.'" 

M.  Albin  Gras  experimented  with  different  substances  in  order  to  ascer- 
tain their  relative  destructiveness  to  the  acarus.  The  following  table  gives 
some  of  the  results  of  his  experiments  : 

Immersed  in  pure  water,  the  acarus  was  alive  after  three  hours. 

"  saline  water,  the  acarus  moved  freely  after  three  hours. 

"  Goulard's  solution,  the  acarus  lived  after  one  hour. 

"  olive,  almond,  or  castor  oil,  the  acarus  lived  more  than  two  hours. 

"  lime-water,  the  acarus  died  in  three-fourths  of  an  hour. 

"  vinegar,  "  "  twenty  minutes. 

alcohol, 
"  turpentine,        "  "  nine  " 

"  iodide  of  potassium,  the  acarus  died  in  four  to  six  minutes. 

It  is  seen  that  vinegar,  lime-water,  alcohol,  turpentine,  and  iodide  of 
potassium  destroy  the  acarus  in  a  short  time.  They  may  be  employed  in 
the  same  manner  as  the  sulphur  ointment.  Camphor  is  also  destructive  to 
this  animalcule,  and  the  linimentum  camphorge,  thoroughly  applied,  is  a  good 
remedy  for  uncomplicated  scabies. 

In  order  to  avoid  the  odor  of  sulphur,  which  is  so  offensive,  one  of  the 
following  ointments  may  be  employed  if  the  patient  be  fastidious : 


R.  Unguent,  hydrarg.  ammoniat., 

Ij; 

Moschi, 

gr.ij; 

OL  lavendul., 

gtt.ij;  . 

01.  amygdal.. 

gj.     Misce.'' 

If  scabies  be  extensive  this  should  not  be  used,  as  its  application  over 
considerable  area  might  endanger  salivation,  but  the  following,  which  is  rec- 
ommended by  Bazin,  and  is  said  to  cure  the  disease  with  three  applications, 
may  be  used  instead  : 

R.  Anthemis  pulv., 
Adipis, 
01.  olivae,  ad.  5J.     Misce. 

In  cases  which  have  been  protracted,  and  in  which  ecthymatous  and  other 
secondary  eruptions  have  occurred,  the  scabies  can  ordinarily  be  readily  cured, 
while  the  other  eruptions  remain  and  disappear  more  slowly.  A  knowledge 
of  this  is  important,  since  the  sulphur  or  other  ointment  employed  for  the 
cure  of  scabies  should  be  discontinued  when  the  itching  ceases  and  vesicles 
no  longer  appear,  and  tonic  or  other  treatment  appropriate  to  cure  these 
secondary  eruptions  should  be  employed  instead.  The  sulphur  ointment 
continued  after  the  scabies  is  cured  does  harm,  since  it  irritates  the  cuticle.  It 
is  essential  in  the  treatment  of  scabies  that  the  linen  be  frequently  changed. 
1  Stille's  Therapeutics,  etc.,  vol.  ii.  p.  561.  "^  From  Wilson. 


INDEX. 


ACEPHALUS,  97 
Acrania,  97 
Albuminuria  in  diphtheria,  392 
Albuminuria  in  scarlet  fever,  300 
Animal  heat,  92 
Aphthous  stomatitis,  742 
Appendicitis,  856 

etiology,  857 

anatomical  characters,  858 

symptoms,  859 

diagnosis,  861 

prognosis,  862 

treatment,  863 
Artificial  feeding,  72 
Atelectasis,  687 

acquired,  687 

symptoms,  anatomical  characters,  689 

treatment,  690 
Attitude  in  disease,  87 

BATHING  in  infancy,  SO 
Blue  disease,  106 
Booker,  W.  D.,  investigations   relating   to 

intestinal  bacteria,  781 
JBrain,  incomplete,  98 

in  inftincy  and  childhood,  520,  521 
Brain,  atrophy  of,  522 
hypertrophy  of,  523 

pathological  anatomy,  523,  524 
causes,  524 

symptoms,  case,  525,  526 
diagnosis,  526 
prognosis,  treatment,  527 
Thrombosis,  527 

anatomical  characters,  528 
causes,  529 

symptoms,  diagnosis,  prognosis,  530 
treatment,  531 
Congestion  of,  531 
causes,  531,  532 

symptoms,  anatomical  characters,  prog- 
nosis, 533 
ti-eatment,  534 
Hemorrhage  of,  534 
Dropsy  of,  congenital,  542 
acquired,  548 
Bronchial  phthisis,  234 
Bronchitis,  677 

causes,  anatomical  characters,  677-679 

symptoms,  680 

diagnosis,  682 

prognosis,  treatment,  683-687 

riALCULI,  874 

\j     Cancrum  oris,  744 

Caput  succedaneum,  117 


Caries,  vertebral,  637 

causes,  symptoms,  diagnosis,  637-639 
prognosis,  treatment,  640 
Catarrhal  laryngitis,  644 
Catarrhal  pharyngitis,  756 
Catarrh,  intestinal,  of  infancy,  785 
Cephaltematoraa,  117 
Cerebro-spinal  fever,  470 
definition,  470 
history,  470-472 
etiology,  472 
its  contagiousness,  474 
secondary,  476 
sex,  age,  477 
symptoms,  478 
mode  of  commencement,  479 
nervous  system,  480 
digestive  system,  485 
pulse,  temperature,  486 
respiratory  system,  487 
cutaneous  surface,  488 
urinary  organs,  488 
special  senses,  489 
symptoms  of  endemic  or  naturalized, 

490 
nature,  491 

anatomical  characters,  492 
prognosis,  495 
diagnosis,  497 
treatment,  498 
curative,  498 
internal,  501 
Cerebro-spinal  system,  diseases  of,  520 
Chicken-pox,  353 
Childhood,  35 

changes  of  organs,  35 
Cholera  infantum,  799 

anatomical  characters,  800 
nature,  802 

diagnosis,   prognosis,   treatment,  SOS- 
SOS 
Chorea,  608 
causes,  609 
sex,  609 
uterine  irritation,  610 
auiiemia,  610 
rheumatism,  610 

lesions  of  brain  and  spinal  cord,  615 
fright,  614 
imitation,  614 
intestinal  irritation,  614 
anatomical  cliaracters,  615 
symptoms,  616 
prognosis,  course,  618 
diagnosis,  619 
treatment,  619 

S93 


894 


INDEX. 


Circulatory  system  in  infancy,  90 
Clothing  in  infancy,  81 
Colitis,  808 
causes,  808 
symptoms,  809 
diagnosis,  809 
prognosis,  809 
treatment,  810 
Colostrum,  48 

constituents  of,  48,  49 
Congestion  of  brain,  531 
of  spinal  cord,  635 
of  stomach,  771 
Conjunctivitis,  120 
mild  or  catarrhal,  120 
purulent  ophthalmia  neonatorum,  121 
symptoms,  122 
course,  results,  123 
preventive  measures,  123,  124 
treatment,  125 
Constipation  of  new-born,  155 
causes,  156 
symptoms,  157 
treatment,  158 
Constipation,  symptomatic,  811 
idiopathic,  813 
causes,  813-815 
symptoms,  815 
treatment,  817 
hygienic,  818 
therapeutic,  820 
Consumption,  221 
Convulsions,  clonic,  570 
internal,  590 
causes,  591 

anatomical  characters,  symptoms,  592 
case,  593 
diagnosis,  prognosis,  mode  of  death, 

594 
treatment,  595 
Coryza,  641 

anatomical  characters,  641 
symptoms,  prognosis,  treatment,  642 
Cough,  nervous,  737 
causes,  737 
treatment,  737,  738 
Cranial  sinuses,  thrombosis  in,  527 
Craniotabes,  190 
Croup,  false  or  spasmodic.    (See  Spasmodic 

Laryngitis,  646.) 
Croup,  membranous  (diphtheritic),  650 
etiology,  650-653 
anatomical  characters,  654 
symptoms,  655 
diagnosis,  656 
prognosis,  659 
treatment,  preventive,  660 
internal,  663 
surgical,  666 
intubation  in,  667-676 
tracheotomy  in,  675 
Cryptorcliia,  874 
Cyanosis,  106 
its  literature,  106 

sex,  time  of  commencement,  107,  108 
symptoms,  108-110 


Cyanosis:  prognosis,  mode  of  death,  111, 
112 
nature  of  malformations,  112 
mode  of  compensation,  113 
morbid  anatomy,  113,  114 
theories  relating  to,  etiology  of,  114,  115 
treatment,  116 

DACTYLITIS,  strumous,  208 
sypliilitica,  259 
Dentition,  750 

pathological  results,  751 
diagnosis,  treatment,  753 
Dentition,  second,  755 
Diagnosis  of  infantile  diseases,  85 

features,  appearance  of  head,  trunk^ 

and  limbs  in  disease,  85-87 
attitude,  movements,  voice,  87 
respiratory  system,  87-90 
circulatory  system,  90 
animal  heat,  92 
digestive  system,  93 
nervous  system,  94 
Diarrhoea  of  the  new-born,  153 

treatment,  154 
Diarrhoea,  simple,  781 

causes,  symptoms,  782 
anatomical  characters,  783 
prognosis,  treatment,  784 
Diarrhoea,  inflammatory,  785 
etiology,  787 
age,  791 
dentition,  791 
anatomical  characters,  795 
Diarrhoea,  choleriform,  799 

treatment,  803 
Digestive  apparatus,  diseases  of,  739 
Digestive  system  in  infancy,  93 
Dilation  of  stomach,  775 
Diphtheria  in  scarlet  fever,  293,  294 
Diphtheria,  356 
history,  356 
etiology,  360 

mode  of  propagation,  364 
contraction  from  animals,  366 
age,  368 
incubation,  370 
nature,  371 
diagnosis,  376 
pultaceous  pharyngitis,  377 
scarlatinous  pharyngitis,  378 
gangrenous  pharyngitis,  378 
herpetic  pharyngitis,  378 
ulcero-membranous  pharyngitis,  378 
anatomical  characters,  378 
the  blood,  381 
brain  and  spinal  cord,  382 
tonsils,  382 
faucial  surface,  uvula,   epiglottis,  lungs, 

383 
vesicular  emphysema,  384 
pulmonary  apoplexy,  384 
lymphatic  glands,  384 
heart,  mouth,  stomach,  intestines,  385 
spleen,  liver,  kidneys,  385,  386 
symptoms,  386 


INDEX. 


895 


•  Diplitlieria :  temperature,  388 

nares,  389 

eye,  ear,  mouth,  389,  390 

oesophagus,  stomach,  intestines,  390 

genito-urinarv  organs,  391 

skin,  392 

albuminuria,  392 

paralysis,  395 

clinical  history,  396 

time  of  commencement,  397 

loss  of  tendon  reflexes,  398 

palatal  paralysis.  399 

multiple  paralysis,  400 

cardiac  paralysis,  401 

etiology,  406 

prognosis,  411 

preventive  treatment,  413 

treatment,  416 

liygienic,  417 

stinuihuits,  418 

quinine,  tuietura   ferri   chloridi,   potas- 
sium chlorate,  421 

hydrargyri  chloridum  corrosivum,  423 

calomel,  425 

turpentine,  426 

pilocarpine,  sodium  benzoate,  427 

treatment,  local,  solvents,  428 

albuminuria,  429 

paralysis,  429 
Dyspepsia,  765 
Dysuria,  874 

ECLAMPSIA,  570 
causes,  571 

premonitory  stage,  symptoms,  572 

partial  eclampsia,  573 

anatomical  characters,  574 

diagnosis,  prognosis,  574,  575 

treatment,  576 
Eczema,  883 

anatomy,  883 

etiology,  varieties,  symptoms,  884 

diagnosis,  885 

treatment,  886 
Empyema,  712,  729 
Encephalocele,  100 
Endocarditis  in  rheumatism,  506 
Enteritis,  808 

causes,  808 

symptoms,  diagnosis,  809 

prognosis,  treatment,  809,  810 
Entero-colitis,  785 
Enuresis,  866 

etiology,  868 

prognosis,  treatment,  870 
Epilepsy,  578 

etiology,  predisposing  causes,  578 

age,  exciting  causes,  578,  579 

svmptoms,  minor  and  major  attacks,  580 

aura,  580-582 

anatomical  characters,  583 

pathology,  584 

diagnosis,  585 

prognosis,  treatment,  586-589 
Erysipelas,  512 

point  of  commencement,  causes,  514 


Erysipelas :  premonitory  symptoms,  515 

symptoms,  516 

prognosis,  duration,  517 

modes  of   death,  pathological  anatomy, 
517,  518 

treatment,  518 
Erythema,  877 

prognosis,  diagnosis,  treatment,  878 
Exercise  in  infancy,  83 

FEEDING,  infantile,  64 
over-feeding,  64 
insufficient,  65 
improper,  66,  67 
quantity  of  food  required,  68 
statistics,  69 
Feeding,  artificial,  72 
Fever,  intermittent,  449 
Fever  and  ague,  449 
Foetus,  effects  of  maternal  impressions  on, 

36 
Follicular  gastritis,  777 
Fright  a  cause  of  chorea,  619 

r<ALACTAGOGUES,  56 

V7     Gangrene  of  mouth,  744 

anatomical  characters,  744 

causes,  symptoms,  745 

diagnosis,  746 

prognosis,  747 

treatment,  748 
Gastritis,  771 

cause,  777 

age,  772 

symptoms,  anatomical  characters,  773 

diagnosis,  prognosis,  treatment,  774 

follicular  (diphtheritic),  775 
Gastro-intestinal  bacteria,  779 
Gastro-intestinal  hemorrhage,  150 
Gastro-malacia,  776 

case,  777 
German  measles,  328 
Glands  in  scrofula,  207 
Glottis,  spasm  of,  590 
Green  color  of  the  stools,  780 
Growth  of  infants,  43 

H^MATEMESIS  and    meltena  neona- 
toi'um,  150 
age,  150 
etiology,  151 

diagnosis,  prognosis,  treatment,  153 
Heart-malformations,  104 
Hemorrhage,  intracranial  (meningeal,  cer- 
ebral), 534 
causes,  anatomical  characters,  535 
meningeal,  536 
cerebral,  537 
symptoms,  538 
capillary,  539 

symptoms  in  meningeal,  540 
diagnosis,  prognosis,  treatment,  541 
Hemorrhage,  umbilical,  128 
Hemorrhage,  gastro-intestinal,  150 
Hooping-cough,  431 
Hydrenceplialocele,  100 


896 


INDEX. 


Hydrocephalus,  congenital,  542 

anatomical  characters,  542 

etiology,  symptoms,  545 

prognosis,  treatment,  547 
Hydrocephalus,  acquired,  548 

causes,  548 

anatomical  characters,  symptoms,  549 

prognosis,  treatment,  550 
Hydrocephalus,  spurious,  566 

anatomical  characters,  case,  566 

symptoms,  567 

causes,  568,  569 

diagnosis,  prognosis,  569 

treatment,  570 

ICTEEUS  neonatorum,  132 
theories  of  its  causation,  133-135 
prognosis,  treatment,  135 
Indigestion,  765 
causes,  765 
symptoms,  766 
prognosis,  767 
diagnosis,  treatment,  768 
Infancy,  33 
organs  in,  34 
mental  faculties  in,  34 
Infantile  paralysis,  624 
Infarctions,  uric-acid,  866 
Inflammation  of  sterno-cleido-mastoid  mus- 
cles, 118 
Intermittent  fever,  449 
etiology,  450 
symptoms,  451 
treatment,  453 
Internal  convulsions,  590 
Intestinal  catarrh  of  infancy,  785 
etiology,  787 
age,  dentition,  791 
symptoms,  792 
anatomical  characters,  797 
diagnosis,  798 
prognosis,  799 
Infantile  cholera,  or  choleriform  diar- 
rhoea, 799 
nature,  802 

diagnosis,  prognosis,  803 
treatment,  803-808 
Intestinal  worms,  822 
Intracranial  hemorrJiage,  534 
Intubation,  668 

difficulties  of  operation,  671 
accidents  and  dangers  of,  672 

asphyxia,  673 
mode  of  extraction,  674 
after-management,  674 
Intussusception,  837 

without  symptoms,  837 
with  symptoms,  838 
previous  health,  causes,  838 
age,  seat,  pathological  anatomy,  839 
in  small  intestines,  839 

cases,  840-842 
in  large  intestines,  842 
symptoms,  844 
diagnosis,  846 
duration,  prognosis,  846,  847 


Intussusception  in  large  intestines :   mode 
of  death,  848 
treatment,  849 

JAUNDICE  of  new-born,  132 
Joints,  inflammation   of,   in   rheuma- 
tism, 505 

KEEATITIS,  strumous,  217 
herpetic  or  phlyctenular,  217 
parenchymatous  or  diffiise,  220 
Kidneys  in  diphtheria,  392 
in  rachitis,  201 
in  scarlet  fever,  300 

LACTATION,  mode  of  determining  capa- 
bility, 44 
hindrances  to,  44 
tender  nipples,  44 
ill-health,  44,  45 
syphilis,  46 
inflammations,  46 
erysipelas  in  mother,  47 
colostrum,  48 
Lactic  acid  a  cause  of  rachitis,  183,  184 
Laryngismus  stridulus,  590 
Laryngitis,  catarrhal,  644 
symptoms,  644 
chronic,  644 

anatomical  characters,  treatment,  645 
spasmodic,  646 

causes,  symptoms,  646 
anatomical  characters,  pathology,  647 
diagnosis,  treatment,  647,  648 
Lockjaw,  159 

Lung,  inflammation  of.     (See  Pneumonia.) 
in  tuberculosis.     (See  Tuberculosis.) 
in  diphtheria.     (See  Diphtheria.) 

MALFORMATIONS,  97 
acrania,  97 
incomplete  brain,  98 
meningocele,      encephalocele,     hydren- 

cephalocele,  99,  100 
spina  bifida,  101 
congenital    abnormalties   in   circulating 

system,  104 
malformations  of  heart,  104 
cyanosis,  106 
Mammary  glands,  119 
Mastitis,  119  . 

Measles,  263 

etiology,  symptoms,  263 
complications,  266 
anatomical  characters,  nature,  268 
diagnosis,  prognosis,  ti-eatment,  269 
German,  328 
Meconium,  33 
Membranous  croup,  650 
Meningeal  hemorrhage,  534 
Meningitis  (tubercular  and  non-tubercular), 
551 
age,  552 

pathological  anatomy,  553 
causes,  556 
premonitory  stage,  557 


INDEX. 


897 


Meningitis :  symptoms,  558 
case,  561 

diagnosis,  prognosis,  562 
treatment,  5t).S 
Meningocele,  100 
Milk,  hnman,  49 
composition,  50 
modification  from  diet,  50 
from  insufficient  food,  50 
from  retention  in  breast,  51 
by  age  and  mental  impressions,  51 
by  catamenial  function  and  by  preg- 
nancy, 52 
difference  in  quantity  and  quality,  54 
effect  of  medicines,  54 
rules  in  regard  to  nursing,  55 
scantiness:  cause,  treatment,  55 
Morbilli.     (See  Meadea.) 
Morbus  ca?ruleus.     (See  Ci/anosis.) 
Mortality  of  early  life,  causes,  39 
internal  malformations,  40 
feebleness  of  system,  4() 
hereditary  disease,  40 
infectious  disease,  40 
anti-hygienic  conditions,  41 
improper  food,  42 
Mother,  care  of,  in  pregnani'v,  35 
Mouth,  inffammation  of,  739 

gangrene  of,  744 
Muguet,  145 
Mumps,  445 

etiology,  incubation,  445 
symptoms,  anatomical  characters,  446 
complications,  sequelse,  446,  447 
diagnosis,  prognosis,  treatment,  447,  448 
Myelitis,  624 

■VTECROSIS,  744 

11     Nephritis  in  diphtheria,  392 

Nephritis  in  scarlet  fever,  300 

Nervous  cough,  737 

Nervous  system  in  infancy,  94 

Newly-born,  diseases  of,  97 

Noma,  744 

Nurse,  selection  of,  59 

OBSTETRICAL  scarlatina,  279 
(Edema  neonatorum,  176 
G'-^sophagitis,  763 

anatomical  characters,  treatment,  764 
OVdium  albicans.     (See  Tlirush.) 
Ophthalmia,  strumous,  217 

herpetic  or  phlyctenular  keratitis,  217 

duration,  diagnosis,  prognosis,  218 

treatment,  218,  219 

parenchymatous  or  diffiise  keratitis,  220 
Otitis  in  scarlet  fever,  296 

PAPULAE  diseases,  882 
Paralysis,  621 
causes:  a  change  in  the  blood,  621 
reflex  influence,  621 
injury  of  a  nerve,  621 
anatomical  change  in  muscular  fibres, 

621 
disease  of  nervous  centres,  a  case,  622 
67 


Paralysis  :  Poliomyelitis  acuta  anterior,  624 
symptoms,  624 

diagnosis,  prognosis,  etiology,  625-627 
treatment,  628 
Paralysis,  facial,  630 

causes,  symptoms,  630 
Paralysis,  pseudo-hypertrophic,  631 
symptoms,  631,  632 
anatomical  characters,  causes,  633 
prognosis,  treatment,  634 
Parotiditis,  445 
Pemphigus  neonatorum,  177 
simplex,  177 
cachecticus,  178 
anatomy,  treatment,  178 
Peptonized  milk,  75 
Peripharyngeal  abscess,  759 
age,  causes,  759 

anatomical  characters,  symptoms,  760 
diagnosis,  762 
prognosis,  treatment,  763 
Perityphlitis,  856 
etiology,  857 

anatomical  characters,  858 
symptoms,  859 
diagnosis,  861 
prognosis,  862 
treatment,  863 
Pertussis,  431 

incubative  period,  age,  causes,  432 
pathological  anatomy,  433 
symptoms,  first  period,  434 
second  period,  434 
third  period,  435 
complications,  436 
diagnosis,  prognosis,  439 
treatment,  440 

carbolic  acid,  cocaine,  antipyrine,  441 
quinine,  442 
sulphur,  443 
prophylaxis,  445 
Pharyngitis,  catarrhal,  756 

anatomical  characters,  756 
symptoms,  prognosis,  diagnosis,  757 
treatment,  758 
Phlebitis,  527 
Phthisis,  221 
Pleurisy  (pleuritis),  704 
frequency,  704,  705 
causes,  705-707 
anatomical  characters,  710 
plastic,  711 

sero-fibrinous,  711,  712 
purulent,  7J2 
hemorrhagic.  713 
symptoms,  716 
physical  signs,  718 
palpitation,  719 
percussion,  719,  72(1 
aascultation,  720 
diagnosis,  721 
prognosis,  723 
treatment,  725 
internal,  726 
thoracentesis,  72S 
empyema,  729 


INDEX. 


Pleurisy  :  treatment :  mode  of  operating,  730 
admission  of  air,  733 
injury  to  lung  by  instruments,  734 
washing  pleural  cavity,  734 
extraction  of  portion  of  ribs,  736 
Pneumonia,  690 

catarrhal,  etiology,  690-693 
croupous,   etiology,   anatomical    charac- 
ters, 693-696 
septic  or  embolismal,  696 
cheesy,  696 

symptoms  of  croupous,  398 
physical  signs,  699 
diagnosis,  700 
prognosis,  ti'eatment,  701 
Post-mortem  gastric  softening,  776 
Pott's  disease,  637 
Pregnancy,  care  of  mother  in,  35 
Pseudo-membranous  croup,  650 
Pulse  in  health,  90 
in  disease,  91 
influenced  by  excitement,  91 

RACHITIS,  179 
frequency,  179,  180 
age,  181 
causes,  182 

anatomical  characters,  186 
cartilaginous  changes,  186 
osseous  changes,  186 
pathology  of,  188 

anatomical   characters   in   stage   of  de- 
formity, 188 
changes  in  cranial  bones,  189 
craniotabes,  190 
symptoms,  190,  191 
changes  in  vertebrae,  192 
in  maxilla;,  193 
in  ribs,  194 

in  bones  of  upper  extremity,  196 
in  bones  of  lower  extremity,  196 
effect  on  dentition,  198 
changes  in  soft  tissues,  198 
reconstruction,  199 
symptoms  of  rachitis,  200 
complications  and  sequelae,  201 
diagnosis,  prognosis,  201-203 
treatment,  203 
Remittent  fever,  454 

symptoms,  diagnosis,  prognosis,  455 
treatment,  455,  456 
Respiratory  system,  diseases  of,  641 

in  infancy,  87 
Retropharyngeal  abscess,  759 
Rheumatism,  acute,  503 
causes,  504 
symptoms,  505 

duration,  prognosis,  diagnosis,  509 
treatment,  510 
Rheumatism,  scarlatinous,  297 
Rickets,  179 
Roseola,  879 

symptoms,   causes,   prognosis,  diagnosis, 

880 
treatment,  881 
Rotlieln,  328 


Rotheln :  premonitory  stage,  330 

symptoms,  {a)  tegumentary  system,  330 
(6)  mucous  membrane,  331 
respiratory  and  digestive  system,  331 
pulse,  temperature,  332 
complications,  prognosis,  332 
nature,    incubative    period,    contagious- 
ness, 332-335 
complications,  diagnosis,  335 
prognosis,  treatment,  336 
Rubeola.     (See  Measles.) 

SCABIES,  890 
cause,  890 
diagnosis,  891 
treatment,  891,  892 
Scarlet  fever,  271 
etiology,  271 
incubative  period,  274 
contagiousness,  275 
variations  in  type,  276 
surgical  scarlatina,  276 
obstetrical  scarlatina,  279 
age,_280 
clinical  facts  regarding  scarlet  fever, 

281 
symptoms,  ordinary  form,  283 
grave  form,  287 
irregular  form,  288 
complications  and  sequels,  289 
nervous  accidents,  290 
inflammation  of  the  faucial  surface, 

291 
diphtheria,  293,  294 
inflammation  of  middle  ear,  296 
scarlatinous  rheumatism,  297 
pleuritis,  298 
dilation  of  the  heart,  299 
nephritis,  dropsy,  300 
parenchymatous  nephritis,  prolifera- 
tion of  nuclei,  301 
interstitial  nephritis,  303 
anatomical  characters,  305 
diagnosis,  306 
prognosis,  308 
treatment,  310 
prophylaxis,  310 
hygienic,  313 
therapeutic,  313 
mild  cases,  313 

ordinary  and  severe  cases,  314 
antiseptic,  318 

complications     and     sequelae,    318, 
328 
Sclerema  neonatorum,  174 
Scrofula,  205 
causes,  205 
•  anatomical  characters,  206 
dactylitis,  208 
symptoms,  209 
prognosis,  211 
treatment,  212 
Sepsis  of  new-born,  136 

first  group,  cases,  137, 140 
second  group,  cases,  140,  143 
third  group,  cases,  143,  145 


INDEX. 


899 


Skin  diseases,  877 
Sleep  in  inCanoy,  .S2 
Sinallpox,  33(3 
S[)asin  of  the  glottis,  590 
Spina  bifida,  101 

diagnosis,   prognosis,    treatment,    102, 
103 
Spinal  cord,  diseases  of,  634 
congestion  of,  035 

anatomical  characters,  symptoms,  636 
treatment,  636,  637 
vertebral  caries,  637 
Stomach,  congestion  of,  771 
inflammation  of,  771 
dilatation  of,  775 
softening  of,  776 
Stomatitis,  simple,  739 

causes,  symptoms,  appearances,  treat- 
ment, 739,  740 
Stomatitis,  ulcerous,  740 

causes,  symptoms,  prognosis,  treatment, 
740^  741 
Stomatitis,  aphthous,  742 

causes,  symptoms,  diagnosis,  prognosis, 
treatment,  743 
Stomatitis,  gangrenous,  744 

anatomical  characters,  744 
causes,  symptoms,  745 
diagnosis,  746 
prognosis,  747 
treatment,  748 
St.  Vitus'  or  St.  Guv's  dance,  608 
Strophulus,  882 
varieties,  882 
treatment,  8S3 
Strumous  ophthalmia,  217 
Syphilis,  251 
etiology,  251 
clinical  history,  253 
coryza,  mucous  patches,  255 
roseola,  pemphigus,  acne,  impetigo,  ec- 
thyma, 256 
visceral  lesions,  257 
osseous  lesions,  258 
dactylitis  syphilitica,  259 
prognosis,  259 
treatment,  260 

TAENIA  solium,  826 
saginata,  827 
elliptica,  827 
Teething,  750 
Tetanus  neonatorum,  159 
causes,  160 

period  of  commencement,  161 
frequency  in  certain  localities,  162 
causes,  163 
symptoms,  170 

mode  of  death,  prognosis,  171 
duration  in  fatal  and  favorable  cases, 

172 
diagnosis,  preventive   treatment,   172, 

173 
treatment,  173,  174 
Tetany,  597 
causes,  597,  600 


Tetany :  symptoms,  601 
cases,  6(32,  605 
pathology,  diagnosis,  606 
prognosis,  treatment,  607 
Thoracentesis,  728 
Thread-worms,  823 
Thrombosis  in  cranial  sinuses,  527 
Thrush,  145 
causes,  145 

anatomical  characters,  146 
symptoms,  147 
diagnosis,  jjrognosis,  148 
treatment,  149 
Tracheotomy,  075 
Tubage  in  menil)ranous  croup,  668 
Tuberculosis,  221 
etiology,  221 
anatomical  charactei's,  224 

in  infancy  and  childhood,  225 
tubercles  in  lungs,  220 
cavities,  emphysema,  228 
tubercles  in  abdominal  viscera,  230 
stomacii  and  intestines,  230 
general  symptoms,  231 
encephalon,  232 

in  tubercles  of  bronchial  glands,  234 
physical  signs,  235 
in  tubercles  of  pleura,  237 
in  tubercles  of  stomach  and  intestines,  237 
diagnosis,  237 
prognosis,  240 
prophylaxis,  241 
treatment,  243 
Typhlitis,  856 
Typhoid  fever,  456 
causation,  456 
anatomical  characters,  459 
pathology,  460 

incubative  period,  symptoms,  461 
duration,  462 
complications,  403 
diagnosis,  464 
prognosis,  465 
treatment,  465-469 
prophylaxis,  469,  470 

ULCEROUS  stomatitis,  740 
Umbilicus,  diseases  of,  127 
vegetations  of,  127 

jirognosis,  diagnosis,  treatment,  128 
hemorrhage  of,  128 
sex,  age,  causes,  129,  130 
symptoms,    prognosis,  treatment,   131, 
132 
Uric-acid  infarctions,  866 
Urine,  incontinence  of,  870 
Urticaria,  881 
causes,   diagnosis,    prognosis,   treatment, 
881 

VACCINIA.  345 
appearances,  symptoms,  34S 
anomalies,  complications,  se(iuels.  349 
ei'vsipelas,  syphilis,  349,  350 
subsequent  vaccinations,  350 
protection  from  vaccination,  351 


900 


INDEX. 


Vaccinia :  selection  of  virus,  352 
Varicella,  353 

symptoms,  354 

diagnosis,  prognosis,  treatment,  355 
Variola,  336 

etiology,  336 

incubative  period,  stage  of  invasion,  337 

stage  of  eruption,  338 
of  desiccation,  338 
of  desquamation,  339 
Varioloid,  340 

mode  of  death,  340 

anatomical  characters,  341 

complications,  341 

diagnosis,  342 

treatment,  343 
Vaughan,  Dr.  V.  C,  remarks  on  intestinal 

bacteria,  781 
Vertebral  caries,  637 
Vulvitis,  875 

etiology,  875 

ti'eatment,  876 


w 


EANING,  62 
Weight  of  infant,  43 


Wet-nurse,  selection  of,  59 
syphilis  in,  59 
character  of  good  milk,  60 
lactometer,  60 
lactoscope,  60 
use  of  microscope,  60 
micro-organisms  in  milk,  60,  61 
return  of  catamenia,  61 
course  of  wet-nursing,  62 
weighing  of  infant,  63 
Whooping-cough,  431 
Worms,  intestinal,  822 

ascaris  Inmbricoides,  823 
oxyuris  vermicularis,  824 
tape-worm,  825 
tsenia  solium,  826 
taenia  saginata,  827 
taenia  elliptica,  827 
bothriocephalus  latus,  828 
trichocephalus  dispar,  828 
'  causes,  829 
symptoms  of  ascaris  Inmbricoides,  830 
of  oxyuris  vermicularis,  831 
of  tape-worm,  831 
diagnosis,  prognosis,  treatment,  832 


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patients  per  month)  ;  Perpetual  (undated,  for  30  patients  weekly  per  year)  ;  and  Per- 
petual (undated,  for  60  patients  weekly  per  year).  The  GO-patient  Perpetual  consists 
of  256  pages  of  assorted  blanks.  The  first  three  styles  contain  32  pages  of  important 
data  and  I'JG  pages  of  assorted  blanks.  Each  style  is  in  one  wallet-shaped  book,  leather- 
bound,  with  pocket,  pencil,  rubber,  and  catheter- scale.     Price,  each,  $1.25.     Ju--:f  ready. 

SPECIAL  COMBINATIONS  WITH  VISITING  LIST. 

The  Amek.  Journal  ($4)  with  Visiting  Lis^t  (§1.25),  or  Yeak-Book  ($1.50),  for 
The  Medical  Neavs  ($4)      "  "  "         "        "  "  "         " 

The  Journal  and  News  ($7.50)       "  "         "        "  "  "         " 

The  Journal,  News,  Visiting  List  and  Year-Book  (see  page  16) 

This  list  is  all  that  could  be  desired.  It  con- 
tains a  vast  amount  of  useful  information,  especi- 
ally for  emergencies,  and  gives  good  tables  of  doses 
and  therapeutics. — Canadian  Practitioner. 

For  convenience  and  elegance  it  is  not  surpass- 
able. — Obstetric  Gazette,  November. 

The  Medical  News  Visiting  List  for  the  year  1892 
contains  certain  improvements  as  compared  with 
previous  issues.  It  is  difficult  to  imagine  any 
ordinary  emergency  occuring  in  medical  practice 
that  is  not  treated  of  in  this  useful  work. — Mon- 
treat  Medical  Journal,  December,  1891. 

The  new  issue  maintains  its  previous  reputation. 


54.75 
4.75 
8.25 
8.50 

It  adapts  itself  to  every  style  of  book-keeping; 
there  is  space  for  all  kinds  of  professional  records ; 
it  is  furnished  with  a  ready- reference  thumb-letter 
index,  and  has  a  most  valuable  text. — Medical 
Record. 

The  Jledical  News  Visiting  List  for  1892  will  be 
found  to  be  one  of  the  best  of  Its  kind.  A  special 
index  facilitates  speedy  reference.  Besides  the 
usual  table  of  doses,  incompatibles,  poisons  and 
antidotes,  it  contains  directions  for  examination 
of  urine,  ligation  of  arteries,  and  a  brief  resume 
of  the  accepted  treatment  of  the  diseases  most 
often  met  ^ilh.— The  Canadian  Prac,  Jan.  16, 1892. 


THE  3IEDICAL  NEWS  PHYSICIANS'  LEDGEB. 

Containing  300  pages  of  fine  linen  "  ledger  "  paper,  ruled  so  that  all  the  accounts  of  a 
large  practice  may  be  conveniently  kept  in  it,  either  by  single  or  double  entry,  for  a  long 
period.  Strongly  bound  in  leather,  with  cloth  sides,  and  with  a  patent  flexible  back, 
which  permits  it  to  lie  perfectly  flat  when  opened  at  any  place.     Price,  $4.00. 


HAItTSHOBNE,  HENBT,  A.  31.,  M,  !>.,  ii.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

A  Conspectus  of  the  Medical  Sciences ;  Containing  Handbooks  on  Anatomy, 
Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics. 
Second  edition,  thoroughly  revised  and  greatly  improved.  In  one  large  royal  12mo. 
volume  of  1028  pages,  with  477  illustrations.     Cloth,  $4.25 ;  leather,  $5.00. 


The  object  of  this  manual  is  to  afford  a  conven- 
ient work  of  reference  to  students  during  the  brief 
moments  at  their  command  while  in  attendance 
upon  medical  lectures.  It  is  a  favorable  sign  that 
It  has  been  found  necessary,  in  a  short  space  of 
time,  to  issue  a  new  and  carefully  revised  edition. 
The  illustrations  are  very  numerous  and  unusu- 
ally clear,  and  each  part  seems  to  have  received 
its  due  share  of  attention.  We  can  conceive  such 
a  work  to  be  useful,  not  only  to  students,  but  to 
practitioners  as  well.    It  reflects  credit  upon  the 


industry  and  energy  of  its  able  editor. — Boston 
Medical  and  Surgical  Journal,  Sept.  3, 187i. 

We  can  say  with  the  strictest  truth  that  it  is  the 
best  work  of  the  kind  with  which  we  are  ac- 
quainted. It  embodies  in  a  condensed  form  all 
recent  contributions  to  practical  medicine,  and  is 
therefore  useful  to  every  busy  practitioner  through- 
out our  country,  besides  being  admirably  adapted 
to  the  use  of  students  of  medicine.  The  book  is 
faithfully  and  ably  executed.— C/iar^esion  Medical 
Journal,  April,  1875. 


LUDLOW,  J,  L.,  31.  n., 

Consulting  Physician  to  the  Philadelphia  Hospital,  etc. 

A  Manual  of  Examinations  upon  Anatomy,  Physiology,  Surgery,  Practice  of 
Medicine,  Obstetrics,  Materia  Medica,  Chemistry,  Pharmacy  and  Therapeutics.  _  To  which 
is  added :         " 
one 

The  arrangement  of  this  volume  in  the  form  of  question  and  answer  renders  it  espe- 
cially suitable  for  the  office  examination  of  students,  and  for  those  preparing  for  graduation. 


ided  a  Medical  Formulary.   Third  edition,  thoroughly  revised,  and  greatly  enlarged.   In 
12mo.  volume  of  816  pages,  with  370  illustrations.     Cloth,  $3.25 ;  leather,  $3.75. 


HOBLYN,  RICH  Ann  D.,  31.  D. 

A  Dictionary  of  the  Terms  Used  in  Medicine  and  the  Collateral 
Sciences.  Kevised,  with  numerous  additions,  by  Isaac  Hays,  M.  D.,  late  editor  of 
The  American  Journal  of  the  Medical  Sciences.  lii  one  large  royal  12mo.  volume  of  520 
double-columned  pages.     Cloth,  $1.50 ;  leather,  $2.00. 

It  is  the  best  book  of  definitions  we  have,  and  ought  always  to  be  upon  the  student's  ta!o\e.— Southern 
Medical  and  Surgical  journal. 


liEA  Brothers  &  Co.'s  Publications — Dictionaries. 


THE    STANDARD. 

the; 

HATIOnAL  UleDieAL  DK^TIOnSRY 

INCLUDING 

English,  French,  German,  Italian  and  Latin  Technical  Terms  used  in  Medicine  and 
the  Collateral  Sciences,  and  a  Series  of  Tables  of  Useful  Data. 


John  %  Billing?,  I|.D,  LL.D,  Ediq.  and  Hai^V,  D.S.L.,  D^^oii. 

Member  of  the  National  Academy  of  Sciences,  Hurgeon  U.  S.  A.,  etc. 
WITH  THE  COLLABORATION  OF 


Prof.  W.  O.  ATWATER. 
FRANK  BAKEE,  M.  D., 
S.  M.  BURNETT,  M.  D., 
W.  T.  COUNCILMAN,  M.  D., 


JAMES  M.  FLINT,  M.  D., 
J.  H.  KIDDER,  M.  D., 
WILLIAM  LEE,  M.D., 
R.  LORINI,  M.D., 


WASHINGTON  MATTHEWS,  M.  D., 
C.  S.  MINOT,  M.D. 
H.  C.  YARROW,  M.  D., 


In  two  very  handsome  royal  octavo  volumes  containing  1574  pages, 
with  two  colored  plates. 

Per  Volume— Cloth,  $6;   Ijcatlier,  $7 ;   Balf  Morocco,  Marbled  Edges,  $8.50.    For  Sale 
hy  Subscription  only.    Specimen  pages  on  application,    A.ddress  the  Publishers, 


The  publishers  have  great  pleasure  in  presenting  to  the  profession  a  new  practical 
working  dictionary  embracing  in  one  alphabet  all  current  terms  used  in  every  depart- 
ment of  medicine  in  the  five  great  languages  constituting  modern  medical  literature. 

For  the  vast  and  complex  labor  involved  in  such  an  undertaking  no  one  better  quali- 
fied than  Dr.  Billings  could  have  been  selected.  He  has  planned  the  work,  chosen  the 
most  accomplished  men  to  assist  him  in  special  departments,  and  personally  supervised 
and  combined  their  work  into  a  consistent  and  uniform  whole. 

Special  care  has  been  taken  to  render  the  definitions  clear,  sharp  and  concise. 
They  are  given  in  English,  with  synonyms  in  French,  German  and  Italian  of  the  more 
important  words  in  English  and  Latin. 

Eegarded  as  a  dictionary,  therefore,  this  standard  work  supplies  the  physician, 
surgeon  and  specialist  with  all  information  concerning  medical  words,  simple  and  com-^ 
pound,  found  in  English,  giving  correct  spelling,  clear,  sharp  definitions  and  accentua- 
tion, and  furthermore  it  enables  him  to  consult  foreign  works  and  to  understand  the  large 
and  increasing  number  of  foreign  words  used  in  medical  English.  It  is  especially  full 
in  phrases  comprising  two,  three  or  more  words  used  in  special  senses  in  the  various 
departments  of  medicine. 

The  work  is,  however,  far  more  than  a  dictionary,  and  partakes  of  the  nature  of  an 
encyclopaedia,  as  it  gives  in  its  body  a  large  amount  of  valuable  therapeutical  and  chemi- 
cal information,  and  groups  in  its  tables,  in  a  condensed  and  convenient  form,  a  vast 
amount  of  important  data  which  will  be  consulted  daily  by  all  in  active  practice. 

The  completeness  of  the  work  is  made  evident  by  the  fact  that  it  defines  84,844 
separate  words  and  phrases. 

The  type  has  been  most  carefully  selected  for  boldness  and  clearness,  and  everything 
has  been  done  to  secure  ease,  rapidity  and  durability  in  use. 


Its  scope  is  one  which  will  at  once  satisfy  the 
stadent  and  meet  all  the  requirements  of  the  med- 
ical practitioner.  Clear  and  comprehensive  defi- 
nitions of  words  should  form  the  prime  feature  of 
any  dictionary,  and  in  this  one  the  chief  aim 
seems  to  be  to  give  the  exact  signification  and  the 
different  meanings  of  terms  in  use  in  medicine 
and  the  collateral  sciences  in  language  as  terse  as 
is  compatible  with  lucidity.  The  work  is  i-emark- 
able,  too,  for  its  fulnebS.  The  enumerations  and 
subdivisions  under  each  word-heading  are  strik- 
ingly complete,  as  regards  alike  the  English  tongue 
and  the  languages  chiefly  employed  by  ancient 
and  modern  science.  It  is  impossible  to  do  justice 
to  the  dictionary  by  any  casual  illustration.  It 
presents  to  the  English  reader  a  thoroughly 
scientific  mode  of  acquiring  a  rich  vocabulary  and 
offers  an  accurate  and  ready  means  of  reference  in 
consulting  works  in  any  of  the    three    modern 


continental  languages  which  are  richest  in  med- 
ical literature.  To  add  to  its  usefulness  as  a  work 
of  reference  some  valuable  tables  are  given. 
Another  feature  of  the  work  is  the  accuracy  of  its 
definitions,  all  of  which  have  been  checked  by 
comparison  with  many  other  standard  works  in 
the  different  languages  it  deals  with.  Apart  from 
the  boundless  stores  of  information  which  may  be 
gained  by  the  study  of  a  good  dictionary,  one  is 
enabled  by  the  work  under  notice  to  read  intelli- 
gently any  technical  treatise  in  any  of  the  four 
chief  modern  languages.  There  cannot  be  two 
opinions  as  to  the  great  value  and  usefulness  of 
this  dictionary  as  a  book  of  ready  reference  for  all 
sorts  and  conditions  of  medical  men.  So  far  as 
we  have  been  able  to  see,  no  subject  has  been 
omitted,  and  in  respect  of  completeness  it  will  be 
found  distinctly  superior  to  any  medical  lexicon 
yet  published. —  The  London  Lancet,  April  5, 1890. 


Lea  Brothers  &  Co.'s  Publications — Anatomy,  Dictionary. 


GRAY,  HENRY,  F,  It,  S., 

Lecturer  on  Anatomy  at  St.  Oeorgc's  Hospital,  London. 

Anatomy,  Descriptive  and  Surgical.  Edited  by  T.  Pickering  Pick:, 
F.  R.  C.  S.,  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  George's  Hospital,  London, 
Examiner  in  Anatomy,  Royal  College  oi  Surgeons  of  England.  A  new  American  from 
tlie  eleventh  enlarged  and  improved  London  edition,  thoroughly  revised  and  re-edited 
by  "William  W.  Keen,  M.  D.,  Professor  of  Surgery  in  the  Jeflerson  Medical  College  of 
Philadelphia.  To  which  is  added  the  second  American  from  the  latest  English  edition  of 
Landmarks,  Medical  and  Surgical,  by  Luther  Holden,  F.  R.  C.  S.  In  one  imperial 
octavo  volume  of  1098  pages,  with  685  large  and  elaborate  engravings  on  wood.  Price  of 
edition  in  black:  Cloth,  $6;  leather,  $7  ;  half  Russia,  $7.50.  Price  of  edition  in  colors 
(see  below):  Cloth,  $7.25;   leather,  $8.25;  half  Russia,  $8.75. 

This  work  covers  a  more  extended  range  of  subjects  than  is  customary  in  the  ordinary 
text-books,  giving  not  only  the  details  necessary  for  the  student,  but  also  the  application  to 
those  details  to  the  practice  of  medicine  and  surgery.  It  thus  forms  both  a  guide  for  the 
learner  and  an  admirable  work  of  reference  for  the  active  practitioner.  The  engravings 
form  a  special  feature  in  the  work,  many  of  them  being  the  size  of  nature,  nearly  all 
original,  and  having  the  names  of  the  various  parts  printed  on  the  body  of  the  cut,  in 
place  of  figures  of  reference  with  descriptions  at  the  foot.  In  this  edition  a  new  departure 
has  been  taken  by  the  issue  of  the  work  with  the  arteries,  veins  and  nerves  distinguished 
by  difierent  colors.  The  engravings  thus  form  a  complete  and  splendid  series,  which  will 
greatly  assist  the  student  in  forming  a  clear  idea  of  Anatomy,  and  will  also  serve  to  refresh 
the  memory  of  those  who  may  find  in  the  exigencies  of  practice  the  necessity  of  recall- 
ing the  details  of  the  dissecting-room.  Combining,  as  it  does,  a  complete  Atlas  of 
Anatomy  with  a  thorough  treatise  on  systematic,  descriptive  and  applied  Anatomy, 
the  work  will  be  found  of  great  service  to  all  physicians  who  receive  students  in  their 
offices,  relieving  both  preceptor  and  pupil  of  much  labor  in  laying  the  groundwork  of  a 
thorough  medical  education. 

For  the  convenience  of  those  who  prefer  not  to  pay  the  slight  increase  in  cost  necessi- 
tated by  the  use  of  colors,  the  volume  is  published  also  in  black  alone,  and  maintained 
in  this  style  at  the  price  of  former  editions,  notwithstanding  its  largely  increased  size. 

Landmarks,  Medical  and  Surgiad,  by  the  distinguished  Anatomist,  Mr.  Luther  Holden, 
has  been  appended  to  the  present  edition  as  it  was  to  the  previous  one.  This  work  gives 
in  a  clear,  condensed  and  systematic  way  all  the  information  by  which  the  practitioner  can 
determine  from  the  external  surface  of  the  body  the  position  of  internal  parts.  Thus 
complete,  the  work  will  furnish  all  the  assistance  that  can  be  rendered  by  type  and 
illustration  in  anatomical  studv. 


The  most  popular  work  on  anatomy  ever  written. 
It  is  sufficient  to  say  of  it  that  this  edition,  thanks 
to  its  American  editor,  surpasses  all  other  edi- 
tions — Jour,  of  the  Ainer.  Med.  Ass^n,  Dec.  31,  1887. 

A  work  which  for  more  than  twenty  years  has 
had  the  lead  of  all  other  text-books  on  anatomy 
throughout  the  civilized  world  comes  to  hand  in 
such  beauty  of  execution  and  accuracy  of  text 
and  illustration  as  more  than  to  make  good  the 
large  promise  of  the  prospectus.  It  would  be  in- 
deed difficult  to  name  a  feature  wherein  the  pres- 
ent American  edition  of  Gray  could  be  mended 
or  bettered,  and  it  needs  no  prophet  to  see  that 
the  royal  work  is  destined  for  many  years  to  come 
to  hold   the  first  place  among  anatomical  text- 


books.   The  work  is  published  with  black  and 
colored  plates.    It  is  a  marvel  of  book-making. — 

A'merican  Practitioner  and  News,  Jan.  21, 1888. 

Gray's  Anatomy  is  the  most  magnificent  work 
upon  anatomy  wiiich  has  ever  been  published  in 
the  English  or  any  other  language. — Cincinnati 
Medical  News,  Nov.  1887. 

As  the  book  now  goes  to  the  purchaser  he  is  re- 
ceiving the  best  work  on  anatomy  that  is  published 
in  any  language. —  Virginia  3Ied.  Monthly,  Dec.  1887. 

Gray's  standard  Anatomy  has  been  and  will  be 
for  years  the  text-book  for  students.  The  book 
needs  only  to  be  examined  to  be  perfectly  under- 
stood.— Medical  Press  of    Western  New   York,  Jan. 


Also  for  sale  separate — 
MOLD  JEN,  ZUTHJEB,  JF.  R.  C.  S., 

Surgeon  to  St.  Bartholomexo' s  and  the  Foundling  Sospitals,  London. 

Landmarks,  Medical  and  Surgical.  Second  American  from  the  latest  revised 
English  edition,  with  additions  by  W.  W.  Keen,  M.  D.,  Professor  of  Artistic  Anatomy  in 
the  Penna.  Academy  of  Fine  Arts.     In  one  12mo.  volume  of  148  pages.     Cloth,  $1.00. 


JDUNGLISON,  ROBLJEY,  M.D,, 

Late  Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia. 

MEDICAL  LEXICON ;  A  Dictionary  of  Medical  Science :  Containing 
a  concise  Explanation  of  the  various  Subjects  and  Terms  of  Anatomy,  Physiology,  Pathol- 
ogy, Hygiene,  Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medical  Juris- 
prudence and  Dentistry,  Notices  of  Climate  and  of  Mineral  Waters,  Formulae  for  Officinal, 
Empirical  and  Dietetic  Preparations.  With  the  Accentuation  and  Etymology  of  the  Terms, 
and  the  French  and  other  Synonymes,  so  as  to  constitute  a  French  as  well  as  an  English 
Medical  Lexicon.  Edited  by  Richard  J.  Dunglison,  M.  D.  In  one  very  large  and 
handsome  royal  octavo  volume  of  1139  pages.  Cloth,  $6.50;  leather,  raised  bands,  $7.50; 
very  handsome  half  Russia,  raised  bands,  $8.00. 

It  has  the  r.are  merit   that  it  certainly  has  no  rival    in   the  English  language  for  accuracy 
and  extent  of  references. — London  Meaical  Gazette. 


Lea  Brothers  &  Co.'s  Publications — Anatomy. 


ALLBN,  SAMmSOJS,  M,  !>., 

Professor  of  Physiology  in  the  University  of  Pennsylvania. 

A  System  of  Human  Anatomy,  Including  Its  Medical  and  Surgical 
Helations.  For  th.e  use  of  Practitioners  and  Students  of  Medicine.  With  an  intro- 
ductory Section  on  Histology.  By  E.  O.  Shakespeahe,  M.  D.,  Ophthalmologist  to 
the  Philadelphia  Hospital.  Comprising  813  double-columned  quarto  pages,  with  380 
illustrations  on  109  full  page  lithographic  plates,  many  of  which  are  in  colors,  and  241 
engravings  in  the  text.  In  six  Sections,  each  in  a  portfolio.  Price  per  Section,  $3.50 ; 
also  bound  in  one  volume,  cloth,  $23.00 ;  very  handsome  half  Russia,  raised  bands  and 
open  back,  $25.00.     For  sale  by  subscription  only.    Apply  to  the  Publishers. 


It  is  to  be  considered  a  study  of  applied  anatomy 
in  its  widest  sense — a  systematic  presentation  of 
sucli  anatomical  facts  as  can  be  applied  to  the 
practice  of  medicine  as  well  as  of  surgeiy.  Our 
author  is  concise,  accurate  and  practical  in  his 
statements,  and  succeeds  admirably  in  infusing 
an  interest  into  the  study  of  what  is  generally  con- 
sidered a  dry  subject.  The  department  of  Histol- 
ogy is  treated  in  a  masterly  manner,  and  the 
ground  is  trayelled  over  by  one  thoroughly  famil- 
iar with  it.    The  illustrations  are  made  with  great 


care,  and  are  simply  superb.  There  is  as  much 
of  practical  application  of  anatomical  points  to 
the  every-day  wants  of  the  medical  clinician  as 
to  those  of  the  operating  surgeon.  In  fact,  few 
general  practitioners  will  read  the  work  without  a 
feeling  of  surprised  gratification  that  so  many 
points,  concerning  which  they  may  never  hare 
thought  before  are  so  well  presented  for  their  con- 
sideration. It  is  a  work  which  is  destined  to  be 
the  best  of  its  kind  in  any  language. — Medical 
Record,  Nov.  25, 1882. 


CLAMKB,  W,  B,,  F,n,  C,S,  &  ZOCKWOOD, C.  B.,  F,B,  C,S, 

Demonstrators  of  Anatomy  at  St.  Bartholomew's  Hospital  Medical  School,  London. 
The  Dissector's  Manual.     In  one  pocket-size  12mo.  volume  of  396  pages,  with 
49  illustrations.    Limp  cloth,  red  edges,  $1.50.    See  Students'  Series  of  Manuals,  page  30 

Messrs.Clarke  and  Lockwood  have  written  abook 
that  can  hardly  be  rivalled  as  a  practical  aid  to  the 


dissector.  Their  purpose,  which  is  "  how  to  de^ 
scribe  the  best  way  to  display  the  anatomical 
structure,"  has  been  fully  attained.  They  excel  in 
a  lucidity  of  demonstration  and  graphic  terseness 
of  expression,  which  only  a  long  training  and 


intimate   association  with   students  could  have 

fiven.  With  such  a  guide  as  this,  accompanied 
y  so  attractive  a  commentary  as  Treves'  Surgical 
Applied  Anatomy  (same  series),  no  student  could 
fail  to  be  deeply  and  absorbingly  interested  in  the 
study  of  anatomy. — New  Orleans  Medical  and  Sur- 
gical Journal,  April,  1884. 


SIBST,  BABTONC,  M.D.,  &  BIEBSOL,  GEO,  A,,  M.D. 

Professor  of  Obstetrics  in  the  University  Professor  of  Anatomy  and  Embryology  in 

of  Pennsylvania.  the  University  of  Pennsylvania. 

Human  Monstrosities.  Magnificent  folio,  containing  about  150  pages  of  text, 
illustrated  with  engravings,  and  39  full-page,  photographic  plates  from  nature.  In  four 
parts,  price,  each,  $5.  Parts  I.  and  11.  just  ready.  Part  III.  shortly.  Limited  edition,  for 
sale  by  subscription  only.     Address  the  Publishers. 


This,  the  second  part  of  what  bids  fair  to  be  the 
best  teratological  treatise  extant,  is  fully  up  to  the 
previous  volume  in  point  of  excellence.  The 
plates  are  superbly  executed  and  the  illustrations 
have  been  made  with  the  specimens  in  the  most 
advantageous  positions  for  purposes  of  study. — 
The  Journal  of  the  American  Medical  Association, 
March  5, 1892. 

We  have  already  referred  at  length  to  the  salient 


points  of  this  beautiful  work,  the  second  volume 
of  which,  containing  the  description  of  monstrosi- 
ties, is  even  more  attractive  than  the  first.  There 
are  more  plates  and  less  space  devoted  to  the 
text  We  can  only  repeat  that  the  work  is  one 
which  reflects  great  credit  upon  American  ob- 
stetric literature,  and  deserves  a  place  in  the 
library  of  every  specialist  and  student  of  anatomy. 
—Medical  Record,  May  21, 1892. 


TBEVBS,  FBBDBBICK,  F,  B,  C.  S., 

Senior  Demonstrator  of  Anatomy  and  Assistant  Surgeon  at  the  London  Hospital. 

Surgical  Applied  Anatomy.  In  one  pocket-size  12mo.  volume  of  540  pages, 
with  61  illustrations.  Limp  cloth,  red  edges,  $2.00.     See  Students'  Series  of  Manuals,  p.  30. 

BELLAMY,  EI)WABI>,  F,  B.  C,  S., 

Senior  Assistant-Surgeon  to  the  Charing-Cross  Hospital,  London. 

The  Student's  Guide  to  Surgical  Anatomy :  Being  a  Description  of  the 
most  Important  Surgical  Eegions  of  the  Human  Body,  and  intended  as  an  Introduction  to 
Operative  Surgery.   In  one  12mo.  volume  of  300  pages,  with  50  illustrations.    Cloth,  $2.25. 

WILSON,  EBASMUS,  F.  B.  8. 

A  System  of  Human  Anatomy,  General  and  Special.  Edited  by  W.  H. 
GoBRECHT,  M.  D.,  Professor  of  General  and  Surgical  Anatomy  in  the  Medical  College  of 
Ohio.  In  one  large  and  handsome  octavo  volume  of  616  pages,  with  397  illustrations. 
Cloth,  $4.00;  leather,  $5.00. 

CLELANjy,  JOMN,M,D.,F,B.S., 

Professor  of  Anatomy  and  Physiology  in  Queen's  College,  Oalway. 

A  Directory  for  the  Dissection  of  the  Human  Body.     In  one  12mo. 

volume  of  178  pages.    Cloth,  $1.25. 


HARTSHORNE'S  HANDBOOK  OP  ANATOMY 
AND  PHYSIOLOGY.  Second  edition,  revised. 
In  one  royal  12mo.  volume  of  310  pages,  with  220 
woodcuts.    Cloth,  $1.75. 


HORNER'S  SPECIAL  ANATOMY  AND  HISTOL- 
OGY. Eighth  edition,  extensively  revised  and 
modified.  In  two  octavo  volumes  of  1007  pages, 
with  ,S20  woodcuts.    Cloth,  SS.OO. 


Lea  Brothers  &  Co.'s  Publications — Phys.,  Physiol.,  Anat.,  Cliem.     7 


DRArJER,  JOHN  C,  M,  !>.,  LL,  D., 

Professor  of  Chemistry  in  the  University  of  the  City  of  New  York. 
Medical  Physics.     A  Text-hook  for  Students  and  Practitioners  of  Medicine.    In 
one  octavo  volume  of  734  pages,  with  376  woodcuts,  mostly  original.   Cloth,  $4. 

No  man  in  America  Wfts  better  fitted  than  Dr. 
Draper  for  the  taslc  he  undertook,  and  he  ha8  pro- 


While  all  enlightened  physicians  will  agr«>e  that 
a  knowledge  of  physics  is  desirable  for  the  medi- 
cal student,  only  those  actually  engaged  in  the 
teaching  of  tlie  primary  subjects  can  be  fully 
aware  of  the  difficulties  encountered  by  students 
who  attempt  the  study  of  these  subjects  without 
a  knowledge  of  either  physics  or  chemistry. 
These  are  especially  felt  by  the  teacher  of  physi- 
ology. 

It  is,  however,  impossible  for  him  to  impart  a 
knowledge  of  the  main  facts  of  his  subject  and 
establish  them  by  reasons  and  experimental  dem- 
onstration, and  at  the  same  time  undertake  to 
teach  ab  initio  the  principles  of  chemistry  or  phys- 
ics. Hence  the  desiraoilitv,  we  may  say  the 
necessity,  for  some  such  work  as  the  present  one. 


vided  the  student  and  practitioner  of  medicine 
with  a  volume  at  once  readable  and  thorough. 
Even  to  the  student  who  has  some  knowledge  of 
physics  this  book  is  useful,  as  it  shows  him  its 
applications  to  the  profession  that  he  has  chosen. 
Dr.  Draper,  as  an  old  teacher,  knew  well  the  diffi- 
culties to  be  encountered  in  bringing  his  subject 
within  the  grasp  of  the  average  student,  and  that 
he  has  succeeded  so  well  proves  once  more  that 
the  man  to  write  for  and  examine  students  is  the 
one  who  has  taught  and  is  teaching  them.  The 
book  is  well  printed  and  fully  illustrated,  and  in 
every  way  deserves  grateful  recognition. —  The 
Montreal  Medical  Journal,  July,  1890. 


POWER,  SBNBY,  M.  J5.,  F.  B.  C.  S., 

Examiner  in  Physiology,  Royal  College  of  Surgeons  of  England. 
Human  Physiology.     Second  edition.     In  one  handsome  pocket-size  12mo.  vol- 
ume of  509  pp.,  with  68  illustrations.    Cloth,  $1.50.    See  Students'  Series  of  Manuals,  p.  30. 

ROBERTSOJ^,  J.  McGBBGOJR,  M.  A.,  M,  B,, 

Muirhead  Demonstrator  of  Physiology,  University  of  Glasgow. 
Physiological  Physics.     In  one  12mo.  volume  of  537  pages,  with  219  illustra- 
tions.    Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  30. 

ments.    It  will  be  found  of  great  value  to  the 
practitioner.    It  is  a  carefully  prepared  book  of 


The  title  of  this  work  sufficiently  explains  the 
nature  of  its  contents.  It  is  designed  as  a  man- 
ual for  the  student  of  medicine,  an  auxiliary  to 
his  text-book  in  physiology,  and  it  would  be  particu- 
larly useful  as  a  guide  to  his  laboratory  experi- 


reference,  concise  and  accurate,  and  as  such  we 
heartily  recommend  it. — Journal  of  the  American 
Medical  Association,  Dec.  6, 1884. 


DALTOW,  JOSW  a,  31,  !>., 

Professor  Emeritus  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 

Doctrines  of  the  Circulation  of  the  Blood.  A  History  of  Physiological 
Opinion  and  Discovery  in  regard  to  the  Circulation  of  the  Blood.  In  one  handsome 
12mo.  volume  of  293  pages.     Cloth,  $2. 


Dr.  Dalton's  work  is  the  fruit  of  the  deep  research 
of  a  cultured  mind,  and  to  the  busy  practitioner  it 
cannot  fail  to  be  a  source  of  instruction.  It  will 
inspire  him  with  a  feeling  of  gratitude  and  admir- 
ation for  those  plodding  workers  of  olden  times, 
who  laid  the  foundation  of  the  magnificent  temple 
of  medical  science  as  it  now  stands. — New  (Orleans 
Medical  and  Surgical  Journal,  Aug.  1885. 

In  the  progress  of  physiological  study  no  fact 
was  of  greater  moment,  none  more  completely 


revolutionized  the  theories  of  teachers,  than  the 
discovery  of  the  circulation  of  the  blood.  This 
explains  the  extraordinary  interest  it  has  to  all 
medical  historians.  The  volume  before  us  is  one 
of  three  or  four  which  have  been  written  within  a 
few  years  by  American  physicians.  It  is  in  several 
respects  the  most  complete.  The  volume,  though 
small  in  size,  is  one  of  the  most  creditable  con- 
tributions from  an  American  pen  to  medical  historj 
that  has  appeared.— ilfed.  <£  Surg.  Rep.,  Dec.  6, 1884. 


BBLL,  F.  JEFFREY,  M.  A., 

Professor  of  Comparative  Anatomy  at  King^s  Collene,  London. 

Comparative  Anatomy  and  Physiology.  In  one  12mo.  volume  of  561  pages, 
with  229  illustrations.  Limp  cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  30. 


The  manual  is  preeminently  a  student's  book — 
clear  and  simple  in  language  and  arrangement. 
It  is  well  and  aisundantly  illustrated,  and  is  read- 
able and  interesting.    On  the  whole  we  consider 


it  the  best  work  in  existence  in  the  English 
language  to  place  in  the  hands  of  the  medical 
student. — Bristol  Medico-Chirurgical  Journal,  Mar. 
1886. 


ELLIS,  GEORGE  VINER, 

Emeritus  Professor  of  Anatomy  in  University  College,  London. 

Demonstrations  of  Anatomy.  Being  a  Guide  to  the  Knowledge  of  the 
Human  Body  by  Dissection.  From  the  eighth  and  revised  London  edition.  In  one  very 
handsome  octavo  volume  of  716  pages,  with  249  illustrations.    Cloth,  $4.25 ;  leather,  $5.25. 

ROBERTS,  JOHN  B,,  A,  M.,  M.  J),, 

Lecturer  in  Anatomy  in  the  University  of  Pennsylvania. 
The  Compend  of  Anatomy.     For  use  in  the  dissecting-room  and  in  preparing 
for  examinations.     In  one  16mo.  volume  of  196  pages.     Limp  cloth,  75  cents. 

Wohler's  Outlines  of  Organic  Chemistry.  Edited  by  Fittig.  Translated 
by  Ira  Eemsen,  M.  D.,  Ph.  D.     In  one  12mo.  volume  of  550  pages.    Cloth,  $3. 

LEHM  ANN'S  MANUAL  OF  CHEMICAL  PHYS-  CARPENTER'S  PRIZE  ESSAY  ON  THE  USE  AND 

lOLOGY.     In  one  octavo  volume  of  327  pages,  abvse  of  Alcoholic  LiQroKS  in  Health  and  Di»- 

with  41  illustrations.    Cloth,  82.25.  t,t-j.-l.        ,       x-  r     ■     ..-c  j     a n 

CARPENTER'S  HUMAN  PHYSIOLOGY.    Edited  ^^^e.  With  explanations  of  scientific  words.  Small 

by  Hejjbt  Power.    In  one  octavo  volume.  12mo.    178  pages.    Cloth,  60  cents. 


Lea  Brothers  &  Co.'s  Publications — Physiology,  Clieiiiistry. 


CMAPMAJ^,  SEIS^RT  C,  M,  Z)., 

Professor  of  Institutes  of  Medicine  and  Medical  Juris,  in  the  Jefferson  Med.  Coll.  of  Philadelphia. 

A  Treatise  on  Human  Physiology.     In  one  handsome  octavo  volume  of 
«25  pages,  with  605  fine  engravings.     Cloth,  |5.50  ;  leather,  $6.50. 

It  represents  very  fully  the  existing  state  of 
physiology.  The  present  work  has  a  special  value 
to  the  student  and  practitioner  as  devoted  more 


to  the  practical  application  of  well-known  truths 
which  the  advance  of  science  has  given  to  the 
profession  in  this  department,  which  may  be  con- 
sidered the  foundation  of  rational  medicine. — Buf- 
falo Medical  and  Surgical  Journal,  Dec.  1887. 

Matters  which  have  a  practical  bearing  on  the 
practice  of  medicine  are  lucidly  expressed;  tech- 
nical matters  are  given  in  minute  detail;  elabo- 
rate directions  are  stated  for  the  guidance  of  stu- 
dents in  the  laboratory.  In  every  respect  the 
work  fulfils  its  promise,  whether  as  a  complete 
treatise  for  the  student  or  for  the  physician ;  for 
the  former  it  is  so  complete  that  he  need  look  no 


farther,  and  the  latter  will  find  entertainment  and 
instruction  in  an  admirable  book  of  reference. — 
North  Carolina  Medical  Journal,  Nov.  1887. 

The  work  certainly  commends  itself  to  both 
studeht  and  practitioner.  What  is  most  demanded 
by  the  progressive  physician  of  to-day  is  an  adap- 
tation of  physiology  to  practical  therapeutics,  and 
this  work  is  a  decided  improvement  in  this  respect 
Over  other  works  in  the  market.  It  will  certainly 
take  place  among  the  most  valuable  text-books. — 
Medical  Age,  Nov.  25, 1887. 

It  is  the  production  of  an  author  delighted  with 
his  work,  and  able  to  inspire  students  with  an  en- 
thusiasm akin  to  his  own. — American  Practitionsr 
and  News,  Nov.  12, 1887. 


nALTON,  JOSN  a,  M.  J>., 

Professor  of  Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York,  etc. 

A  Treatise  on  Human  Physiology.  Designed  for  the  use  of  Students  and 
Practitioners  of  Medicine.  Seventh  edition,  thoroughly  revised  and  rewritten.  In  one 
very  handsome  octavo  volume  of  722  pages,  with  252  beautiful  engravings  on  wood.  Cloth, 
$5.00;  leather,  $6.00. 


From  the  first  appearance  of  the  book  it  has 
been  a  favorite,  owing  as  well  to  the  author's 
renown  as  an  oral  teacher  as  to  the  charm  of 
simplicity  with  which,  as  a  writer,  he  always 
succeeds  in  investing  even  intricate  subjects. 
It  must  be  gratifying  to  him  to  observe  the  fre- 
quency with  which  his  work,  written  for  students 
and  practitioners,  is  quoted  by  other  writers  on 
physiology.  This  fact  attests  its  value,  and,  in 
great  measure,  its  originality.  It  now  needs  no 
such  seal  of  approbation,  however,  for  the  thou- 
sands who  have  studied  it  in  its  various  editions 


have  never  been  in  any  doubt  as  to  its  sterling 
worth.— iV.  F.  Medical  Journal,  Oct.  1882. 

Professor  Dalton's  well-known  and  deservedly- 
appreciated  work  has  long  passed  the  stage  at 
which  it  could  be  reviewed  in  the  ordinary  sense. 
The  work  is  eminently  one  for  the  medical  prac- 
titioner, since  it  treats  most  fully  of  those  branches 
of  physiology  which  have  a  direct  bearing  on  the 
diagnosis  and  treatment  of  disease.  The  work  is 
one  which  we  can  highly  recommend  to  all  our 
readers. — Dublin  Journal  of  Medical  Science,  Feb.'83. 


FOSTBM,  3IICMAEL,  M.  2).,  F.  M.  S., 

Prelector  in  Physiology  and  Fellow  of  Trinity  College,  Cambridge,  England. 
Text-Book  of  Physiology.     New  (fourth)  and  enlarged  American  from  the 
fifth  and  revised  English  edition,  with  notes  and  additions.     In  one  handsome  octavo  vol- 
ume of  1072  pages,  with  232  illustrations.     Cloth,  $4.50 ;  leather,  $5.50.      Just  ready. 


The  appearance  of  another  edition  of  Foster's 
Physiology  again  reminds  us  of  the  continued 
popularity  of  this  most  excellent  work.  There 
<!an  be  no  doubt  that  this  text-book  not  only  con- 
tinues to  lead  all  others  in  the  English  language, 
but  that  this  last  edition  is  superior  to  its  prede- 
cessors. It  is  evident  that  the  author  has  devoted 
a  considerable  amount  of  time  and  labor  in  its 
preparation,  nearly  every  page  bearing  evidences 
of  careful  revision.  Although  the  work  of  the 
American  editor  in  former  editions  has  been  by 


the  author  largely  adopted  in  a  modified  form  in 
this  revision,  much  was  still  Jeft  to  be  done  by  the 
editor  to  render  the  work  fully  adapted  to  the  wants 
of  our  American  students,  so  that  the  American 
edition  will  undoubtedly  continue  to  supply  the 
market  on  this  side  of  the  Atlantic.  The  work 
has  been  published  in  the  characteristic  creditable 
style  of  the  Lea's,  and  owing  to  its  enormous  sale, 
is  offered  at  an  extremely  low  price. — The  Medical 
and  Surgical  Reporter,  Jan.  9, 1S92. 


SIMOW,  W,,  Ph,  J>.,  M,  !>., 

Professor  of  Chemistry  and  Toxicology  in  the   College  of  Physicians  and  Su/rgeons,  Baltimore,  and 
Professor  of  Chemistry  m  the  Maryland  College  of  Pharmacy. 

Manual  of  Chemistry.  A  Guide  to  Lectures  and  Laboratory  work  for  Beginners 
in  Chemistry.  A  Text-book,  specially  adapted  for  Students  of  Pharmacy  and  Medicine. 
New  (third)  edition.  In  one  8vo.  volume  of  477  pages,  with  44  woodcuts  and  7  colored 
plates  illustrating  56  of  the  most  important  chemical  tests.     Cloth,  $3.25.    Just  ready. 

nothing  to  be  desired.   As  a  student's  manual  this 
work  is  of  the  highest  oidei.— The  Medical  N'eivs, 
February  20, 1892. 
While  possessing  all  the  usual  qualities  of  an 


Among  the  many  works  on  chemistry  offered 
for  the  use  of  the  medical  student,  there  is  prob- 
ably none  that  outrivals  Dr.  Simon's  work  in  prac- 
tical arrangement  and  thoroughness.  A  special 
feature  of  the  book,  and  one  that  deserves  the 
greatest  praise,  is  the  presence  therein  of  the 
beautiful  colored  plates  representing  fifty-six 
chemical  reactions.  To  say  that  they  are  splen- 
didly and  artistically  executed  hardly  does  them 
justice.  They  must  convey  to  the  mind  of  the 
student  lasting  impressions  of  the  color-changes 
that  he  has  noted  in  his  experiments  in  the  labor- 
atory, and  the  perusal  of  this  work  must  recall 
them  vividly  to  recognition.  The  many  cuts  are 
well  selected,  and  the  make-up  of  the  book  leaves 


excellent  text-book  for  the  student  or  laboratory, 
this  "Manual"  presents  the  unique  advantage  of 
furnishing  plates  showing  the  variously  shaded 
colors  of  certain  chemicals,  etc.,  and  their  re- 
actions. The  chapter  on  Urinalysis  is  excellent. 
This  "Chemistry"  is  especially  valuable  to  medi- 
cal students  and  practitioners,  as  devoting  so 
much  of  detail  to  descriptions  of  analyses,  tests, 
etc.,  of  those  things  with  which  the  doctor  has 
mostly  to  deal. —  Virginia  Medical  Monthly,  Jan- 
uary, 1892. 


VLOWBS,  FJEtAWK,  J>.  Sc,  London, 

Senior  Science- Master  at  the  High  School,  Newcastle-under-Lyme,  etc. 

An  Elementary  Treatise  on  Practical  Chemistry  and  Qualitative 
Inorganic  Analysis.  Specially  adapted  for  use  in  the  Laboratories  of  Schools  and 
Colleges  and  by  Beginners.  Third  American  from  the  fourth  and  revised  English  edition. 
In  one  12mo.  volume  of  387  pages,  with  55  illustrations.     Cloth,  $2.50. 


Lea  Brothers  &  Co.'s  Publications — Chemistry. 


9 


FBANKIjAND,  m,  n.  C.  i.,  f.  b.s.,  <&jajpjp,  f.  jr,,  f,  i.  c\. 


Professor  of  Chevusfry  in  the  Normal  School 
of  Science,  London. 


Assijit.  Prof,  of  Chemistry  in  the  Normal 
School  of  Science,  London. 


Inorganic  Chemistry.     In  one  handsome  octavo  volume  of  677  pages  with  51 
woodcuts  and  2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 


This  work  sliould  supersede  other  works  of  its 
class  in  the  medical  colleges.  It  is  certain  Iv  better 
adapted  than  any  work  upon  chemistry.with  which 
wt<  are  a<^(iuainted,  to  impart  that  clear  and  full 
knowledge  of  the  science  which  students  of  med- 
icine should  have.  Physicians  who  feel  that  their 
chemical  knowledge  is  behind  the  times,  would 
do  well  to  study  this  work.  Tl.e  description**  and 
demonstrations  are  made  so  plain  that  there  is 
no  difficulty  in  understanding  them. — Cincinnati 
Medical  News,  January,  18S6. 


'I'his  excellent  freatisH  will  not  fail  to  take  its 
place  as  one  of  the  very  best  on  tlie  subject  of 
which  it  treats.  We  have  been  much  pleased 
with  the  comprehensive  and  lucid  manner  in 
which  the  difhculties  of  chemical  notation  and 
nomenclature  iiave  been  f^leared  up  by  the  writers. 
It  shows  on  every  page  that  the  problem  of 
reuderinf;  the  obscurities,  of  this  science  easy 
of  comprehension  has  long  and  successfully 
engaged  the  attention  of  the  authors. — Medical 
and  Surgical  Reporter,  October  31, 1885. 


FOWNES,  GEORGE,  Fh.  D. 

A  Manual  of  Elementary  Chemistry;  Theoretical  and  Practical.  Em- 
bodying Watts'  Physical  and  Inuryanic  Chemistry.  New  American,  from  tiie  twelfth  English 
edition.  In  one  large  royal  12mo.  volume  of  1061  pages,  with  168  illustrations  on  wood 
and  a  colored  plate.     Cloth,  $2.75 ;  leather,  $3.25. 

Fownes'   Chemistry  has    been    a  standard  text-  ,  work  as  one  of  the    very  best  text-book.s    upon 
book  upon  chemistry  for  many  years.     Its  merits  ' 


are  very  fully  known  by  chemists  and  physicians 
everywhere  in  this  country  and  in  England.  As 
the  science  has  advanced  by  the  making  of  new 
discoveries,  the  work  has  been  revised  so  as  to 
keep  it  abreast  of  the  times.  It  has  steadily 
maintained  its  position  as  a  textbook  with  medi- 
cal students.  In  this  work  are  treated  fully:  Heat, 
Light  and  Electricity,  including  Magnetism.  The 
influence  exerted  Dy  these  forces  in  chemical 
action  upon  health  and  disease,  etc.,  is  of  the  most 
important  kind,  and  should  be  familiar  to  every 
medical    practitioner.      We    can    commend    the 


chemistry   extant. —  Clncinnatr  Med.  iV«i«s,  Oct. ' 

Of  all  the  works  on  chemistry  intended  for  the 
use  of  medical  students,  Fownes'  Chemistry  is 
perhaps  the  most  widely  used.  Its  popularity  is 
based  upon  its  excellence.  This  last  edition  con- 
tains all  of  the  material  found  in  the  previous, 
and  it  is  also  enriched  by  the  addition  of  Watta*^ 
Physical  and  Inorganic  Chemistry.  All  of  the  mat- 
ter is  brought  to  the  present  standpoint  of  chemi- 
cal knowledge.  We  may  safely  predict  for  this 
work  a  continuance  of  the  fame  and  favor  it  enjoys 
among  medical  students. — Neio  Orleans  Medical 
and  Surgical  Journal,  March,  1886. 


ATTFIELD,  JOJBLN,  M,  A,,  F7i.  D.,  F,  I.  C,  F.  iJ.  S,,  Etc, 

Professor  of  Practical  Chemistry  to  the  Pharmaceutical  Society  of  Oreat  Britain,  etc. 

Chemistry,  General,  Medical  and  Pharmaceutical;  Including  the  Chem- 
istry of  the  U.  S.  Pharmacopoeia.  A  Manual  of  the  General  Principles  of  the  Science, 
and  their  Application  to  Medicine  and  Pharmacy.  A  new  American,  from  the  twelfth- 
English  edition,  specially  revised  by  the  Author  for  America.  In  one  handsome  royal 
12mo.  volume  of  782  pages,  with  88  illustrations.   Cloth,  $2.75;  leather,  $3.25. 


Attfield's  Chemistry  is  the  most  popular  book 
among  students  of  medicine  and  pharmacy.  This 
popularity  has  a  good,  substantial  basis.  It  rests 
upon  real  merits.  Attfield's  work  combines  in  the 
happiest  manner  a  clear  exposition  of  the  theory 
of  chemistry  with  the  practical  application  of  this 
knowledge  to  the  everyday  dealings  of  the  phy- 
sician and  pharmacist.  His  discernment  is  shown 
not  only  in  what  he  puts  into  his  work,  but  also  in 
what  he  leaves  out.  His  book  is  precisely  what 
the  title  claims  for  it.  The  admirable  arrangement 
of  the  text  enables  a  reader  to  get  a  good  idea  of 
chemistry  without  the  aid  of  experiments,  and 


again  it  is  a  good  laboratory  guide,  and  finally  it 
contains  such  a  mass  of  well-arranged  information 
that  it  will  always  serve  as  a  handy  book  of  refer- 
ence. He  does  not  allow  anyunutilizable  knowl- 
edge to  slip  into  his  book;  his  long  years  of 
experience  have  produced  a  work  which  is  both 
scientific  and  practical,  and  which  shuts  out 
everything  in  the  nature  of  a  superfluity,  and 
therein  lies  the  secret  of  its  success.  This  last 
edition  shows  the  marks  of  the  latest  progress 
made  in  chemistry  and  chemical  teaching. — New 
Orleans  Medical  and  Surgical  Journal,  Nov.  1889. 


BLOXAM,  CSABLES  i., 

Professor  of  Chemistry  in  King's  College,  London. 

Chemistry,  Inorganic  and  Organic.  New  American  from  the  fifth  Lon- 
don edition,  thoroughly  revised  and  much  improved.  In  one  very  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2.00 ;  leather,  $3.00. 

Comment  from  us  on  this  standard  work  is  al-  i  maintains  the  position  it  has  always  held  as  one  of 
most  superfluous.  It  differs  widely  in  scope  and  I  the  best  manuals  of  general  chemistry  tn  the  Eng- 
aim  from  that  of  Attfield,  and  in  its  way  is  equally  i  lish  language. — Detroit  Lancet,  Feb.  1884. 
beyond  criticism.  It  adopts  the  most  direct  meth- j  We  know  of  no  treatise  on  chemistry  which 
ods  in  stating  the  principles,  hypotheses  and  facts  I  contains  so  much  practical  information  in  the 
of  the  science.  Its  language  is  so  terse  and  lucid,  j  same  number  of  pages.  The  book  can  be  readily 
and  its  arrangement  of  matter  so  logical  in  se-  [  adapted  not  only  to  the  needs  of  those  who  desire 
quence  that  the  student  never  has  occasion  to  ,  a  tolerably  complete  course  of  chemistry,  but  also 
complain  that  chemistry  is  a  hard  study.  Much  [  to  the  needs  of  those  who  desire  only  a  general 
attention  is  paid  to  experimental  illustrations  of  I  knowledge  of  the  subject.  It  is  both  a  satisfactory 
chemical  principles  and  phenomena,  and  the  '  text-book,  and  a  useful  book  of  reference.— £os<ora 
mode  of  conducting  these  experiments.    The  book  ,  Medical  and  Surgical  Journal,  June  19, 1884. 

GBEENE,  WILLIA3I  S.,  M.  J>., 

Demonstrator  of  Chemistry  in  the  Medical  Department  of  the  University  of  Pennsylvania. 
A  Manual  of  Medical  Chemistry.  For  the  use  of  Students.  Based  upon  Bow- 
man's Medical  Chemistrv.  In  one  12mo.  volume  of  310  pages,  with  74  illus.  Cloth,  $1.75. 
It  is  a  concise  manual  of  three  hundred  pages,  !  the  recognition  of  compounds  due  to  pathological 
giving  an  excellent  summary  of  the  best  methods  I  conditions.  The  detection  of  poisons  is  treated 
of  analyzingthe  liquids  and  solidsof  the  body,  both  ]  with  sufficient  fulness  for  the  piirpose  of  the  stu- 
for  tee  escimationof  their  normal  constituent  and  '.  dentor  practitioner. — Boston  Jl.  of  Chem.  June, '80. 


10  Lea  Brothers  &  Co.'s  Publications — Ghem.,  Pharin. 

VAVGSAN,  riClOM  C,  I*h.  D.,  M.  I)„ 

Prof,  of  Phys.  and  Path.  Chem.  and  Assoc.  Prof,  of  Therap.  and  Mat.  Med.  in  the  Univ.  of  Mich. 

and  NOVY,  FREnjEItlCK  G,,  M,  D. 

Instructor  in  Hygiene  and  Phys.  Chem.  in  the  Univ.  of  Mich. 

Ptomaines,  Leucomaines  and  Bacterial  Proteids ;  or  the  Chemical 
Factors  in  the  Causation  of  Disease.  New  (second)  edition.  In  one  handsome 
12mo.  volume  of  389  pages.     Cloth,  $2,25,     Just  ready. 


The  title  of  this  volume  brings  prominently  to 
view  the  correct  pathology  of  a  host  of  diseases. 
Modern  chemistry  has  furnished  no  more  striking 
evidence  of  its  value  than  the  discovery  of  these 
ultimate  causes  of  disease,  a  step  which  neces- 
sarily precedes  any  rational  knowledge  of  cure  or 
grevention.  These  successful  methods  of  research 
ave  also  thrown  a  flood  of  light  upon  the  Leuco- 
maines or  Physiological  Alkaloids.  The  literature 
of  the  subjects,  already  vast,  was  before  the 
preparation  of  this  work  scattered  and  unattainable 


by  those  who  had  most  need  of  its  help,  namely, 
general  practitioners.  For  the  student  no  more 
important  branch  of  chemistry  exists.  The  early 
demand  for  the  second  edition  of  a  work  on  so 
new  a  department  of  science,  augurs  well  for  the 
curriculum  in  those  colleges  which  have  already 
made  it  a  branch  of  study,  and  for  the  growing 
promptness  on  the  part  of  the  profession  to  recog- 
nize and  use  the  most  enlightened  methods  for 
the  benefit  of  their  patients. —  The  Southern  Prac- 
titioner, December,  1891. 


MEMSJEN,  IBA,  M.  D,,  I*h,  2>., 

Professor  of  Chemistry  in  the  Johns  Hopkins  University,  Baltimore' 

Principles  of  Theoretical  Chemistry,  with  special  reference  to  the  Constitu- 
tion of  Chemical  Compounds.  Fourth  and  thoroughly  revised  edition.  In  one  handsome 
-royal  12dio.  volume  of  about  350  pages.     Preparing. 

€SABZES,  T,  CBANSTOVN,  M,  !>.,  F,  C.  S.,  M,  S,, 

Formerly  Asst.  Prof,  and  Demonst.  of  Chemistry  and  Chemical  Physics,  Queen's  College,  Belfast. 

The  Elements  of  Physiological  and  Pathological  Chemistry.     A 

Handbook  for  Medical  Students  and  Practitioners.  Containing  a  general  account  of 
TNutrition,  Foods  and  Digestion,  and  the  Chemistry  of  the  Tissues,  Organs,  Secretions  and 
Excretions  of  the  Body  in  Health  and  in  Disease.  Together  with  the  methods  for  pre- 
paring or  separating  their  chief  constituents,  as  also  for  their  examination  in  detail,  and 
an  outline  syllabus  of  a  practical  course  of  instruction  for  students.  In  one  handsome  octavo 
volume  of  463  pages,  with  38  woodcuts  and  1  colored  plate.    Cloth,  $3.50. 

nowadays.  Dr.  Charles  has  devoted  much  space 
to  the  elucidation  of  urinary  mysteries.  He  does 
this  with  much  detail,  and  yet  in  a  practical  and 
intelligible  manner.  In  fact,  the  author  has  filled 
his  book  with  many  practical  hints. — Medical  Rec- 
ord, December  20,  1884. 


Dr.  Charles  is  fully  impressed  with  the  impor- 
tance and  practical  reach  of  his  subject,  and  he 
has  treated  it  in  a  competent  and  instructive  man- 
ner. We  cannot  recommend  a  better  book  than 
the  present.  In  fact,  it  fills  a  gap  in  medical  text- 
books, and  that  is  a  thing  which  can  rarely  be  said 


HOFFMAJ^N,  F,,  A.M,,  Fh.JD.,  &  FOWFB,  F,B,,  Fh.I>., 

Public  Analyst  to  the  State  of  New  York.  Prof,  of  Anal.  Chem.  in  the  Phil.  Coll.  of  Pharmacy. 

A  Manual  of  Chemical  Analysis,  as  applied  to  the  Examination  of  Medicinal 
Chemicals  and  their  Preparations.  Being  a  Guide  for  the  Determination  of  their  Identity 
and  Quality,  and  for  the  Detection  of  Impurities  and  Adulterations.  For  the  use  of 
Pharmacists,  Physicians,  Druggists  and  Manufacturing  Chemists,  and  Pharmaceutical  and 
Medical  Students.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one  very 
handsome  octavo  volume  of  621  pages,  with  179  illustrations.    Cloth,  $4.25. 


It  is  admirable  and  the  information  it  under- 
takes to  supply  is  both  extensive  and  trustworthy. 
The  selection  of  processes  for  determining  the 
purity  of  the  substances  of  which  it  treats  is  ex- 
cellent and  the  description  of  them  singularly 


explicit.  Moreover,  it  is  exceptionally  free  from 
typographical  errors.  We  have  no  hesitation  in 
recommending  it  to  those  who  are  engaged  either 
in  the  manufacture  or  the  testing  of  medicinal 
chemicals. — London  Pharm.  Jour,  and  Trans.,  1883. 


PAMBISS,  FnWAMJ), 

Late  Professor  of  the  Theory  and  Practice  of  Pharmacy  in  the  Philadelphia  College  of  Pharmacy. 
A  Treatise  on  Pharmacy :    Designed  as  a  Text-book  for  the  Student,  and  as  a 
Guide  for  the  Physician  and  Pharmaceutist.    With  many  Formulae  and  Prescriptions. 
Fifth  edition,  thoroughly  revised,  by  Thomas  S.  Wdegand,  Ph.  G.     In  one  handsome 
octavo  volume  of  1093  pages,  with  256  illustrations.    Cloth,  $5.00 ;  leather,  $6.00. 


No  thorough-going  pharmacist  will  fail  to  possess 
himself  of  so  useful  a  guide  to  practice  and  no 
physician  who  properly  estimates  the  value  of  an 
accurate  knowledge  of  the  remedial  agents  em- 
ployed by  him  in  daily  practice,  so  far  as  their 
miscibility,  compatibility  and  most  effective  meth- 


ods  of  combination  are  concerned,  can  aflFord  to 
leave  this  work  out  of  the  list  of  their  works  of 
reference.  The  country  practitioner,  who  must 
always  be  in  a  measure  his  own  pharmacist,  will 
find  it  indispensable. — Louisville  Medical  News, 
March  29, 1884. 


KALFE,  CSAMLES  H.,  M,  J).,  F,  M.  C.  F,, 

Assistant  Physician  at  the  London  Hospital. 
Clinical  Chemistry.     In  one  pocket-size  12mo.  volume  of  314  pages,  with  16 
illustrations.     Limp  cloth,  red  edges,  $1.50.     See  Students^  Series  of  Manuals,  page  30. 

CLASSEN,  ALEXAJmEM, 

Professor  in  the  Royal  Polytechnic  School,  Aix-la-Chapelle. 

Elementary  Quantitative  Analysis.    Translated,  with  notes  and  additions, 
Edgak  F.  Smith,  Ph.  D.,  Assistant  Professor  of  Chemistry  in  the  Towne  Scientific  School, 
University  of  Penna.    In  one  12mo.  volume  of  324  pages,  with  36  illus.    Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therapeutics.    11 


STILLJE,  A.,  M.D.,LL.J).,  &  MAISCH,  J,  M.,Phar,D,, 

Prof,  of  Mat.  Med.  a?i<i  Botany  in  Phila. 
College  of  Pharmnci/,Sec'y  to  the  Ameri- 
can Pharmaceutical  Association. 


Professor  Emeritus  of  the  Theory  and  Prac- 
tice of  Medicine  and  of  Clinical  Medicine 
in  the  University  of  Pennsylvania. 


The  National  Dispensatory. 

CONTAINING  THE  NATURAL  HISTORY.  CHEMISTRY.  PHARMACY,  ACTIONS  AND    USES   OF 

MEDICINES,  INCLUDING  THOSE  RECOGNIZED  IN  THE  PHARMACOPdIAS  OF  THE 

UNITED  STATES,  GREAT  BRITAIN  AND  GERMANY,  WITH  NUMEROUS 

REFERENCES   TO  THE  FRENCH  CODEX. 

Fourth  edition  revised,  and  covering  the  new  British  Pharmacopoeia.  In  one  mag- 
nificent imperial  octavo  vohime  of  1794  pages,  witli  311  elaborate  engravings.  Price 
in  cloth,  $7.25  ;  leather,  raised  bands,  $8.00 ;  half  Russia,  $9.00.  \*2%ts  work  will  be 
furnished  with  Patent  Ready  Reference  Thumb-letter  Index  for  $1.00  in  addition  to  the  price 
in  any  style  of  binding. 


It  is  with  much  pleasure  that  the  fourth  edition 
of  this  magnificent  work  is  received.  The  authors 
and  publishers  have  reason  to  feel  proud  of  this, 
the  most  comprehensive,  elaborate  and  accurate 
work  of  the  kind  ever  printed  in  this  country.  It 
is  no  wonder  that  it  has  become  the  standard  au- 
thority for  both  the  medical  and  pharmaceutical 
profession,  and  that  four  editions  have  been  re- 
miired  to  supply  the  constant  and  increasing 
demand  since  its  first  appearance  in  1879.  The 
entire  field  has  been  gone  over  and  the  various 
articles  revised  in  accordance  with  the  latest 
developments  regarding  the  attributes  and  thera- 
peutical action  ot  drugs.    The  remedies  of  recent 


discovery  have  received  due  attention.— iTansaa 
City  Meaical  Index,  Nov.  1887. 

We  think  it  a  matter  for  congratulation  that  the 
profession  of  medicine  and  that  of  pharmacy  have 
shown  such  appreciation  of  this  great  work  as  to  call 
for  four  edit]ons  within  the  comparatively  brief 
period  of  eight  years.  The  matters  with  which  it 
deals  are  of  so  practical  a  nature  that  neither  the 
physician  nor  the  pharmacist  can  do  without  the 
latest  text-books  on  them,  especially  those  that  are 
so  accurate  and  comprehensive  as  this  one.  The 
book  is  in  every  way  creditable  both  to  the  authors 
and  to  the  publishers. — Neio  York  Medical  Journal, 
May  21, 1887. 


MAISCM,  JOJELN3I.,  I'har.  J)., 

Professor  of  Materia  Medica  and  Botany  in  thej'hiladelphia  College  of  Pharmacy. 

A  Manual  of  Organic  Materia  Medica;  Being  a  Guide  to  Materia  Medica  of 
the  Vegetable  and  Animal  Kingdoms.  For  the  use  of  Students,  Druggists,  Pharmacists 
and  Physicians.  New  (fifth)  edition,  thoroughly  revised.  In  one  handsome  royal 
12mo.  volume  of  about  550  pages,  with  about  275  illustrations.    In  press. 

A  notice  of  the  previous  edition  is  appended. 
For  everyone   interested    in    materia    medica,  |  fore  his  eyes.    That  it  answers  its  purposes  in  this 
Maisch's  Manual,  first  published  in  1S82,  and  now  1  respect  the  rapid  succession  of  editions  is  the  best 

in  its  fourth  edition,  is  an  indispensable  book.     '-'" t^.-xu-  ^ .-x.  i — i-  _/-i.u.  . :  — 

For  the  American  pharmaceutical  student  it  is 
the  work  which  will  give  him  the  necessary  knowl- 
edge in  the  easiest  way,  partly  because  the  text  is 
brief,  concise,  and  free  from  unnecessary  matter, 
and  partly  because  of  the  numerous  illustrations, 
whicn  bring  facts  worth  knowing  immediately  be- 


evidence.  It  is  the  favorite  book  of  the  American 
student  even  outside  of  IMaisch's  several  hundred 
personal  students.  The  arrangement  of  its  con- 
tents shows  the  practical  tendency  of  the  book. 
Maisch's  system  of  classification  is  easy  and  com- 
prehensive.— Pharmaceutisehe  Zeitung,  Germany^ 
1890. 


EDJES,  BOBEBT  T.,  M.  jD., 

Jackson  Professor  of  Clinical  Medicine  in  harvard  University,  Medical  Department. 

A  Text-Book  of  Therapeutics  and  Materia  Medica.    Intended  for  the 
Use  of  Students  and  Practitioners.    Octavo,  544  pages.     Cloth,  $3.50 ;  leather,  $4.50. 

It  possesses  all  the  essentials  which  we  expect 
in  a  book  of  its  kind,  such  as  conciseness,  clear- 
ness, a   judicious    classification,  and   a   reason 


able  degree  of  dogmatism.  All  the  newest  drugs 
of  promise  are  treated  of.  The  clinical  index  at 
the  end  will  be  found  very  useful.    We  heartily 


on  having  produced  so  good  a  one. — N.  Y.  Medical 
Journal,  Feb.  18, 1888. 

Dr.  Edes'  book  represents  better  than  any  older 
book  the  practical  therapeutics  of  the  present 
day.  The  book  is  a  thoroughly  practical  one.  The 
classification  of  remedies  has  reference  to  their 


commend  the  book  and  congratulate  the  author  t  therapeutic  action. — Pharmaceutical  £ra,  Jan.  1888. 


BBTICB,  J,  MITCHBLL,  M,  Z>.,  F,  B,  C.  P., 

Physician  and  Lecturer  on  Materia  Medica  and  Therapeutics  at  Charing  Cross  Hospital,  London. 
Materia  Medica  and  Therapeutics.    An  Introduction  to  Rational  Treatment. 
Fourth  edition.   12mo.,  591  pages.   Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  30. 

GBIFFITH,  BOBEBT  EGLESFIELB,  M,  D. 

A  Universal  Formulary,  containing  the  Methods  of  Preparing  and  Adminis- 
tering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceut- 
ists. Third  edition,  thoroughly  revised,  with  numerous  additions,  by  John  M.  Maisch, 
Phar.D.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  College  of  Pharmacy. 
In  one  octavo  volume  of  775  pages,  with  38  illustrations      Cloth,  $4.50 ;  leather,  $5.50. 


HERM.4NN'S  EXPERIMENTAL  PHARMACOL- 
OGY. A  Handbook  of  Methods  for  Determinin  g 
the  Physiological  .Action  of  Drugs.  Translated, 
with  the  -Author's  permission,  and  with  exten- 
sive additions,  by  R.  M.  Smith,  M.  D.  12mo., 
199  pages,  with  32'illustrations.     Cloth,  51.50. 


STrLLE'S  THERAPEUTICS  AND  MATERIA 
MEDiCA.  A  Systematic  Treatise  on  the  Action 
and  Uses  of  Medicinal  Agents,  including  their 
Description  and  History.  Fourth  edition,  re- 
vised and  enlarged.  In  two  octavo  volumes,  con- 
taining 1936  pages.    Cloth, 810.00;  leather,  512.00. 


12     Lea  Brothers  &  Co.'s  Publications — Mat.  Med.,  Therapeutics. 


A  SYSTEM   OF  PRACTICAL  THERAPEUTICS 


BY  AMERICAN  AND  FOREIGN  AUTHORS. 

Edited  by  HOBART  AMORY  HARE,  M.  D. 


Professor  of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of  Philadelphia. 

Assisted   by  Walter   Chrystie,   M.  D.,   Formerly  Instructor  in  Physical 

Diagnosis  in  the  University  of  Penna. 

In  a  series  of  contributions  by  seventy-eight  eminent  authorities.  In  three  large 
octavo  volumes  of  about  1100  page3  each,  with  illustrations  Vols.  I.,  II.  and  III.  jiLst 
ready.  Price,  per  volume:  Cloth,  8B5.00;  leather,  $600 ;  half  Kussia,  |7.00.  For  sate  by 
subscription  only.     Address  the  Publishers.     Full  prospectus  free  to  any  address  on  application. 


The  work  is  one  of  equal  importance  with  any 
that  has  ever  been  issued.  The  time  is  ripe  for  a 
system  of  therapeutics.  Every  practitioner  must 
have  felt  how  meagre  is  the  therapeutical  side  of 
our  best  works  In  medicine.  Now  this  system 
will,  we  believe,  just  fill  the  niche  that  has  so  long 
been  left  vacant.  Many  excellent,  but  more  or 
less  limited,  treatises  on  the  subject  have  from 
time  to  time  appeared,  chiefly  in  connection  with 
manuals  of  Materia  Medica,  but  this  is  the  first 
comprehensive  system  we  have  seen.  Surgical 
therapeutics  have  been  introduced  wherever  nec- 
essary to  make  clear  and  complete  the  subject 
under  discussion.  The  system  will  fill  a  very  im- 
portant place  in  medical  literature,  which  has 
hitherto  been  vacant,  and  the  work  should  be  in 
the  hands  of  every  practising  physician  in  the 
■country. — The  Canada  Lancet,  March,  1892. 


Any  doubt  as  to  the  necessity  for  a  new  work  on 
therapeutics  will  be  dissipated  by  a  reference  to 
this  system,  which  will  create  for  itself  a  perma- 
nent position  in  medical  literature.  Here  are 
brought  together  the  deliberate  opinions  and  the 
mature  results  of  the  experience  of  men  skilled 
in  their  respective  departments,  while  the  litera- 
ture of  the  world  has  been  liberally  drawn  upon. 
The  limits  of  the  ordinary  review  will  only  permit 
of  passing  reference  to  the  different  articles,  as 
each  in  itself  is  a  monograph,  while  several  con- 
stitute treatises.  The  work  reflects  great  credit 
upon  contributors,  editors  and  publishers.  It  is  a 
monument  to,  as  it  is  a  record  of,  scientific  thera- 
peutics. It  should  be  in  the  library  of  every 
progressive  practitioner  of  medicine. — The  Medi- 
cal News,  Feb.  13,  1892. 


MABB,  SOB  ART  AMOBY,  B.  Sc,  M.  D., 

Professor   of  Materia  Medica  and  Therapeutics  in  the  Jefferson  Medical  College  of  Philadelphia; 
Secretary  of  the  Convention  for  the  Revisior\  of  the  United  States  Pharmacopoeia  of  1890. 

A  Text-Book  of  Practical  Therapeutics;  V»7^ith  Especial  Eeference  to  the 
Application  of  Remedial  Measures  to  Disease  and  their  Employment  upon  a  Rational 
Basis.  With  special  chapters  by  Dbs.  G.  E.  de  Schweinitz,  Edward  Martin, 
J.  Howard  Eeeves  and  Barton  C.  Hirst.  New  (2d)  and  revised  edition.  In  one 
handsome  octavo  volume  of  650  pages.     Cloth,  $3.75 ;  leather,  $4.75. 

This  work  has  received  the  rare  distinction 
among  medical  works  of  reaching  a  second  edition 
six  months  after  its  first  appearance.    We  note 


among  the  important  new  featurps  characterizing 
the  second  edition,  additional  information  regard- 
ing the  remedies  recently  added  to  the  Materia 
Medica;  the  method  of  employing  the  rest  cure; 
the  use  of  suspension  in  the  treatment  of  locomo- 
tor ataxia  and  allied  affection.s.  Many  new  pre- 
scriptions have  also  been  inserted  to  illustrate 
the  best  modes  of  applying  remedies.      Among 


other  features  of  this  practically  helpful  treatise 
which  will  make  reference  to  it  convenient  and 
profitable,  are  the  arrangement  of  titles  of  drugs 
and  diseases  in  alphabetical  order,  according  to 
their  English  names;  the  introduction  of  the 
preparations  of  the  British  Pharmacopoeia;  a  dose 
list  of  drugs  officinal  and  unofficinal.  In  addition 
to  the  general  index,  a  copious  and  explanatory 
index  of  diseases  and  remedies  has  been  appended 
which  will  render  the  contents  easily  accessible. 
—  The  Medical  Age,  July  10, 1891. 


BBUJ^TON,  T,  LATJDBB,  M,D.,  B,Sc.,  F,B.S,,  F.B.CB., 

Lecturer  on  Materia  Medica  and  Therapeutics  at  St.  Bartholomew's  Hospital,  London,  etc. 

A  Text-Book  of  Pharmacology,  Therapeutics  and  Materia  Medica; 

Including  the  Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
Adapted  to  the  U.  S.  Pharmacopoeia  by  Francis  H.  Williams,  M.  D.,  of  Harvard  Univer- 
sity Medical  School.  Third  edition.  Octavo,  1305  pages,  230  illustrations.  Cloth,  $5.50 ; 
leather,  $6.50. 

made  in  various  directions  in  the  art  of  therapeu- 
tics, and  it  now  stands  unrivalled  in  its  thoroughly 
scientific  presentation  of  the  modes  of  drug  action. 
No  one  who  wishes  to  be  fully  up  to  the  times  in 
this  science  can  afford  to  neglect  the  study  of  Dr. 
Brunton's  work.  The  indexes  are  excellent,  and 
add  not  a  little  to  the  practical  value  of  the  book. 
—Medical  Record,  May  25, 1889. 


No  words  of  praise  are  needed  for  this  work,  for 
it  has  already  spoken  for  itself  in  former  editions. 
It  was  by  unanimous  consent  placed  among  the 
foremost  books  on  the  subject  ever  published  in 
any  language,  and  the  better  it  is  known  and  studied 
the  more  highly  it  is  appreciated.  The  present 
edition  contains  much  new  matter,  the  insertion 
of  which  has  been  necessitated  by  the  advances 


FABQVHABSOW,  BOBBBT,  M,  I),,  F,  B,  C,  JP.,  LL,  D., 

Lectwrer  on  Materia  Medica  at  St.  Mary's  Hospital  Medical  School,  London. 

A  Guide  to  Therapeutics  and  Materia  Medica.  Fourth  Arnerican, 
from  the  fourth  English  edition.  Enlarged  and  adapted  to  the  U.  S.  Pharmacopoeia.  By 
Frank  Woodbury,  M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  and  Clinical 
Medicine  in  the  Medico-Chirurgical  College  of  Philadelphia.  In  one  handsome  12mo. 
volume  of  581  pages.     Cloth,  $2.50. 

It  may  correctlybe  regarded  as  the  most  modern  |  copcBias,  as  well  as  considering  all  non-oflBcial  but 
work  of  its  kind.  It  is  concise,  yet  complete,  important  new  drugs,  it  becomes  in  fact  a  miniature 
Containing  an  account  of  all  remedies  that  have  dispensatory. — Pacific  Medical  Journal,  June,  1889. 
a  place  in  the  British  and  United  States  Pharma-  | 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Med. 


13 


FLINT,  AUSTIN,  31.  D.,  LL,  D., 

Prof,  of  the  Principles  and  Prnetice  of  Med.  and  of  Clin.  M(.d.  in  Bellevve  Hospital  Medical  College,  N.  7. 

A  Treatise  on  the  Principles  and  Practice  of  Medicine.  Designed  for 
the  use  of  Students  and  Practitioners  of  Medicine.  Sixth  edition,  thorouglily  revised 
and  rewritten  by  tlie  Author,  assisted  by  William  H.  Welch,  M.  D.,  Professor  of 
Pathology,  Johns  Hopkins  University,  Baltimore,  and  Austin  Flint,  Jr.,  M.  D.,  LL.  D., 
Professor  of  Physiology,  Bellevue  Hospital  Medical  College,  N.  Y.  In  one  very  handsome 
octavo  volume  of  1160  pages,  with  illustrations.  Cloth,  $5.50;  leather,  $6.50. 
No  textrbook  on  t)ie  principles  and  practice  of    in    city,  town,  village,  or  at  some  cro.=s-road9,  is 


medicinp  has  ever  met  in  tfiis  country  with  such 
general  approval  by  medical  students  and  practi- 
tioners as  the  work  of  Professor  Flint.  In  all  the 
medical  colleges  of  tho  United  States  it  is  the  fa- 
vorite work  upon  Practice;  and,  as  we  have  stated 
before  in  alluding  to  it,  there  is  no  other  medical 
work  that  can  be  so  generally  found  in  the  libra- 
ries of  physicians.  In  every  state  and  territory 
of  this  vast  country  the  book  that  will  be  most  likely 
to  be  found  in  the  office  of  a  medical  man,  whether 


Flint's  Practice.  \\e  make  this  statement  to  a 
considerable  extent  from  personal  observation,  and 
it  is  the  testimony  also  of  others.  An  examina- 
tion shows  tiiat  very  considerable  changes  have 
been  made  in  the  sixth  edition.  The  work  may  un- 
doubtedly be  regarded  as  fairly  representing  the 
present  state  of  the  science  of  medicine,  and  as 
reflecting  the  views  of  those  who  exemplify  in 
their  practice  the  present  stage  of  progress  of  med- 
ical art. — Cincinnati  Medical  ]S"eii:t,  Oct.  1886. 


BBISTOWE,  JOHN  SYEB,  M,  D.,  LL.  !>.,  F.  JR.  S., 

Senior  Physician  to  and  Lecturer  on  Medicine  at  St.  Thomas'  Hospital,  London. 

A  Treatise  on  the  Science  and  Practice  of  Medicine.  Seventh  edi- 
tion.    In  one  large  octavo  volume  of  1325  pages.     Cloth,  $6.50 :  leather,  $7.50. 

Dr.  Bristowe's  now  famous  treatise  appears  in  '  tion,  systematic,  scientific  and  practical,  contain- 
its  seventh  edition.  It  has  long  passed  the  stage  ;  ing  the  matured  experience  of  a  physician  who 
in  which  it  requires  critical  examination  or  com-  !  has  every  claim  to  be  considered  an  authority, 
mendation,  and  has  thoroughly  established  itself  '  and  composed  in  a  style  which  attracts  the  prac- 
as  among  the  most  complete  and  useful  of  text-  '  titioner  as  much  as  the  student.  No  one  can  say 
books. — British  3fedicalJoumal, September  27, 'iSQO.  I  that  this  book  has  obtained  a  success  which  was 

It  is  a  work  that  is  built  on  a  stable  founda- |  undeserved. —  The  Lancet,  July  12,  ISOO. 


HABTSSOBNF,  SFNRT,  M.  i).,  LL.  D., 

Lately  Professor  of  Hygiene  in  the  University  of  Pennsylvania. 

Essentials  of  the  Principles  and  Practice  of  Medicine.    A  Handbook 
for  Students  and  Practitioners.     Fifth  edition,  thoroughly  revised  and  rewritten.     In  one 
royal  12mo.  volume  of  669  pages,  with  144  illustrations.     Cloth,  $2.75. 
Within  the  compass  of  600  pages  it  treats  of  the  ]  a  better  average  of  actual  practical  treatment  than 


history  of  medicine,  general  pathology,  general 
symptomatology, and  physical  diagnosis  (including 
laryngoscope,  ophthalmoscope,  etc.),  general  ther- 
apeutics, nosology,  and  special  pathology  and  prac- 
tice. There  is  a  wonderful  amount  of  information 
contained  in  this  work,  and  it  is  one  of  the  best 
of  its  kind  that  we  have  seen. — Glnsgow  Medical 
Journal,  Nov.  1S82. 
An  indispensable  book.    No  work  ever  exhibited 


this  one;  and  probably  not  one  writer  in  our  day 
had  a  better  opportunity  than  Dr.  Hartshorne  for 
condensing  all  the  views  of  eminent  practitioners 
into  a  12mo.  The  numerous  illustrations  will  be 
very  useful  to  students  especially.  These  essen- 
tials are  most  valuable  in  affording  the  means  to 
see  at  a  glance  the  whole  literature  of  any  disease, 
and  the  most  valuable  treatment. — Chicago  Medical 
Journal  and  E.raminer,  April,  1882. 


RFTNOLDS,  J.  BUSSFLL,  M.  2)., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 

A  System  of  Medicine.  With  notes  and  additions  by  Henr"2  Hartshorne, 
A.  M.,  M.  D.,  late  Professor  of  Hygiene  in  the  University  of  Pennsylvania.  In  three  large 
and  handsome  octavo  volumes,  containing  3056  double-columned  pages,  with  317  illustra- 
tions. Price  per  volume,  cloth,  $5.00;  sheep,  $6.00;  half  Kussia,  raised  bands,  $6.50. 
Per  set,  cloth,  $15.00;  leather,  $18.00;  half  Kussia,  $19.50.     Sold  only  by  subscription. 


COHEN,  SOLOMON  SOLIS,  M.  D., 

Professor  of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadelphia  Polyclinic. 

A  Handbook  of  Applied  Therapeutics.  Being  a  Study  of  Principles 
Applicable  and  an  Exposition  of  Methods  Employed  in  the  Management  of  the  Sick. 
In  one  large  12mo.  volume,  with  illustrations.     Preparing. 


STiLLE  ON  CHOLERA:  Its  Origin,  History, 
Causation,  Symptoms,  Lesions,  Prevention  and 
Treatment.  In  one  handsome  l'2mo.  volume  of 
1G3  pages,  with  a  chart.    Cloth,  S1.25. 

WATSON'S  LECTURES  ON  THE  PRINCIPLES 
AND  PRACTICE  OF  PHYSIC.  From  the  fifth 
English  edition.  Edited  with  additions,  and  190 
illustrations, by  Hf.net  Hartshorne,  A.M.,  M.  D., 
late  Professor  of  Hygiene  in  the  University  of 
Pennsylvania.  In  two  large  octavo  volumes  of 
1840  pages.    Cloth,  S9.00;  leather,  $11.00. 

FLINT  ON  PHTHISIS:  ITS  MORBID  ANAT- 
OMY, ETIOLOGY,  SYMPTOMATIC    EVENTS 


AND  COMPLICATIONS,  FATALITY  AND 
PROGNOSIS,  TREATMENT  AND  PHYSICAL 
DIAGNOSIS;  in  ii  series  of  Clinical  Studies.  In 
one  octavo  volume  of  442  pages.    Cloth,  33.50. 

FLINT'S  PRACTICAL  TREATISE  ON  THE 
DIAGNOSIS,  PATHOLOGY  AND  TREATMENT 
OF  DISEASES  OF  THE  HEART.  Second  re- 
vised and  enlarged  edition.  In  one  octavo  vol- 
ume of  550  pages,  with  a  plate.    Cloth,  $4. 

FLINT'S  ESSAYS  ON  CONSERVATIVE  MEDI- 
CINE AND  KINDRED  TOPICS.  In  one  very 
handsome  royal  12mo.  volume  of  210  pages. 
Cloth,  S1.3S. 


14 


Lea  Brothers  &  Co.'s  Publications — System  of  Med. 


For  Sale  by  Subscription  Only. 


A  System  of  Practical  Medicine. 

BY  AMERICAN  AUTHORS. 

Edited  by  WILLIAM  PEPPER,  M.  D.,  LL.  D., 

PROVOST  AND  PKOFESSOK  OF  THE  THEORY  ANB  PRACTICE  OP  MEDICINE  AND   OF 
CLINICAIj  MEDICINE  IN  THE  UNIVERSITY  OF  PENNSYLVANIA, 

Assisted  by  Louis  Starr,  M.  D.,  Clinical  Professor  of  tlie  Diseases  of  Children  in  the 
Hospital  of  the  University  of  Pennsylvania. 

The  complete  work,  in  five  volumes,  containing  5573  pages,  with  198  illustrations,  is  now  ready. 
Price  per  volume,  cloth,  $5;  leather,  $6  ;  half  Russia,  raised  bands  and  open  back,  |7. 


In  this  great  work  American  medicine  is  for  the  first  time  reflected  by  its  worthiest 
teachers,  and  presented  in  the  fiill  development  of  the  practical  utility  which  is  its  pre- 
eminent characteristic.  The  most  able  men — from  the  East  and  the  West,  from  the 
North  and  the  South,  from  all  the  prominent  centres  of  education,  and  from  all  the 
hospitals  which  afford  special  opportunities  for  study  and  practice — have  united  in 
generous  rivalry  to  bring  together  this  vast  aggregate  of  specialized  experience. 

The  distinguished  editor  has  so  apportioned  the  work  that  to  each  author  has  been 
assigned  the  subject  which  he  is  peculiarly  fitted  to  discuss,  and  in  which  his  views 
Avill  be  accepted  as  the  latest  expression  of  scientific  and  practical  knowledge.  The 
practitioner  will  therefore  find  these  volumes  a  complete,  authoritative  and  unfailing  work 
of  reference,  to  which  he  may  at  all  times  turn  with  full  certainty  of  finding  what  he  needs 
in  its  most  recent  aspect,  whether  he  seeks  information  on  the  general  principles  of  medi- 
cine, or  minute  guidance  in  the  treatment  of  special  disease.  So  wide  is  the  scope  of  the 
work  that,  with  the  exception  of  midwifery  and  matters  strictly  surgical,  it  embraces  the 
whole  domain  of  medicine,  including  the  departments  for  which  the  physician  is  accustomed 
to  rely  on  special  treatises,  such  as  diseases  of  women  and  children,  of  the  genito-urinary 
organs,  of  the  skin,  of  the  nerves,  hygiene  and  sanitary  science,  and  medical  ophthalmology 
and  otology.  Moreover,  authors  have  inserted  the  formulas  which  they  have  found  most 
efficient  in  the  treatment  of  the  various  affections.  It  may  thus  be  truly  regarded  as  a 
Complete  Library  of  Practical  Medicine,  and  the  general  practitioner  possessing  it 
may  feel  secure  that  he  will  require  little  else  in  the  daily  round  of  professional  duties. 

In  spite  of  every  effort  to  condense  the  vast  amount  of  practical  information  fur- 
nished, it  has  been  impossible  to  present  it  in  less  than  5  large  octavo  volumes,  containing 
about  5600  beautifully  printed  pages,  and  embodying  the  matter  of  about  15  ordinary 
octavos.     Illustrations  are  introduced  wherever  requisite  to  elucidate  the  text. 

A   detailed  prospectus  will  be  sent   to  any  address  on  application  to  the  publishers. 


These  two  volumes  bring  this  admirable  work 
to  a  close,  and  fully  sustain  the  high  standard 
reached  by  the  earlier  volumes;  we  have  only 
therefore  to  echo  the  eulogium  pronounced  upon 
them.  We  would  warmly  congratulate  the  editor 
and  his  collaborators  at  the  conclusion  of  their 
laborious  task  on  the  admirable  manner  in  which, 
from  first  to  last,  they  have  performed  their  several 
duties.  They  have  succeeded  in  producing  a 
work  which  will  long  remain  a  standard  work  of 
reference,  to  which  practitioners  will  look  for 
guidance,  and  authors  will  resort  for  facts. 
From  a  literary  point  of  view,  the  work  is  without 
any  serious  blemish,  and  in  respect  of  production, 
it  has  the  beautiful  finish  that  Americans  always 
give  their  works. — Edinburgh  Medical  Journal,  Jan. 
1887. 

*  *  The  greatest  distinctively  American  work  on 
the  practice  of  medicine,  and,  indeed,  the  super- 
lative adjective  would  not  be  inappropriate  were 
even  all  other  productions  placed  in  comparison. 
An  examination  of  the  five  volumes  is  sufficient 
to  convince  one  of  the  magnitude  of  the  enter- 
prise, and  of  the  success  which  has  attended  its 
fulfilment.— r/ie  Medical  Age,  July  26, 1886. 

This  huge  volume  forms  a  fitting  close  to  the 
great  system  of  medicine  which  in  so  short  a  time 
has  won  so  high  a  place  in  medical  literature,  and 
has  done  such  credit  to  the  profession  in  this 
country.  Among  the  twenty-three  contributors 
are  the  names  of  the  leading  neurolosists  in 
America,  and  most  of  the  work  in  the  volume  is  of 
the  highe.«t  order. — Boston  Medical  and  Surgical 
Journal,  July  21, 1887. 

We  consider  it  one  of  the  grandest  works  on 
Practical  Medicine  in  the  English  language.  It  is 
a  work  of  which  the  profession  of  this  country  can 
feel   proud.     Written   exclusively  by  American 


physicians  who  are  acquainted  with  all  the  varie- 
ties of  climate  in  the  United  States,  the  character 
of  the  soil,  the  manners  and  customs  of  the  peo- 
ple, etc.,  it  is  peculiarly  adapted  to  the  wants 
of  American  practitioners  of  medicine,  and  it 
seems  to  us  that  every  one  of  them  would  desire 
to  have  it.  It  has  been  truly  called  a  "  Complete 
Library  of  Practical  Medicine,"  and  the  general 
practitioner  will  require  little  else  in  his  round 
of  professional  duties. — Cincinnati  Medical  News, 
March,  1886. 

Each  of  the  volumes  is  provided  with  a  most 
copious  index,  and  the  work  altogether  promises 
to  be  one  which  will  add  much  to  the  medical 
literature  of  the  present  century,  and  reflect  great 
credit  upon  the  scholarship  and  practical  acumen 
of  its  authors. — 77ie  London  Lancet,  Oct.  3,  1885. 

The  feeling  of  proud  satisfaction  with  which  the 
American  profession  sees  this,  its  representative 
system  of  practical  medicine  issued  to  the  medi- 
cal world,  IS  fully  justified  by  the  character  of  the 
work.  The  entire  caste  of  the  system  is  in  keep- 
ing with  the  best  thoughts  of  the  leaders  and  fol- 
lowers of  our  home  school  of  medicine,  and  the 
combination  of  the  scientific  study  of  disease  and 
the  practical  application  of  exact  and  experimen- 
tal knowledge  to  the  treatment  of  human  mal- 
adies, makes  every  one  of  us  share  in  the  pride 
that  has  welcomed  Dr.  Pepper's  labors.  Sheared 
of  the  prolixity  that  wearies  the  readers  of  the 
German  school,  the  articles  glean  these  same 
fields  for  all  that  is  valuable.  It  is  the  outcome 
of  American  brains,  and  is  marked  throughout 
by  much  of  the  sturdy  independence  of  thought 
and  originality  that  is  a  national  characteristic. 
Yet  nowhere  is  there  lack  of  study  of  the  most 
advanced  views  of  the  day. — North  Carolina  Medi- 
cal Journal,  Sept.  1886. 


Lea  Brothers  &  Co.'s  Publications — Practice  of  Medicine.       15 


WMITLA,  WILLIAM,  M.  D., 

Professor  of  Materia  Medica  ami  Therapeuties  in  the  Queen's  College,  Belfast. 

A  Dictionary  of  Treatment ;  or  Therapeutic  Index,  including  Medi- 
cal and  Surgical  Therapeutics.  Revised  and  adapted  to  the  United  States 
Pliarraacopoeia.     In  one  square,  octavo  volume  of  917  pages.     Cloth,  $4.00.     Just  ready. 


Dr.  Whitla  has,  we  think,  been  fortunate  in  tlie 
selection  of  a  title  for  his  latest  work.  We  have 
already  dictionaries  of  medicine  and  dictionaries 
of  surgery;  he  now  provides  us  with  a  dictionary 
of  treament.  And  reference  to  the  volume  shows 
that  it  really  is  what  it  professes  to  be.  Tlie  sev- 
eral diseased  conditions  are  arranged  in  alphabet- 
ical order,  and  the  methods— medical,  surgical, 
dietetic,  and  climatic— by  which  they  may  be  met, 
considered.  On  every  page  we  find  clear  and  de- 
tailed directions  for  treatment,  supported  by  the 
author's  ])ersonal  authority  and  experience,  whilst 
the  recommendations  of  other  competent  observers 
are  also  critically  examined.    Tiie  book  abounds 


the  younger  practitioner  will  find  in  it  exactly  the 
help  he  so  often  needs  in  the  treatment  both  of 
those  who  are  ill,  and  those  who  are  ailing.  At  the 
same  time  the  most  experienced  members  of  the 
profession  may  usefully  consult  its  pat^es  for  the 
purpose  of  learning  what  is  really  trustworthy  in 
the  later  therapeutic  developments.  The  Diction- 
ary ii!,  in  short,  the  recorded  experience  of  a  prac- 
tical scientific  therapeutist,  who  has  carefully 
studied  diseases  and  disorders  at  the  bed-side  and 
in  the  consulting-room,  and  has  earnestly  ad- 
dressed liimself  to  the  cure  and  relief  of  his 
patients.  Dr.  Whitla  is  to  be  congratulated  upon 
the  thoroughness  with  which  he  has  realised  his 


with  useful,  practical  liints  and  suggestions,  and  |  idea.— The  Glasgow  Medical  Journal,  April,  1892. 


FOTSJEBGILL,  J.  31.,  M.  D.,  Bdin,,  M.  B,  C.  1*.,  Lond., 

Physician  to  the  City  of  London  Hospital  fo'^  Diseases  of  the  Chest. 

The  Practitioner's  Handbook  of  Treatment ;  Or,  The  Principles  of  Thera- 
peutics.  Third  edition.    In  one  8vo.  vol.  of  661  pages.    Cloth,  $3.75  ;  leather,  $4.75. 

To  have  a  description  of  the  normal  physiologi-  i  This  is  a  wonderful  book.  If  there  be  such  a 
cal  processes  of  an  organ  and  of  the  methods  of  I  thing  as  "  medicine  made  easy,"  this  is  the  work  to 
treatment  of  its  morbid  conditions  brought  j  accomplish  this  result.— Fa.  Med.  jJfoni/i.,  June,'87. 
together  in  a  single  chapter,  and  the  relations!  It  is  an  excellent,  practical  work  on  therapeutics, 
between  the  two  clearlv  staled,  cannot  fail  to  prove  1  well  arranged  and  clearly  expressed,  useful  to  the 


a  great  convenience  to  many  thoughtful  but  bu.sy 
physicians.  The  practical  value  of  the  volume  is 
greatly  increased  by  the  introduction  of  many 
prescriptions.  That  the  profession  appreciates 
that  the  author  has  undertaken  an  important  work 
and  has  accomplished  it  is  shown  by  the  demand 
for  this  third  edition. — N.  Y.  Med.  Jour.,  June  11, '87. 


student  and  young  practitioner,  perhaps  even  to 
the  old. — Dublin  Journal  of  Medical  Science,  March, 
1888. 

We  do  not  know  a  more  readable,  practical  and 
useful  work  on  the  treatment  of  disease  than  the 
one  we  have  now  before  us. — Pacific  Medical  and 
Surgical  Journal,  October,  1887. 


FINLATSON,  JAMES,  M.  2).,  Editor, 

Physician  and  Lecturer  on  Clinical  Medicine  in  the  Glasgow  Western  Infirmary,  etc. 

Clinical  Manual  for  the  Study  of  Medical  Cases.  With  Chapters 
by  Prof.  Gairdner,  Prof.  Stephenson,  Dr.  Robertson,  Dr.  Gemmell  and  Dr.  Coats.  Second 
edition.     In  one  12mo.  volume  of  682   pages,  with   158   illustrations.    Cloth,  $2.50. 

has  no  competitor,  nor  is  it  likely  to  have  as  long 
as  future  editions  maintain  its  present  standard  of 
excellence.      The  general  practitioner  will  find 


We  are  pleased  to  see  a  second  edition  of  this 
admirable  book.  It  is  essentially  a  practical 
treatise  on  medical  diagnosis,  in  which  every  sign 
and  symptom  of  disease  is  carefully  analyzed,  and 
their  relative  significance  in  the  different  affec- 
tions in  which  they  occur  pointed  out.  From  their 
sj'nthesis  the  student  can  accurately  determine 
the  disease  with  which  he  has  to  deal.     The  book 


many  practical  hints  in  its  pages,  while  a  careful 
study  of  the  work  will  save  him  from  many  pitfalls 
in  diagnosis.— LiuerpooJ  Medico-Chirurgical  Jour- 
nal, January,  1887. 


MUSSEB,  JOSW  JET.,  M,  D., 

Assistant  Professor  of  Clinical  Medicine,  University  of  Pennsylvania,  Philadelphia. 

A  Practical  Treatise  on  Medical  Diagnosis.    For  the  Use  of  Students  and 
Practitioners.     In  one  octavo  volume  of  about  650  pages.     Preparing. 

LYMAN,  HENBT  M.,  M,  D., 

Professor  of  the  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago. 

A  Text-Book  of  the  Principles  and  Practice  of  Medicine.     For  the 

Use  of  Medical  Students  and  Practitioners.     In  one  octavo  volume  of  about  900  pages, 
with  illustrations.     In  press. 

SLABEBSSON,  S.  O.,  M.  D., 

Senior  Physician  to  and  late  Led.  on  Principles  and  Practice  of  Med.  at  Chiy's  ffospital,  London. 
On  the  Diseases  of  the  Abdomen ;     Comprising  those  of  the  Stomach,  and 
other  parts  of  the  Alimentary  Canal,  (Esophagus,  Caecum,  Intestines  and  Peritoneum.  Second 
American   from  third  enlarged  and  revised  English  edition.     In  one  handsome  octavo 
volume  of  554  pages,  with  illustrations.     Cloth,  $3.50. 

This  valuable  treatise  on  diseases  of  the  stomach  I  rectum.      A  fair  proportion  of  each   chapter  is 
and  abdomen  will  be  found  a  cycloposdia  of  infor-  |  devoted  to  symptoms,  pathology,  and  therapeutics, 
mation,  systematically  arranged,  on  all  diseases  of    — JS'ew  York  Medical  Jouri\al,  April,  1870. 
the   alimentary    tract,    from    the    mouth    to  the  ] 


TANNER'S  MANUAL  OF  CLINICAL  MEDICINE 
AND  PHYSICAL  DIAGNOSIS.  Third  American 
from  the  second  London  edition.  Revised  and 
enlarged  by  Tilbury  Fox,  M.D.  In  one  12mo. 
volume  of  302  pp  ,  with  illus.    Cloth,  31.50. 

A  TREATISE  ON  FEVER.  By  Robert  D.  Lyons, 
K.  C.  C.    In  one  8vo.  vol.  of  354  pp.    Cloth,  62.25. 


LECTURES  9N  THE  STUDY  OP  FEVER.  By 
A.  Hudson  .  M.  D.,  M.  R.  I.  A.  In  one  octavo 
volume  of  308  pages.    Cloth,  82.50. 

LA  ROCHE  ON  YELLOW  FEVER,  considered  in 
its  Historical,  Pathological,  Etiological  and 
Therapeutical  Relations.  In  two  lar^e  and  hand- 
some octavo  volumes  of  1468  pp.    Cloth,  S7.00. 


16     Lea  Brothers  &  Co.'s  Publications — Hygiene,  Eleetr.,  Pract. 


BAMTBLOLOW,  BOBERTS,  A,  M.,  M,  D,,  LL,  J>., 

Prof,  of  Materia  Medica  and  General  Therapeutics  in  the  Jefferson  Med.  Coll.  of  Phila.,  etc. 
Medical  Electricity.     A  Practical  Treatise  on  the  Applications  of  Electricity 


to  Medicine  and  Surgery.     Third  edition, 
pages,  with  110  illustrations.     Cloth,  $2.50. 

The  fact  that  this  work  has  reached  its  third  edi- 
tion in  sis  years,  and  that  it  has  been  kept  fully 
abreast  with  the  increasing  use  and  knowledge  of 
eleetrieity,demonstrates  its  claim  to  be  considered 
a  practical  treatise  of  tried  value  to  the  profession. 
The  matter  added  to  the  present  edition  embraces 


In  one  very  handsome  octavo  volume  of  30S 

the  most  recent  advances  in  electrical  treatment. 
The  illustrations  are  abundant  and  clear,  and  the 
work  constitutes  a  full,  clear  and  concise  manual 
well  adapted  to  the  needs  of  both  student  and 
practitioner. —  The  Medical  News,  May  14, 1887. 


YBO,  I.  BVMNEY,  M,  D.,  F.  M,  C.  JP., 

Professor  of  Clinical  Therapeutics  in  King^s   College,  London,  and  Physician  to  King^s   College 
Hospital. 

Pood  in  Health  and  Disease.    In  one  12mo.  volume  of  590  pages.    Cloth,  $2. 
See  Series  of  Clinical  Manuals,  page  31. 


Dr.Yeo  supplies  in  a  compact  form  nearly  all  that 
the  practitioner  requires  to  know  on  the  subject  of 
diet.  The  work  is  divided  into  two  parts— food  in 
health  and  food  in  disease.  Dr.  Yeo  has  gathered 
together  from  all  quarters  an  immense  amount  of 
useful  information  within  a  comparatively  small 


compass,  and  he  has  arranged  and  digested  his 
materials  with  skill  for  the  use  of  the  practitioner. 
We  have  seldom  seen  a  book  which  more  thor- 
oughly realizes  the  object  for  which  it  was  written 
than  this  little  work  of  Dr.  Yeo. — British  Medical 
Journal,  Feb.  8, 1890. 


IIICHABJDSON,  B.  W.,  M.D„  LL.  D.,  F.M,S,, 

Fellow  of  the  Royal  College  of  Physicians,  Lo'ndon. 
Preventive  Medicine.   In  one  octavo  volume  of  729  pages.   Cloth, 


Dr.  Richardson  has  succeeded  in  producing  a 
work  which  is  elevated  in  conception,  comprehen- 
sive in  scope,  scientific  in  character,  systematic  in 
arrangement,  and  which  is  written  in  a  clear,  con- 
cise and  pleasant  manner.  He  evinces  the  happy 
faculty  of  extracting  the  pith  of  what  is  known  on 
the  subject,  and  of  presenting  it  In  a  most  simple, 
intelligent  and  practical  form.  There  is  perhaps 
no  similar  work  written  for  the  general  public 
that  contains  such  a  complete,  reliable  and  instruc- 


\ ;  leather, : 


tive  collection  of  data  upon  the  diseases  common 
to  the  race,  their  origins,  causes,  and  the  measures 
for  their  prevention.  The  descriptions  of  diseases 
are  clear,  chaste  and  scholarly ;  the  discussion  of 
the  question  of  disease  is  comprehensive,  masterly 
and  fully  abreast  with  the  latest  and  best  knowl- 
edge on  the  subject,  and  the  preventive  measures 
advised  are  accurate,  explicit  and  reliable. — The 
American  Journal  of  the  Medical  Sciences,  April,  1884. 


THE  TJEAB  BOOK  OF  TREATMENT  FOB  1892. 

A  Comprehensive  and  Critical  Review  for  Practitioners  of  Medi- 
cine and  Surgery.     In  one  12mo.  volume  of  about  500  pages.    Cloth,  $1.50.      Shortly. 
^*^  For  special  commutations  with  periodicals  see  pages  1  and  2. 
A  notice  of  the  previous  edition  is  appended. 


The  "Year-Book"  is  too  well  known  and  too 
highly  appreciated  to  need  comment.  The  im- 
mense strides  taken  in  the  progress  of  medicine 
in  all  its  branches  make  it  impossible  for  anyone 
to  keep  up  with  the  timfs.  Hence  the  necessity 
of  the  book  in  hand.  Its  score  of  co-authors  sift 
out  what  is  useful  in  literature  and  present  it  in  a 


concise  and  readable  form.  Thus,  with  compara- 
tively little  labor,  the  busy  practitioner  gets  the 
gist  of  medical  literature  the  world  over.  Every 
branch  of  medicine  is  covered — new  remedies,  old 
ones  with  new  applications,  new  operations,  all 
receiving  attention. — Meaical  Record,  May  21, 1892. 


TJBCE  YEAB-BOOK  OF  TBEAT3IENT  FOB,  1891. 

12mo.,  485  pages.     Cloth,  $1.50. 

THE  YE AB- BOOKS  of  TBEATMENTfor  '86,  '87  and  '90 

Similar  to  above.     12mo.,  320-341  pages.    Limp  cloth,  $1.25  each. 

SCMBEIBEB,  JOSEFFL,  M.  JD. 

A  Manual  of  Treatment  by  Massage  and  Methodical  Muscle  Ex- 
ercise. Translated  by  Walter  Mendelson,  M.  D.,  of  New  York.  In  one  handsome 
octavo  volume  of  274  pages,  with  117  fine  engravings. 


STURGES'  INTRODUCTION  TO  THE  STUDY 
OF  CLINICAL  MEDICINE.  Being  a  Guide  to 
the  Investigation  of  Disease.  In  one  handsome 
12mo.  volume  of  127  pages.    Cloth,  $1.25. 

DAVIS'  CLINICAL  LECTURES  ON  VARIOUS 
IMPORTANT  DISEASES.  By  N.  S.  Davis, 
M.  D.  Edited  by  Fbank  H.  Davis,  M.  D.  Second 
edition.    12mo.  287  pages.    Cloth,  81.75. 

TODD'S  CLINICAL  LECTURES  ON  CERTAIN 
ACUTE  DISEASES.  In  one  octavo  volume  of 
320  pages.    Cloth.  82.50. 

PAVY'S  TREATISE  ON  THE  FUNCTION  OF  DI- 
GESTION; its  Disorders  and  their  Treatment. 
From  the  second  London  edition.  In  one  octavo 
volume  of  238  pages.    Cloth,  $2.00. 

BARLOW'S  MANUAL  OF  THE  PRACTICE  OF 
MEDICINE.  With  additions  by  D.  F.  Condie, 
M.D.     1  vol.  8vo.,  pp.  603.     Cloth,  $2.50. 

CHAMBERS'  MANUAL  OF  DIET  AND  REGIMEN 
TN  HEALTH  AND  SICKNESS.  In  one  hand 
■^e  octavo  volume  of  302  pp.    Cloth,  $2.75. 


HOLLAND'S  MEDICAL  NOTES  AND  REFLEC- 
TIONS. 1  vol.  8vo.,  pp.  493.     Cloth,  $3.50. 

FULLER  ON  DISEASES  OF  THE  LUNGS  AND 
AIR-PASSAGES.  Their  Pathology,  Physical  Di- 
agnosis, Symptoms  and  Treatment.  From  the 
second  and  revised  English  edition.  In  one 
octavo  volume  of  475  pages.    Cloth,  $3.50. 

WALSHE  ON  THE  DISEASES  OF  THE  HEART 
AND  GREAT  VESSELS.  Third  American  edi- 
tion.    In  1  vol.  8vo.,  416  pp.    Cloth,  $3.00. 

SLADE  ON  DIPHTHERIA;  its  Nature  and  Treat- 
ment, with  an  account  of  the  History  of  its  Pre- 
valence in  various  Countries.  Second  and  revised 
edition.    In  one  12mo.  vol.,  158  pp.     Cloth,  $1.25. 

SMITH  ON  CONSUMPTION;  its  Early  and  Reme- 
diable Stages.    1  vol.  8vo.,  253  pp.    Cloth,  $2.25. 

LA  ROCHE  ON  PNEUMONIA.  1  vol.  8vo.  of  490 
pages.    Cloth,  $3.00. 

WILLIAMS  ON  PULMONARY  CONSUMPTION; 
its  Nature,  Varieties  and  Treatment.  With  an 
analysis  of  one  thousand  cases  to  exemplify  its 
duration.   In  one  8vo.  vol.  of  303  pp.  Cloth,  $2.50. 


Lea  Brothers  &  Co.'s  Publications — Phys.  Diag.,  Throat,  Hist.     17 


FLINT,  AUSTIN,  M,  !>.,  LL.  !>., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  Bellevtie  Hospital  Medical  College,  N.  T. 

A.  Manual  of  Auscultation  and  Percussion ;  Of  the  Physical  Diagnosis  of 
Diseases  of  the  Lunojs  ami  Heart,  and  of  Thoracic  Aneurism.  Fifth  edition. 
Edited  by  James  C.  Wilson,  M.  D.,  Lecturer  on  Physical  Diagnosis  in  the  Jefrerson 
Medical  College,  Philadelphia.      In  one  handsome  royal  12mo.  volume  of  274  pages,  with 

12  illustrations.  Cloth,  $1.75. 

This  little  book  through  its  various  editions  has  1  oughness  of  Prof.  Flint's  investigations.  For  stu- 
probably  done  more  to  udvanoe  the  science  of  I  dents  it  is  excellent.  Its  value  is  shown  both  in 
physical  exploration  of  the  chest  than  any  other  j  the  arrangement  of  the  material  and  in  the  clear, 
dissertation  upon  the  subject,  and  now  in  its  fifth  I  concise  style  of  expression.  For  the  practitioner 
edition  it  is  as  near  perfect  as  it  can  be.  The  ;  It  is  a  ready  manual  for  reference.— ivoriA  Ameri^ 
rapidity  with  which  previous  editions  were  sold  can  Practitioner,  January, 'iSQl. 
shows  how  the  profession  appreciated   the  thor-  | 


BBOADBENT,  W.  jBT.,  M.  D.,  F.  M.  C.  F., 

Physician  to  and  Lecturer  on  Medicine  at  St.  Mary's  Hospital,  London. 

The  Pulse.  In  one  12mo.  volume  of  312  pages.  Cloth,  $1.75.  See  Series  of  Clin- 
ical Manuals,  page  31. 

BROWNE,  LENNOX,  F,  B.  C,  S,,  E., 

Senior  Physician  to  the  Central  London  Throat  and  Ear  Hospital. 

The  Throat  and  Nose  and  Their  Diseases.  Fourth  and  enlarged  edition. 
In  one  imperial  octavo  volume  of  about  750  pages,  with  120  illustrations  in  color,  and  235 
engravings  on  wood.     Preparing. 

A  notice  of  the  previous  edition  is  appended. 

The  beautiful  and  typical  colored  plates  form  [  tical  text-book  on  diseases  of  the  throat  and  nose 
a  valuable  and  instructive  atlas,  the  equal  of  which  j  extant.     We  are  glad  to  learn  that  it  is  being 
is  not  to  be  found  in  any  modern  work,  treating  j  translated  into  French  and  Germaa.— The  Provin- 
of  these  subjects.    Mr.  Lennox   Browne  is  to  be  i  cial  Medical  Journal,  August  1, 1890. 
congratulated  on  having  produced  the  best  prac-  1 


SEILEB,  CABL,  M.  I)., 

Lecturer  on  Laryngoscopy  in  the  University  of  Pennsylvania. 

A  Handbook  of  Diagnosis  and  Treatment  of  Diseases  of  the  Throat, 
Nose  and  Naso-Pharynx.  Third  edition.  In  one  handsome  royal  12mo.  volume 
of  373  pages,  with  101  illustrations  and  2  colored  plates.     Cloth,  $2.25. 

Few  medical  writers  surpass  this  author  in  I  of  topics  and  methods.  The  book  deserves  a  large 
ability  to  make  his  meaning  perfectly  clear  In  a  sale,  especially  among  general  practitioners— CAi- 
few  words,  and  in  discrimination  in  selection,  both  |  cago  Medical  Journal  and  Examiner,  April,  1839. 


COHEN,  J.  SOLIS,  M.  D., 

Lecturer  on  Laryngoscopy  and  Diseases  of  the  Throat  and  Chest  in  the  Jefferson  Medical  College. 

Diseases  of  the  Throat  and  Nasal  Passages.  A  Guide  to  the  Diagnosis  and 
Treatment  of  Affections  of  the  Pharynx,  CEsophagus,  Trachea,  Larynx  and  Nares.  Third 
edition,  thoroughly  revised  and  rewritten,  with  a  large  number  of  new  illustraticcs.  In 
one  very  handsome  octavo  volume.     Preparing. 


SCHAFEB,  EDWABD  A.,  F.  B.  S., 

Jodrell  Professor  of  Physiology  in  University  College,  London. 
The  Essentials  of  Histology.     New  (second)  edition.     In  one  octavo  volume 
of  about  300  pages,  with  281  illustrations.     In  press. 


KLEIN,  E.,  M,  n.,  F,  B.  S., 

Joint  Lecturer  on  Oeneral  Anat.  and  Phys.  in  the  Med.  School  of  St.  Bartholomew's  Hasp.,  London. 
Elements  of  Histology.     Fourth  edition.     In  one  12mo.  volume  of  376  pages, 
with  19-1  illus.    Limp  cloth,  $1.75.      See  Students'  Serie.^  of  Manuals,  page  30. 


FLINT'S  PRACTICAL  TREATISE  ON  THE  I  BODIES  IN  THE  AIR-PASSAGES.  In  one 
PHYSICAL  EXPLORATION  OF  THE  CHEST  1  octavo  volume  of  452  pages,  with  59 illustrations. 
AND    THE    DiAONOSIS    OF    DISEASES    AF- i      Cloth,  S2.T5. 


FECTING     THE     RESPIR.\TORY     ORGANS. 

Second  and  revised  edition.    In  one  handsome 

octavo  volume  of  591  pages.    Cloth,  S4.50. 

BROWNE  ON  KOCH'S  REMEDY  IN  RELATION 


WOODHEAD'S  PRACTIC.\L  PATHOLOGY.  A 
Manual  for  Students  and  Practitioners.  In  one 
beautiful  octavo  volume  of  497  pages,  with  136 
exquisitely  colored  illustrations. 


TO  THROAT  CONSUMPTION.    In  one  octavo  !  PEPPER'S   SURGICAL    PATHOLOGY.      In  one 
volume  of  121  pages,  with  45  illustrations,  4  of  I      pocket'Size  12mo.  volume  of  511  pages,  with  81 
which  are  colored,  and  17  charts,    Cloth,  SI. 50.     1     illustrations.    Limp  cloth,  red  edges,  S2.00.    See 
GROSS'  PRACTICAL  TREATISE  ON  FOREIGN  |      Students'  Series  of  Manuals,  page  31. 


18     Lea  Brothers  &  Co.'s  Publications — Pathology,  Bacteriology. 


GIBBES,  HENEAGB,  M.  JD., 

Professor  of  Pathology  in  the  University  of  Michigan,  Medical  Department. 

Practical  Pathology  and  Morbid  Histology.    In  one  very  handsome  octavo 
volume  of  314  pages,  with  60  illustrations,  mostly  photographic.     Cloth,  $2.75. 


This  is,  in  part,  an  expansion  of  the  little  work 
published  by  the  author  some  years  ago,  and  his 
aoknowledged  skill  as  a  practical  microscopist  will 
give  weight  to  his  instructions.  Indeed,  m  ful- 
ness of  directions  as  to  the  modes  of  investigating 
morbid  tissues  the  book  leaves  little  to  be  desired. 


The  work  is  throughout  profusely  illustrated  with 
reproductions  of  micro-photographs.  We  may 
say  that  the  practical  histologist  will  gain  much 
useful  information  from  the  book. — The  London 
Lancet,  January  23, 1892. 


ABBOTT,  A,  C,  31.  B., 

First  Assistant,  Laboratory  of  Hygiene,  University  of  Penna.,  Philadelphia. 

The  Principles  of  Bacteriology :  a  Practical  Manual  for  Students  and  Physi- 
In  one  12mo.  volume  of  259  pages  with  32  illustrations.     Cloth,  $2.     Just  ready. 


cians. 

During  the  last  decade  numerous  works  on  this 
subject  have  been  brought  before  the  profession; 
yet,  while  many  of  them  are  exhaustive  treatises, 
much  of  the  laboratory  technique  requisite  to  the 
needs  of  beginners  was  omitted  or  most  scantily 
treated.  On  reading  this  manual  of  Dr.  Abbott, 
any  one  familiar  with  the  subject  will  readily 
recognize  the  fact  that  the  book  is  not  merely  a 
compilation  from  other  worlis,  but   one   giving 


evidence  of  the  originality  of  the  author,  as  well 
as  complete  knowledge  of  the  practical  details  of 
bacteriology.  -His  "  scheme  for  the  study  of  an 
organism "  furnishes  an  excellent  guide  to  the 
student.  Of  equal  importance  is  the  chapter  on 
disinfectants,  antiseptics  and  skin  disinfection. 
It  will  form  a  valuable  addition  to  the  literature 
of  laboratory  technique  and  bacteriological  inves- 
tigation.—TAe  Therapeutic  Gazette,  May  16, 1892. 


SEJS'J^,  NICHOLAS,  M.n,,  Bh.B,, 

Professor  of  Surgery  in  Rush  Medical  College,  Chicago. 
Surgical  Bacteriology.     New   (second)   edition.    In  one  handsome  octavo 
268  pages,  with  13  plates,  of  which  10  are  colored,  and  9  engravings.  Cloth,  $2. 

makes  it  possible  for  the  busy  practitioner,  whose 


of 


The  book  is  really  a  systematic  collection  in  the 
most  concise  form  of  such  results  as  are  published 
in  current  medical  literature  by  the  ablest  workers 
in  this  field  of  surgical  progress  ;  and  to  these  are 
added  the  author's  own  views  and  the  results  of 
liis  clinical  experience  and  original  investigations. 
The  book  is  valuable  to  the  student,  but  its  chief 
value  lies  in  the  fact  that  such  a  compilation 


time  for  reading  is  limited  and  whose  sources  of 
information  are  often  few,  to  become  conversant 
with  the  most  modern  and  advanced  ideas  in  sur- 
gical pathology,  which  have  "laid  the  foundation 
for  the  wonderful  achievements  of  modern  sur- 
gery."— Annals  of  Surgery,  March,  1892. 


GMEEJSr,  T,  HENItT,  M.  B,, 

Lecturer  on  Pathology  and  Morbid  Anatomy  at  Charing-Oross  Hospital  Medical  School,  London. 
Pathology  and  Morbid  Anatomy.     Sixth  American  from  the  seventh  revised 
English  edition.    Octavo,  539  pp.,  with  167  engravings.   Cloth,  |2.75. 


The  Pathology  and  Morbid  Anatomy  of  Dr. 
Green  is  too  well  known  by  members  of  the  medi- 
cal profession  to  need  any  commendation.  There 
is  scarcely  an  intelligent  physician  anywhere  who 
has  not  the  work  in  his  library,  for  it  is  almost  an 
essential.  In  fact  it  is  better  adapted  to  the  wants 
of  general  practitioners  than  any  work  of  the  kind 
witn  which  we  are  acquainted.  The  works  of 
German  authors  upon  pathology,  which  have  been 


translated  into  English,  are  too  abstruse  for  the 
physician.  Dr.  Green's  work  precisely  meets  his 
wishes.  The  cuts  exhibit  the  appearances  of 
pathological  structures  just  as  they  are  seen 
through  the  microscope.  The  fact  that  it  is  so 
generally  employed  as  a  textbook  by  medical  stu- 
dents is  evidence  that  we  have  not  spoken  too 
much  in  its  favor. — Cincinnati  Medical  News,  Oct. 
1889. 


BATJVE,  JOSEBH  F,,  M,  B.,  F,  B,  C.  JP., 

Senior  Assistant  Physician  and  Lecturer  on  Pathological  Anatomy,  St.  Thomas'  Hospital,  London. 
A  Manual  of  General  Pathology.     Designed  as  an  Introduction  to  the  Prac- 
tice of  Medicine.    Octavo  of  524  pages,  with  152  illus.  and  a  colored  plate.     Cloth,  $3,50. 


Knowing,  as  a  teacher  and  examiner,  the  exact 
needs  of  medical  students,  the  author  has  in  the 
work  before  us  prepared  for  their  especial  use 
what  we  do  not  hesitate  to  say  is  the  best  introduc- 
tion to  general  pathology  that  we  have  yet  ex- 
amined. A  departure  which  our  author  has 
taken  is  the  greater  attention  paid  to  the  causa- 
tion of  disease,  and  more  especially  to  the  etiologi- 


cal factors  in  those  diseases  now  with  reasonable 
certainty  ascribed  to  pathogenetic  microbes.  In 
this  department  he  has  been  very  full  and  explicit, 
not  only  in  a  descriptive  manner,  but  in  the  tech- 
nique of  investigation.  The  Appendix,  giving 
methods  of  research,  is  alone  worth  the  price  of  the 
book,  several  times  over,  to  every  student  of 
pathology. — St.  Louis  Med.  and  Surg.  Jbwr.,  Jan. '89. 


COATS,  JOSEFS,  M.  B,,  F.  F,  F,  S,, 

Pathologist  to  the  Glasgow  Western  Infirmary. 

A  Treatise  on  Pathology.    In  one  very  handsome  octavo  volume  of  829  pages, 

'" Cloth,  15.50 ;  leather,  $6.50. 

manner,  the  changes  from  a  normal  condition 


with  339  beautiful  illustrations. 


Medical  students  as  well  as  physicians,  who 
desire  a  work  for  study  or  reference,  that  treats 
the  subjects  in  the  various  departments  in  a  very 
thorough  manner,  but  without  prolixity,  will  cer- 
tainly give  this  one  the  preference  to  any  with 
which  we  are  acquainted.  It  sets  forth  the  most 
recent   discoveries,  exhibits,    in  an   interesting 


effected  in  structures  by  disease,  and  points  out 
the  characteristics  of  various  morbid  agencies, 
so  that  they  can  be  easily  recognized.  But,  not 
limited  to  morbid  anatomy,  it  explains  fully  how 
the  functions  of  organs  are  disturbed  by  abnormal 
conditions.— Oincinnaii  Medical  News,  Oct.  1883. 


Lea  Brothers  &  Co.'s  Publications — Xerv.  and  Ment.  Dis.,  etc.     19 


BOSS,  JAMES,  ilf.D.,  F.B.C.JP.,  LL.D,, 


Senior  Assistant  Physician  to  the  Manchester  Royal  Infirmary. 

A  Handbook  on  Diseases  of  the  Nervous    System.     In 
volume  of  725  pages,  with  184  illustrations.     Cloth,  $4.50;  leather,  $5.50. 

The  book  before  us  is  entitled  to  the  highest 
consideration ;  it  is  painstaking,  scientific  and 
exeeedinglv  comprehensive. — New  York  Medical 
Journal,  Jiliv  Id,  1886. 

The  author  has  rendered  a  great  service  to  the 
profession  by  condensing  into  one  volume  the 
principal  facts  pertaining  to  neurology  and  nerv- 
ous diseases  as  understood  at  the  present  time, 
and  he  has  succeeded  in  producing  a  work  at  once 
brief  and  practical  yet  scientific,  without  entering 
into  the  discussion  of  theorists,  or  burdening  the 
mind  with  mooted  questions. — Pacific  Medical  and 
Suri^ical  Journal  ana  Western  Lancet,  May,  188G. 

This  admirable  work  is  intended  for  students  of 
medicine  and  for  such  medical  men  as  have  no  time 


one   octavo 


for  lengthy  treatises.  In  the  present  instance  the 
duty  of  arranging  the  vast  store  of  material  at  the 
disposal  of  the  author,  and  of  abridging  the  de- 
scription of  the  different  aspects  of  nervous  dis- 
eases, has  been  performed  with  singular  skill,  and 
the  result  is  a  concise  an(i  philosophical  guide  to 
the  department  of  medicine  of  which  it  treats. 
Dr.  Ross  holds  such  a  high  scientific  position  that 
any  writings  which  bear  his  name  are  naturally 
expected  to  have  the  impress  of  a  poweriui  intel- 
lect. In  every  part  this  handbook  merits  the 
highest  praise,  and  will  no  doubt  be  found  of  the 
greatest  value  to  the  student  as  well  as  to  the  prac- 
titioner.— Edinbur<iti  Medical  Journal,  Jan.  1887. 


HJ3IILTON,  ALLAJ^  McLAJSTE,  M,  D,, 

Attending  Physician  at  the  Hospital  for  Epileptics  and  Paralytics,  BlaekioelVs  Island,  N.  7. 
Nervous  Diseases ;  Their  Description  and  Treatment.  Second  edition,  thoroughly 
revised  and  rewritten.  In  one  octavo  volume  of  598  pages,  with  72  illustrations.  Cloth,  $4. 
When  thefirstedition  of  this  good  book  appeared  j  characterized  this  book  as  the  best  of  its  kind  in 
we  gave  it  our  emphatic  endorsement,  and  the  !  any  language,  which  is  a  handsome  endorsement 
present  edition  enhances  our  appreciation  of  the  !  from  an  exalted  source.  The  improvements  in  the 
book  and  its  author  as  a  safe  guide  to  students  of  j  new  edition,  and  the  additions  to  it,  will  justify  its 
clinical  neurology.  One  of  the  best  and  most  purchase  even  by  those  who  possess  the  old. — 
critical  of  Englisn  neurological  journals,  Brain,  has  j  Alienist  and  Neurologist,  April,  1882. 

TVKE,  DANIEL  HACK,  M,  D., 

Joint  Author  of  The  Manual  of  Psychological  Medicine,  etc. 

Illustrations  of  the  Influence  of  the  Mind  upon  the  Body  in  Health 
and  Disease.  Designed  to  elucidate  the  Action  of  the  Imagination.  ISTew  edition. 
Thoroughly  revised  and  rewritten.  In  one  8vo.  vol.  of  467  pp.,  with  2  col.  plates.   Cloth,  $3. 

It  is  impossible  to  peruse  these  interesting  chap-  1  method  of  interpretation.  Guided  by  an  enlight- 
ters  without  being  convinced  of  the  author's  per-  [  ened  deduction,  the  author  has  reclaimed  for 
feet  sincerity,  impartiality,  and  thorough  mental  i  science  a  most  interesting  domain  in  psychology, 
grasp.  Dr.  Tuke  has  es:hibited  the  requisite  previously  abandoned  to  charlatans  and  empirics, 
amount  of  scientific  address  on  all  occasions,  and  This  book,  well  conceived  and  well  written,  must 
the  moreintricate  the  phenomena  the  more  firmly  commend  itself  to  every  thoughtful  understand- 
has   he  adhered  to  a  physiological  and  rational  1  ing. — New  York  Medical  Journal,  September  6,  ISSi. 

GBAY,  LAJSnON  CAMTEM,  31.  D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System  in  the  Neio  York  Polyclinie. 

A  Practical  Treatise  on  Nervous  and  Mental  Diseases.    Ingress. 
CLOJJSTON,  THOMAS  S.,  M,  D,,  F,  B.  C.  F.,  L,  B.  C,  S., 

Lecturer  on  Mental  Diseases  in  the  University  of  Edinburgh. 

Clinical  Lectures  on  Mental  Diseases.  With  an  Appendix,  containing  an 
Abstract  of  the  Statutes  of  the  United  States  and  of  the  Several  States  and  Territories  re- 
lating to  the  Custody  of  the  Insane.  By  Charles  F.  Folsom,  M.  D.,  Assistant  Professor 
of  Mental  Diseases,  Med.  Dep.  of  Harvard  Univ.  In  one  handsome  octavo  volume  of  541 
pages,  with  eight  lithographic  plates,  four  of  which  are  beautifully  colored.     Cloth,  $4. 

The  practitioner  as  well  as  the  student  will  ac- 
cept the  plain,  practical  teaching  of  the  author  as  a 
forward  step  in  the  literature  of  insanity.    It  is 


refreshing  to  find  a  physician  of  Dr.  Clouston's 
experience  and  high  reputation  giving  the  bed- 
side notes  upon  which  his  experience  has  been 
founded  and  his  mature  judgment  established. 
Such  clinical  observations  cannot  but  be  useful  to 


the  general  practitioner  in  guiding  him  to  a  diag- 
nosis and  indicating  the  treatment,  especially  in 
many  obscure  and  doubtful  cases  of  mental  dis- 
ease. To  the  American  reader  Dr.  Folsom's  Ap- 
pendix adds  greatly  to  the  value  of  the  work,  and 
will  mike  it  a  desirable  addition  to  every  library. 
— American  Psychological  Jow^nal,  July,  188i. 


108  pages. 


•.  Folsom's  Abstract  may  also  be  obtained  separately  in  one  octavo  volume  of 
Cloth,  $1.50. 


SAVAGE,  GEOBGE  H.,  M.  !>., 

Lecturer  on  Mental  Diseases  at  Ouy's  Hospital,  London. 

Insanity  and  Allied  Neuroses,  Practical  and  Clinical.    In  one  12mo.  vol. 
of  551  pages,  with  IS  illus.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31.  ■> 

.4s  ,1  handbook,  a  guide  to  the  practitioner  and  carefully  selected,  and  as  regards  treatment  sound 
student,  the  book  fulfils  an  admirable  purpose,  common  sense  is  everywhere  apparent.  Dr.  Sav- 
The  many  forms  of  insanity  are  described  with  age  has  written  an  excellent  manual  for  the  prac- 
characterlstic  clearness,  the  illustrative  cases  are    titioner  and  student. — Amer.Jour.of  Insan.,  K'pT.''So. 

JPEAYFAIB,  W,  S.,  M,  JD.,  F,  B,  C,  JP, 

The  Systematic  Treatment  of  Nerve  Prostration  and  Hysteria.    In 
one  handsome  small  12mo.  volume  of  97  pages.     Cloth,  $1.00. 

BLANDFORD  ON  IXS.\XITY  AND  ITS  TREAT-  JONES'  CLINICAL  OBSERVATIONS  ON  FUNC 
MENT.-  Lectures  on  the  Treatment,  Medical  TIONAL  NERVOUS  DISORDERS.  Second 
and  Legal,  of  Insane  Patients.  Inone  very  hand- ■  American  Edition.  In  one  handsome  octavo 
some  octavo  volume.  !      volume  of  340  pages.    Cloth,  $3.25. 


20  Lea  Brothers  &  Co.'s  Publications — Surg-ery. 

mobbhts,  jo  BLJsr  b,,  m,  i>.. 

Professor  of  Anatomy  and  Surgery  in  the  Philadelphia  Polyclinic.  Professor  of  the  Principles  and 
Practice  of  Surgery  in  the  Woman's  Medical  College  of  Pennsylvania.  Lecturer  in  Anatomy  in  the  Univer- 
sity of  Pennsylvania. 

The  Principles  and  Practice  of  Modern  Surgery.  For  the  use  of  Students 
and  Practitioners  of  Medicine  and  Surgery.  In  one  very  handsome  octavo  volume  of  780 
pages,  with  501  illustrations.     Cloth,  $4.50;  leather,  $5.50. 

This  work  is  a  very  comprehensive  manual  upon 
general  surgery,  and  will  doubtless  meet  witn  a 
favorable  reception  by  the  profession.  It  has  a 
thoroughly  practical  character,  the  subjects  are 
treated  with  rare  judgment,  its  conclusions  are  in 
accord  with  those  of  the  leading  practitioners  of 
the  art,  and  its  literature  is  fully  up  to  all  the  ad- 


vanced doctrines  and  methods  of  practice  of  the 
present  day.  Its  general  arrangement  follows 
this  rule,  and  the  author  in  his  desire  to  be  con- 
cise and  practical  is  at  times  almost  dogmatic,  but 
this  is  entirely  excusable  considering  the  admira- 
ble manner  in  which  he  has  thus  increased  the 
usefulness  of  his  work. — Med.  Bee,  Jan.  17,  1891. 


ASHBUBST,  JOM^N,  Jr,,  M,  J)., 

Barton  Prof,  of  Surgery  and  Clin.  Surgery  in  Univ.  of  Penna.,  Surgeon  to  the  Penna.  Hasp.,  Phila. 

The  Principles  and  Practice  of  Surgery.  Fifth  edition,  enlarged  and 
thoroughly  revised.  In  one  large  and  handsome  octavo  volume  of  1144  pages,  with 
642  illustrations.     Cloth,  $6;  leather,  $7. 

A  complete  and  most  excellent  work  on  surgery. 
It  is  only  necessary  to  examine  it  to  see  at  once 
its  excellence  and  real  merit  either  as  text-book 
for  the  student  or  a  guide  for  the  general  practi- 
tioner. It  fully  considers  in  detail  every  surgical 
injury  and  disease  to  which  the  body  is  liable,  and 


every  advance  in  surgery  worth  noting  is  to  be 
found  in  its  proper  place.  It  is  unquestionably  the 
best  and  most  complete  single  volume  on  surgery, 
in  the  English  language,  and  cannot  but  receive 
that  continued  appreciation  which  its  merits  justly 
demand. — Southern  Practitioner,  Feb.  1890. 


DBTJITTf  BOBJEBT,  M,  B,  C,  S,f  etc. 

Manual  of  Modern  Surgery.  Twelfth  edition,  thoroughly  revised  by  Stan- 
liEY  Boyd,  M.  B.,  B.  S.,  F.  E,.  C.  S.  In  one  8vo.  volume  of  965  pages,  with  373  illustra- 
tions.    Cloth,  $4 ;  leather,  $5. 

Druitt's  Surgery  has  been  an  exceedingly  popu-  I  appreciated  that  a  copy  was  issued  by  the  Govern- 
lar  work  in  the  profession.  It  is  stated  that  50,000  ment  to  each  surgeon.  The  present  edition,  while 
copies  have  been  sold  in  England,  while  in  the  it  has  the  same  features  peculiar  to  the  work  at 
United  States,  ever  since  its  first  issue,  it  has  been  first,  embodies  all  recent  discoveries  in  surgery, 
used  as  a  textrbook  to  a  very  large  extent.  Dur-  and  is  fully  up  to  the  times.— Cincinnati  Medical 
ing  the  late  war  in  this  country  it  was  so  highly  |  Ne^os,  September,  1887. 

GANT,  FBEJDEBICK  JAMBS,  F,  B.  C.  S,, 

Senior  Surgeon  to  the  Royal  Free  Hospital,  London. 
The  Student's  Surgery.     A  Multum  in  Parvo.      In  one  square  octavo  volume 
of  848  pages,  with  159  engravings.     Cloth,  $3.75. 

GBOSS,  S,  D.,  M.  !>.,  LL,  J>.,  J>.  C.  L,  Oxon.,  LL,  ID, 
Cantab. f 

Emeritus  Professor  of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia. 
A  System,  of  Surgery:    Pathological,   Diagnostic,  Therapeutic  and  Operative. 
Sixth  edition,  thoroughly  revised  and  greatly  improved.  ^  In  two  large  and  beautifully 
printed  imperial  octavo  volumes  containing  2382  pages,  illustrated  by  1623  engravings. 
Strongly  bound  in  leather,  raised  bands,  $15;  very  handsome  half  Russia,  $16. 

BALL,  CMABLES  B.,  M.  Ch,,  I>ub.,  F,  B,  C,  S.,  E., 

Surgeon  and  Teacher  at  Sir  P.  Dun's  Hospital,  Dublin. 

Diseases  of  the  Rectum  and  Anus.  In  one  12mo.  volume  of  417  pp., 
with  54  cuts,  and  4  colored  plates.     Cloth,  $2.25.     See  Series  of  Clinical  Manuals  31. 

YO  VNG,  JAMES  K.,  M.  !>., 

Instructor  in  Orthopoedic  Surgery,  University  of  Pennsylvania,  Philadelphia. 

A  Manual  of  Orthopaedic  Surgery,  Suitable  for  Students  and  Prac- 
titioners.    In  one  12mo.  volume  of  about  400  pages,  fully  illustrated.    Preparing. 

BUT  LIN,  SEWBT  T.,  F.  B.  C,  S., 

Assistant  Surgeon  to  St.  Bartholomew's  Hospital,  London. 
Diseases    of   the   Tongue.      In  one  12mo.  volume  of  456  pages,  with  S  colored 
plates  and  3  woodcuts.    Cloth,  $3.50.    See  Series  of  Clinical  Manuals,  jpage  31. 

GOULD,  A.  FEABCE,  M.  S.,  M.  B,,  F.  B.  C.  S„ 

Assistant  Surgeon  to  Middlesex  Hospital. 

Elements  of  Surgical  Diagnosis.  In  one  pocket-size  12mo.  volume  of  589 
pages.     Cloth,  $2.00.     See  Students'  Series  of  Manuals,  page  30. 


PIRRIE'S  PRINCIPLES  AND  PRACTICE  OF 
SURGERY.  Edited  by  John  Neill,  M.  D.  In 
one  8vo.  vol.  of  784  pp.  with  316  illus.    Cloth,  83.75. 

MILLER'S  PRINCIPLES  OF  SURGERY.  Fourth 
American  from  the  third  Edinburgh  edition.  In 


one  8vo.  vol.  of  638  pages,  with  340  illustrations. 
Cloth,  $3.75. 
MILLER'S  PRACTICE  OF  SURGERY.     Fourth 
and  revised  American  edition.    In  one  large  8vo. 
vol.  of  682  pp.,  with  364  illustrations.    Cloth  ,$3.75. 


Lea  Brothers  &  Co.'s  Publications — Surg-ery. 


21 


EJRICHSBN,  JOHN  E,,  F,  B,  S„  F,  B,  C.  S,, 

Professor  of  Surgery  in  University  College,  London,  etc. 

The  Science  and  Art  of  Surgery ;  Being  a  Treatise  ou  Surgical  Injuries,  Dis- 
eases and  Operations.  From  tlie  eightli  and  enlarged  English  edition.  In  two  large  8vo. 
volumes  of  2316  pages,  with  984  engravintis  on  wood.     Cloth,  $9;  leather,  $11. 

For  many  years  this  classic  work  has  been  of  the  former  edition  has  been  dropped  and  no 
made  by  preference  of  teachers  the  princijial  discovery,  device  or  improvement  which  has 
text-book  on  surgery  for  medical  students,  while  marked  the  progress  of  surgery  during  the  last 
through  translations  into  the  leading  continental  decade  lias  been  omitted.  The  illustrations  are 
languages  it  may  be  said  to  guide  the  surgical  many  and  executed  in  the  highest  style  of  art. 
teachings  of  the  civilized  world.    No  excellence  !  — Louisvil/e  Medical  JS'eios,  Feb.  14, 1885. 

BBTANT,  THOMAS,  F.b7c7^^ 

Surgeon  ayid  Lecturer  un  Surgery  at  Guy'i,  Hospital,  London. 
The  Practice  of  Surgery.     Fourth  American  from  the  fourth  and  revised  Eng- 
lish edition.     In  one  large  and  very  handsome  imperial  octavo  volume  of  1040  pages,  with 
727  illustrations.     Cloth,  $6.50 ;  leather,  $7.50. 

The  fourth  edition  of  this  work  is  fully  abreast  j  place  the  work  among  the  highest  order  of  text- 
of  the  times.  The  author  handles  his  subjects  j  nooks  for  the  medical  student.  Almost  every 
with  that  degree  of  judgment  and  skill  wnich  is  I  topic  in  surgery  is  presented  in  such  a  form  as  to 
attained  by  years  of  patient  toil  and  varied  ex-  enable  the  busy  practitioner  to  review  any  subject 
perience.  The  present  edition  is  a  thorough  re-  in  every-day  practice  in  a  short  time.  No  time  is 
vision  of  those  which  preceded  it,  with  much  new  '  lost  with  useless  theories  or  superfluous  verbiage, 
matter  added.  His  diction  is  so  graceful  and  In  short,  the  work  is  eminently  clear,  logical  and 
logical,  and  his  explanations  are  so  lucid,  as  to    pTSiCti<iSil.-ChicagoMed.Joii.r.a7idEj-ninine7,ApT.'86. 

WHABTON,  HEN  BY  B.,  M.  D., 

Demonstrator  of  Surgery  and  Lecturer  on  Surgical  Diseases  of  Children  in  the  Univ.  of  Penna. 

Minor  Surgery  and  Bandaging.  In  one  very  handsome  12mo.  volume  oi 
498  pages,  with  403  engravings,  many  being  photographic.     Cloth,  $3.00. 

This  new  work  must  take  a  first  rank  as  soon  as 
examined.  Bandaging  is  well  described  by  words, 
and  the  methods  are  illustrated  by  photographic 


drawings,  so  as  to  make  plain  each  step  taken  in 
the  application  of  bandages  of  various  kinds  to  dif- 
ferent parts  of  the  body  and  extremities — including 
the  head.  The  various  operations  are  likewise  de- 
scribed and  illustrated,  so  that  it  would  seem  easy 


rious  established  operations  are  described  in  detail. 
Hence  this  worii  becomes  a  most  valuable  compan- 
ion-book to  any  of  the  more  pretentious  treatises 
on  surgery,  where  simply  the  general  advice  is 
given  to  bandage,  amputate,  intubate,  operate,  etc. 
For  the  student  and  young  surgeon,  it  is  a  very 
valuable  instruction  book  from  which  to  learn  how 
to  do  what  may  be  advised,  in  general  terms,  to  be 


for  the  tyro  to  do  the  gravest  amputation.  The  va-  i  done.— Virginia  Medical  Monthly,  October  1891. 

TBEVES,  FBEHEBICK,  F,  B.  C.  S., 

Surgeon  and  Lecturer  on  Anatomy  at  the  London  Hospital. 

A  Manual  of  Operative  Surgery.     In  two  octavo  volumes  containing  1550 
pages,  with  422  original  engravings.    Complete  work,  cloth,  $9;  leather,  $11.    Just  ready 


Mr.  Treves  in  this  admirable  manual  of  opera 
tive  surgery  has  in  each  instance  practically 
assumed  that  operation  has  been  decided  upon 
and  has  then  proceeded  to  give  the  various  opera- 
tive methods  which  may  he  employed,  with  a 
criticism  of  their  comparative  value  and  a  detailed 
and  careful  description  of  each  particular  stage 
of  their  performance.  Especial  attention  has  been 
paid  to  the  preparatory  treatment  of  the  patient 
and  to  the  details  of  the  after  treatment  of  the 
case,  and  this  is  one  of  the  most  distinctive  among 
the  many  excellent  features  of  the  book.  We  have 
no  hesitation  in  declaring  it  the  best  work  on  the 
subject  in  the  English  language,  and  indeed,  in 
many  respects,  the  best  in  any  language.    It  can- 


not fail  to  be  of  the  greatest  use  both  to  practical 
surgeons  and  to  those  general  practitioners  who, 
owing  to  their  isolation  or  to  other  circumstances, 
are  forced  to  do  much  of  theirown  operative  work. 
We  feel  called  upon  to  recommend  the  book  so 
strongly  for  the  excellent  judgment  displayed  in 
the  arduous  task  of  selecting  from  among  the 
thousands  of  varying  procedures  those  most 
worthy  of  description;  for  the  way  in  which  the 
still  more  difficult  task  of  choosing  among  the 
best  of  those  has  been  accomplished;  and  for  the 
simple,  clear,  straightforward  manner  in  whicii 
the  information  thus  gathered  from  all  surgical 
literature  has  been  conveyed  to  the  reader. — 
Annals  of  Surgery,  March,  1892. 


TBEVES,  FBEDEBICK,  F.  B.  C.  S., 

Hunterian  Professor  at  the  Royal  College  of  Surgeons  of  England. 
A  Manual    of   Surgery.     In  Treatises  by  Various  Authors.      In  three  12mo. 
volumes,  containing  1866  pages,  with  213  engravings.     Price  per  set,  cloth,  $6.     See 
Students'  Series  of  Manuals,  page  30. 

the  salient  points  and  the  beginnings  of  new  sub- 
jects are  always  printed  in  extra-heavy  type,  so 
that  a  person  may  find  whatever  information  he 
may  be  in  need  of  at  a  moment's  glance. — Cin- 
cinnati Lancet-Clinie,  August  21, 1886. 


We  have  here  the  opinions  of  thirty-three 
authors,  in  an  encyclopsedic  form  for  easy  and 
ready  reference.  The  three  volumes  embrace 
every  variety  of  surgical  affections  likely  to  be 
met  with,  the  paragraphs  are  short  and  pithy,  and 


HOLMES,  TIMOTHY,  M.  A., 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  System  of  Surgery ;  Theoretical  and  Practical.  IN  TREATISES  BY 
VARIOUS  AUTHORS.  American  edition,  thoroughly  revised  and  re-edited 
by  John  H.  Packard,  M.  D.,  Surgeon  to  the  Episcopal  Hospital,  Philadelphia,  assisted 
by  a  corps  of  thirty-three  of  the  most  eminent  American  surgeons.  In  three  large  octavo 
volumes  containing  3137  pages,  with  979  illustrations  on  wood  and  13  lithographic  plates. 
Price  per  set,  cloth,  $18.00 ;  leather,  $21.00.     Sold  only  by  svAscription. 

TBEVES,  FBEHEBICK,  F,  B.  C.  S,, 

Surgeon  to  and  Lecturer  on  Surgery  at  the  London  Hospital. 
Intestinal  Obstruction.     In  one  pocket-size  12mo.  volume  of  522  pages,  with  60 
illustrations.  Limp  cloth,  blue  edges,  $2.00.    See  Series  of  Clinical  ManucUs,  page  31. 


22      Lea  Brothers  &  Co.'s  Publications — Surgery,  Frac,  Disloc, 


SMITH,  STJEPSBN,  M.  J)., 

Professor  of  Clinical  Surgery  in  the  University  of  the  City  of  New  York. 

The  Principles  and  Practice  of  Operative  Surgery.  Second  and 
thoroughly  revised  edition.  In  one  very  handsome  octavo  volume  of  892  pages,  with 
1005  illustrations.     Cloth,  $4.00;  leather,  $5.00, 


This  excellent  and  very  valuable  book  is  one  of 
the  most  satisfactory  works  on  modern  operative 
surgery  yet  published.  Its  author  and  publisher 
have  spared  no  pains  to  make  it  as  far  as  possible 
an  ideal,  and  their  efforts  have  given  it  a  position 
prominent  among  the  recent  works  in  this  depart- 
ment of  surgery.  The  book  is  a  compendium  for 
the  modern  surgeon.  The  present  edition  is  much 
en  I  arged,  and  the  text  has  been  thoroughly  revised , 
so  as  to  give  the  most  improved  methods  in  asep- 
tic surgery,  and  the  latest  instruments  known  for 


operative  work.  It  can  be  truly  said  that  as  a  hand- 
book for  the  student,  a  companion  for  the  surgeon, 
and  even  as  a  book  of  reference  for  the  physician 
not  especially  engaged  in  the  practice  of  surgery, 
this  volume  will  long  hold  a  most  conspicuous 
place,  and  seldom  will  its  readers,  no  matter  how 
unusual  the  subject,  consult  its  pages  in  vain.  Its 
compact  form,  excellent  print,  numerous  illustra- 
tions, and  especially  its  decidedly  practical  char- 
acter, all  combine  to  commend  it. — Boston  Medical 
and  Surgical  Journal,  May  10, 1888. 


SOLMES,  TIMOTHY,  M.  A,, 

Surgeon  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

A  Treatise  on  Surgery ;  Its  Principles  and  Practice.  From  the  fifth 
English  edition,  edited  by  T.  Pickering  Pick,  F.  E.  C.  S.  In  one  octavo  volume  of  997 
pages,  with  428  illustrations.     Cloth,  $6.00;  leather,  $7.00 


To  the  younger  members  of  the  profession  and 
to  others  not  acquainted  with  the  book  and  its 
merits,  we  take  pleasure  in  recommending  it  as  a 
surgery  complete,  thorough,  well-written,  fully 
illustrated,  modern,  a  work  siifficiently  volumi- 
nous for  the  surgeon  specialist,  adequately  concise 


for  the  general  practitioner,  teaching  those  things 
that  are  necessary  to  be  known  for  tne  successful 
prosecution  of  the  physician's  career,  imparting: 
nothing  that  in  our  present  knowledge  is  consid- 
ered unsafe,  unscientific  or  inexpedient. — Pacific 
Medical  Journal,  July,  1889. 


HAMILTOJSr,  FRANK  H,,  M,  D.,  LL,  !>., 

Surgeon  to  Bellevue  Hospital,  New  York. 

A  Practical  Treatise  on  Fractures  and  Dislocations.  New  (8th)  edi- 
tion, revised  and  edited  by  Stephen  Smith,  A.  M.,  M.  D.,  Professor  of  Clinical  Surgery 
in  the  University  of  the  City  of  New  York.  In  one  very  handsome  octavo  volume  of  832 
pages,  with  507  illustrations.     Cloth,  $5.50 ;  leather,  $6.50. 


It  has  received  the  highest  endorsement  that  a 
work  upon  a  department  of  surgery  can  possibly 
receive.  It  is  used  as  a  text-book  in  every  medi- 
cal college  of  this  country,  and  the  publishers 
have  been  called  upon  to  print  eight  editions  of  it. 
It  has  been  said  with  truth  that  it  is  doubtful  if 
any  surgical  work  has  appeared  during  the  last 
half  century  which  more  completely  filled  the 
place  for  which  it  was  designed.  Its  great  merits 
appear  most  conspicuously  in  its  clear,  concise, 
and  yet  comprehensive  statement  of  principles, 
which  renders  it  an  admirable  text- book  for  teach- 
er and  pupil,  and  in  its  wealth  of  clinical  materials, 
which  adapts  it  to  the  daily  necessities  of  the 


practitioner.  Fractures  and  dislocations  are  inju- 
ries which  the  general  practitioner,  in  his  charac-_ 
ter  as  a  surgeon,  is  most  called  upon  to  treat.  They' 
form  a  part  of  surgery  that  he  cannot  avoid  taking 
charge  of.  Under  the  circumstances,  therefore, 
he  needs  all  the  aid  he  can  secure.  But  what 
better  assistance  can  he  seek  than  a  work  that  is- 
devoted  exclusively  to  treating  fractures  and  dis- 
locations, and  consequently  contains  full  infor- 
mation, in  plain  language,  for  the  management  of 
every  emergency  that  is  likely  to  be  met  with  in 
such  injuries  ?  We  consider  that  the  work  before 
us  should  be  in  the  libraryof  every  practitioner. — 
Cincinnati  Medical  News,  February,  1891. 


STIMSOJS^,  LBWIS  A,,  B,  A,,  M.  D., 

Professor  of  Clinical  Surgery  in  the  Medical  Faculty  of  Univ.  of  City  of  N.  Y., 
A  Manual  of  Operative  Surgery.     Second  edition.    In  one  very  handsome 
royal  12mo.  volume  of  503  pages,  with  342  illustrations.     Cloth,  $2.50. 

There  is  always  room  for  a  good  book,  so  that    -'^--•^-^  -  "■= 

while  many  works  on  operative  surgery  must  be 
considered  superfluous,  that  of  Dr.  Stimson  has 
held  its  own.  The  author  knows  the  difficult  art 
of  condensation.  Thus  the  manual  serves  as  a 
work  of  reference,  and  at  the  same  time  as  a 
handy  guide.  It  teaches  what  it  professes,  the 
steps  of  operations.  In  this  edition  Dr.  Stimson 
has  sought  to  indicate  the  changes  that  have  been 


effected  in  operative  methods  and  procedures  by 
the  antiseptic  system,  and  has  added  an  account 
of  many  new  operations  and  variations  in  the 
steps  of  older  operations.  We  do  not  desire  to 
extol  this  manual  above  many  excellent  standard 
British  publications  of  the  same  class,  still  we  be- 
lieve that  it  contains  much  that  is  worthy  of  imi- 
tation.— British  Medical  Journal,  Jan.  22, 1887. 


By  the  same  Author. 
A  Treatise  on  Fractures  and  Dislocations.    In  two  handsome  octavo  vol- 
umes.   Vol.  I.,  Fbactures,  582  pages,  360  beautiful  illustrations.    Vol.  II.,  Disloca- 
tions, 540  pages,  with  163  illustrations.     Complete  work,  cloth,  $5.50 ;  leather,  $7.50- 
Either  volume  separately,  cloth,  $3.00 ;  leather,  $4.00. 


The  appearance  of  the  second  volume  marks  the 
completion  of  the  author's  original  plan  of  prepar- 
ing a  work  which  should  present  in  the  fullest 
manner  all  that  is  known  on  the  cognate  subjects 
of  Fractures  and  Dislocations.  The  volume  on 
Fractures  assumed  at  once  the  position  of  authority 
on  the  subject,  and  its  companion  on  Dislocations 
will  no  doubt  be  similarly  received.  The  closing 
volume  of  Dr.  Stimson's  work  exhibits  the  surgery 


of  Dislocations  as  it  is  taught  and  practised  by  the 
most  eminent  surgeons  of  the  present  time.  Con- 
taining the  results  of  such  extended  researches  it 
must  for  a  long  time  be  regarded  as  an  authority 
on  all  subjects  pertaining  to  dislocations.  Every 
practitioner  of  surgery  will  feel  it  incumbent  on 
him  to  have  it  for  constant  reference. — Cincinnati 
Medical  News,  May,  1888. 


I*ICK,  T,  BICKBBINGf  F.  M.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  St.  George's  Hospital,  London. 

Fractures  and  Dislocations.     In  one  12mo.  volume  of  530  pages,  with  93^ 

illustrations.     Limp  cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31, 

MABSJS,  HOWARD,  F.  B,  C,  S., 

Senior  Assistant  Surgeon  to  and  Lecturer  on  Anatomy  at  St.  Bartholomew's  Hospital,  London, 
Diseases  of  the  Joints.     In  one  12mo.  volume  of  468  pages,  with  64  woodcuts- 
and  a  colored  plate.     Cloth,  $2.00.     See  Series  of  Clinical  Manuals,  page  31. 


Lea  Brothers  &  Co.'s  Publications — Otology,  Ophthalmology.    23 
BVBNETT,  CHABLES  H,,  A,  M.,  M.  JD., 

Professor  of  Otology  in  the  Philadelphia  Polyclinic;  President  of  the  American  Otologieal  Society. 

The  Ear,  Its  Anatomy,  Physiology  and  Diseases.  A  Practical  TreatiBe 
for  the  use  of  Medical  Students  and  Practitioners.  Second  edition.  In  one  handsome 
octavo  vohime  of  580  pages,  with  107  illustrations.   Cloth,  $4.00 ;  leather,  $5.00. 

Wenote  with  pleasure  the  appearance  of  a  second  I  carried  out,  and  much  new  matter  added.  Dr. 
edition  of  this  vahiable  work.  When  it  first  came  [  Burnett's  worlt  must  be  regarded  as  a  very  valua- 
out  it  was  accepted  by  the  profession  as  one  of  i  bie  contribution  to  aural  surgery,  not  only  on 
the  standard  works  on  modern  aural  surgery  in  I  account  of  its  comprehensiveness,  but  because  it 
the  English  language;  and  in  his  second  edition  I  contains  the  results  of  the  careful  personal  observa- 
Dr.  Burnett  lias  fully  maintained  his  reputation,  I  tion  and  experience  of  thiseminenlaural  surgeon, 
for  the  book  is  replete  with  valuable  information  '  — London  Lancet,  Feb.  21, 1885. 
and  suggestions.    The  revision  has  been  carefully  ; 


BEBBY,  GEOBGE  A,,  M.  B.,  F,  B,  C.  S,,  Ed,, 

Ophthalmic  Surgeon,  Edinburgh  Royal  Infirmary. 

Diseases  of  the  Eye.  A  Practical  Treatise  for  Students  of  Ophthalmology.  JSTew 
(second)  edition.  In  one  octavo  volume  of  about  700  pages,  with  about  150  illustrations, 
62  of  which  are  beautifully  colored.     Preparing. 

A  notice  of  the  previous  edition  is  appended. 

This  newest  candidate  for  favor  among  ophthal-  |  novice — with  a  mass  of  details  with  no  key  to  their 
mologicalstudent.s  is  designed  to  be  purely  clinical  :  unravelling.  It  is  apparent  that  the  literature  of 
in  character  and  the  plan  is  well  adnered  to.  We  each  subject  has  been  gone  over  in  a  very  thor- 
have  been  forcibly  struck  by  the  rare  good  taste  j  ough  manner.  The  fact  that  he  was  writing  a 
in  the  selection  of  what  is  essential  which  per-  |  clinical  treatise  for  beginners  and  not  an  encyclo- 
vades  the  book.  The  author  seems  to  have  the  \  peedia  has  always  been  present  with  the  author, 
uncommon  faculty  of  viewing  his  subject  as  a  ,  The  number  and  excellence  of  the  colored  illus- 
whole  and  seizing  the  salient  points  and  not  con-  j  trations  in  the  text  deserve  more  than  a  passing 
fusing  his  reader — presumably  a  student  and  a  |  notice. — Archives  of  Ophthalmology,  Sept.  1889. 


NETTLESMIB,  EDWABD,  F,  B.  C,  S., 

Ophthalmic  Surgeon  at  St.  Thomas'  Hospital,  London.    Surgeon  to  the  Royal  London  {Moorfields) 
Ophthalmic  Sospital. 

Diseases  of  the  Eye.  Fourth  American  from  the  fifth  English  edition,  thor- 
oughly revised.  With  a  Supplement  on  the  Detection  of  Color  Blindness,  by  Wil- 
liam Thomson,  M.  D.,  Professor  of  Ophthalmology  in  the  Jefferson  Medical  College. 
In  one  12mo.  volume  of  500  pages,  with  164  illustrations,  selections  from  Snellen's  test- 
types  and  formulae,  and  a  colored  plate.     Cloth,  $2.00. 


This  is  a  well-known  and  a  valuable  work.  It 
was  primarily  intended  for  the  use  of  students, 
and  supplies  their  needs  admirably,  but  it  is  as 
useful  for  the  practitioner,  or  indeed  more  so.  It 
does  not  presuppose  the  large  amount  of  recondite 
knowledge  to  be  present  which  seems  to  be  as- 
sumed in  some  of  our  larger  works,  is  not  tedious 
from  over-conciseness,  and  yet  covers  the  more 


important  parts  of  clinical  ophthalmology.  A 
supplement  is  made  to  the  present  edition  on  the 
practical  examination  of  railroad  employes  as  to 
color-blindness  and  acuteness  of  vision  and  hear- 
ing. This  is  well  written,  and  contains  good 
suggestions  for  those  who  may  be  called  on  to 
make  such  examinations. — Hew  York  Medical 
Journal,  December  13, 1890. 


JULEB,  SEJVBT  E.,  F,  B.  C.  S., 

Senior  AssH  Surgeon,Royal  Westminster  Ophthalmic  Hosp. ;  late  Clinical  Ass't,  Moorfields,  London. 

A  Handbook  of  Ophthalmic  Science  and  Practice.  English  Edition. 
Handsome  Sv^o.  volume  of  442  pages,  with  125  woodcuts,  27  colored  plates,  selec- 
tions from  Test-types  of  Jaeger  and  Snellen,  and  Holmgren's  Color-blindness  Test. 
Cloth,  $5.50  ;  leather,  $6.50. 


It  presents  to  the  student  concise  descriptions 
and  typical  illustrations  of  all  important  eye  affec- 
tions, placed  in  juxtaposition,  so  as  to  be  grasped 
at  a  glance.  Beyond  a  doubt  it  is  the  best  illus- 
trated handbook  of  ophthalmic  science  which  has 


illustrations  are  nearly  all  original.  We  have  ex- 
amined this  entire  work  with  great  care,  and  it 
represents  the  commonly  accepted  views  of  ad- 
vanced ophthalmologists.  We  can  most'heartily 
commend  this  book  to  all  medical  students,  prac- 


ever  appeared.    Then,  what  is  still  better,  these  i  titioners  and  specialists. — Detroit  Lancet,  Jan.  '85. 


JS^OBBIS,  WM.  F.,  M.  2>.,  and  OLIVEB,  CSAS.  A.,  M.  D. 

Clin.  Prof,  of  Ophthalmology  in  Univ.  of  Pa. 

A  Text-Book  of  Ophthalmology.  In  one  octavo  volume  of  about  500  pages, 
with  illustrations.     In  press. 

CABTEB,  B,  BBUJOENELL,   &  FBOST,  W,  AI>A3IS, 

F.  B.  C.  S.,  F,  B.  C.  S.f 

Ophthalmic  Surgeon  to  and  Led.  on  Ophthal-  Ass't  Ophthalmic  Surgeon  aiid  Joint  Led. 

mic  Surgery  at  St.  George's  Hospital,  London.  .  on  Oph.  Sur.,  St.  George's  Hosp.,  Loiuion. 

Ophthalmic  Surgery.  In  one  12mo.  volume  of  559  pages,  with  91  woodcuts, 
color-blindness  test,  test-types  and  dots  and  appendix  of  formulae.  Cloth,  $2.25.  See 
Series  of  Clinical  Manuals,  page  31. 

WELLS  ON  THE  EYE.    In  one  octavo  volume.       LAWSON  ON  INJURIES  TO  THE  EYE,  ORBIT 

H^^^^r^*^  ^frP=T¥,?^^4^v ^/^^?^'   ^^°A  ^^  AND  EYELIDS :  Their  Immediate  and  Remote 

OPHTHALMIC  SURGER\,  for  the  use  of  Prac-:  _,„  ^  ,  ,  .  ,„, 

titioners.    Second  edition.    In  one  octavo  vol- !  Effects.    In  one  octavo  volume  of  404  pages,  with 

ume  of  227  pages,  with  65  illus.    Cloth,  82.75.     i  92  illustrations.    Cloth,  $3.50. 


24    Lea  Brothers  &  Co.'s  Publications — Urin.  Dis.,  Dentistry,  etc. 


ROBERTS,  SIR  WILLIAM,  31.  D,, 

Lecturer  on  Medicine  in  the  Manchester  School  of  Medicine,  etc. 

A  Practical  Treatise  on  Urinary  and  Benal  Diseases,  including  Uri- 
nary Deposits.  Fourth  American  from  the  fourth  London  edition.  In  one  hand- 
some octavo  volume  of  609  pages,  with  81  illustrations.     Cloth,  $3.50. 


It  may  be  said  to  be  the  best  book  in  print  on  the 
subject  of  which  it  treats. — The  American  Journal 
of  the  Medical  Sciences,  Jan.  1886. 

The  peculiar  value  and  finish  of  the  book  are  in 
a  measure  derived  from  its  resolute  maintenance 
of  a  clinical  and  practical  character.  It  is  an  un- 
rivalled exposition  of  everything  which  relates 
directly  or  indirectly  to  the  diagnosis,  prognosis 
and  treatment  of  urinary  diseases,  and  possesses 


a  completeness  not  found  elsewhere  in  our  lan- 
guage in  its  account  of  the  different  affections.— 
The  Manchester  Medical  Chronicle,  July,  1885. 

The  value  of  this  treatise  as  a  guide  book  to  the 
physician  in  daily  practice  can  hardly  be  over- 
estimated. That  it  is  fully  up  to  the  level  of  our 
present  knowledge  is  a  fact  reflecting  great  credit 
upon  Dr.  Roberts,  who  has  a  wide  reputation  as  a 
busy  practitioner. — Medical  Record,  July  31, 1886. 


Diet  and  Digestion. 


By  the  Same  Author. 

In  one  12mo.  volume  of  270  pp.  Cloth,  |1.50. 


Just  ready. 


rURDY,   CMARLMS  W.,  M.  />.,  Chicago. 

Bright's  Disease  and  Allied  Affections  of  the  Kidneys. 

volume  of  288  pages,  with  illustrations.     Cloth,  ' 


In  one  octavo 


The  object  of  this  work  is  to  "furnish  a  system 
atic,  practical  and  concise  description  of  the 
pathology  and  treatment  of  the  chief  organic 
diseases  of  the  kidney  associated  with  albuminu- 
ria, which  shall  represent  the  most  recent  ad- 
vances in  our  knowledge  on  these  subjects  ;"  and 
this  definition  of  the  object  is  a  fair  description  of 
the  book.    The  work  is  a  useful  one,  giving  in  a 


short  space  the  theories,  facts  and  treatments,  and 
going  more  fully  into  their  later  developments. 
On  treatment  the  writer  is  particularly  strong, 
steering  clear  of  generalities,  and  seldom  omit- 
ting, what  text-books  usually  do,  the  unimportant 
items  which  are  all  important  to  the  general  prac- 
titioner.—  The  Manchester  Medical  Chronicle,  Oct. 
1886. 


MORRIS,  HENRY,  M.  B.,  F.  R.  C.  S., 

Surgeon  to  and  Lecturer  on  Surgery  at  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Kidney.     In  one  12mo.  volume  of  554  pages,  with  40 
woodcuts,  and  6  colored  plates.  Limp  cloth,  $2.25.   See  Series  of  Clinical  Manuals,  page  31. 


In  this  manual  we  have  a  distinct  addition  to 
surgical  literature,  which  gives  information  not 
elsewhere  to  be  met  with  in  a  single  work.  Such 
a  book  was  distinctly  required,  and  Mr.  Morris 
has  very  diligently  and  ably  performed  the  task 


he  took  in  hand.  It  is  a  full  and  trustworthy 
book  of  reference,  both  for  students  and  prac- 
titioners in  search  of  guidance.  The  illustrations 
in  the  text  and  the  chromo-lithographs  are  beau- 
tifully executed. — The  London  -Lancei,  Feb.  26, 18S6. 


See  Series 


LUCAS,  CLEMENT,  M.  B.,  B.  S.,  E.  R.  C.  S., 

Senior  Assistant  Surgeon  to  Guy^s  Hospital,  London. 
Diseases   of  the   Urethra.      In  one   12mo.  volume.     Preparing. 
of  Clinical  Manuals,  page  4. 

TMOMI'SON,  SIR  HENRY, 

Surgeon  and  Professor  of  Clinical  Surgery  to  University  College  Hospital,  London. 

Lectures  on  Diseases  of  the  Urinary  Organs.  Second  American  from  the 
third  English  edition.    In  one  8vo.  volume  of  203  pp.,  with  25  illustrations.    Cloth,  $2.25. 

By  the  Same  Author. 
On  the  Pathology  and  Treatment  of  Stricture  of  the  Urethra  and 
Urinary  Pistulse.    From  the  third  English  edition.    In  one  octavo  volume  of  359 
pages,  with  47  cuts  and  3  plates.     Cloth,  $3.50. 

THE  AMERICAN  SYSTEM  OF  DENTISTRY. 

In  Treatises  by  Various  Authors.  Edited  hj  Wilbur  F.  Litch,  M.  D., 
D.  D.  S.,  Professor  of  Prosthetic  Dentistry,  Materia  Medica  and  Therapeutics  in  the 
Pennsylvania  College  of  Dental  Surgery.  In  three  very  handsome  octavo  volumes  con- 
taining 3160  pages,  with  1863  illustrations  and  9  full-page  plates.  Per  volume,  cloth,  $6 ; 
leather,  $7;  half  Morocco,  gilt  top,  $8.  The  complete  work' is  now  ready.  For  sale  by 
subscription  only. 


As  an  encyclopeedia  of  Dentistry  it  has  no  su- 
perior. It  should  form  a  part  of  every  dentist's 
library,  as  the  information  it  contains  is  of  the 
greatest  value  to  all  engaged  in  the  practice  of 
cientistry. — American  Jour.  Dent.  Sci.,  Sept.  1886. 

A  grand  system,  big  enough  and  good  enough 
and  handsome  enough  for  a  monument  (which 


doubtless  it  is),  to  mark  an  epoch  In  the  history  of 
dentistry.  Dentists  will  be  satisfied  with  it  and 
proud  of  it — they  must.  It  is  sure  to  be  precisely 
what  the  student  needs  to  put  him  and  keep  him 
in  the  right  track,  while  the  profession  at  large 
will  receive  incalculable  benefit  from  it. — Odonto- 
graphic  Journal,  Jan.  1887. 


COLEMAN,  A.,  L.  R.  C.  F.,  F.  R.  C.  S.,Exam.  L.  2>.  S., 

Senior  Dent.  Surg,  and  Lect.  on  Dent.  Surg,  at  St.  Bartholomew's  Hosp.  and  the  Dent.  Hasp.,  London. 

A  Manual  of  Dental  Surgery  and  Pathology.  Thoroughly  revised  and 
adapted  to  the  use  of  American  Students,  by  Thomas  C.  StelLiWAGen,  M.  A.,  M.  D., 
D.  E».  S.,  Prof,  of  Physiology  in  the  Philadelphia  Dental  College.  In  one  handsome  octavo 
volume  of  412  pages,  with  331  illustrations.     Cloth,  $3.25. 


It  should  be  in  the  possession  of  every  practi- 
tioner in  this  country.  The  part  devoted  to  first 
and  second  dentition  and  irregularities  in  the  per- 
manent teeth  is  fully  worth  the  price.  In  fact, 
price  should  not  be  considered  in  purchasing  such 


work.  If  the  money  put  into  some  of  our  so- 
called  standard  textrbooks  ccnild  be  converted  into- 
such  publications  as  this,  much  good  would  result. 
— Southern  Dental  Journal,  May,  1882. 


BASHAM    on    renal  DISEASES:    A  Clinical 
Guide  to  their  Diagnosis  and  Treatment.    In 


one  12mo.  vol.  of  304  pages,  with  21  lUustratlonB. 
Cloth,  $2.00. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Men,  "Venereal.        25 


GBOSS,  SAMUBL  TT.,  A,  3I„  31.  J>.,  ii.  D., 

J^ofesbor  of  t lie  FYinciplea  of  Surrjei-y  and  of  Clinictd  Surgery  in  the  JeJJeraon  Medicnl  College  of  Phila. 

A  Practical  Treatise  on  Impotence,  Sterility,  and  Allied  Disorders 
of  the  Male  Sexual  Organs.  Fourth  edition,  tlioroughly  revised  by  F.  R, 
Sturgis,  M.  D.,  Prof,  of  Diseases  of  the  Genito-Urinary  Organs  and  of  Venereal  Diseases, 
N.  Y.  Post  Grad.  Med.  School.  In  one  very  handsome  octavo  volume  of  165  pages, 
with  18  illustrations.     Cloth,  $1.50. 


Three  editions  of  Professor  (ttoss'  valuable  book 
have  been  exhausted,  and  .still  the  demand  i» 
unsupplied.  Dr.  Sturgis  has  revised  and  added 
to  the  previous  editions,  and  the  pew  one  appears 
more  complete  and  more  valuable  than  before. 
Four  important  and  generally  misunderstood  sub- 
jects are  treated — impotence,"  sterility,  spermator- 
rhcBa,  and  prostatorrhoia.  The  book  is  a  practical 
one  and  in  addition  to  the  scientific  and  very  in- 
teresting discussions  on  etiology,  symptoms,  etc., 
there  are  lines  of  treatment  laid  down  that  any 
practitioner  can  follow  and  which  have  met  with 


success  in  the  hands  of  author  and  editor. — Medi- 
cal Record,  Feb.  25, 1891. 

It  has  been  the  aim  of  the  author  to  supply  in  a 
compact  form,  practical  and  strictly  scientific 
information  especially  adapted  to  the  wants  of  the 
general  practitioner  in  regard  to  a  class  of  common 
and  grave  disorders  The  work  contains  very 
many  facts  in  regard  to  the  sexual  disorders  of 
men,  of  the  most  interesting  character.  We  com- 
mend the  study  of  it  lo  every  professional  man, 
and  especially  to  those  engaged  in  the  general 
practice  of  medicine. — Cin.  Med.  News,  Jan.  189X. 


TAYZOJR,  M,  W.y  A.  M.,  M.  !>., 

Clinical  Professor  of  Genito-Urinary  Diseases  in  the  College  of  Physicians  and  Surgeons,  New  York, 
Prof,  of  Venereal  and  Skin  Diseases  in  the  University  of  Vermont. 

The  Pathology  and  Treatment  of  Venereal  Diseases.  Including  the 
results  of  recent  investigations  upon  the  subject.  Being  the  sixth  edition  of  Bumstead 
and  Taylor.  Entirely  rewritten  by  Dr.  Taylor.  Large  8vo.  volume,  about  900  j)ages, 
with  about  150  engravings,  as  well  as  numerous  chromo-lithographs.     In  active  preparation. 

A  notice  of  the  previous  edition  is  appended. 


It  is  a  splendid  record  of  honest  labor,  wide 
research,  just  comparison,  careful  scrutiny  and 
original  experience,  which  will  always  be  held  as 
a  high  credit  to  American  medical  literature.  This 
Is  not  only  the  best  work  in  the  English  language 


upon  the  subjects  of  which  it  treats,  but  also  one 
wnich  has  no  equal  in  other  tongues  tor  its  clear, 
comprehensive  and  practical  handling  of  its 
themes. — Am.  Jour,  of  the  Med.  Sciences,  Jan.  1884. 


CVLVER,  B,  M,,  31.  D,,  and  SAYJDBN^,  J.  JR.,  31.  D. 

Pathologist  and  Assistant  Attending  Surgeon,  Chief  of  Clinic  Venereal  Department,   Van- 

Manhattan  Hospital,  N.  Y.      '  derbi.lt  Clinic,  Col.ofPhys.  and  Surys.,  N.  Y. 

A  Manual  of  Venereal  Diseases.    In  one  12mo.  volume  of  289  pageS;  with 
33  illustrations.     Cloth,  $1.75.     Ju&t  ready. 


This  book  is  a  practical  treatise,  presenting  in  a 
condensed  form  the  essential  features  of  our  pres- 
ent knowledge  of  the  three  venereal  diseases, 
syphilis,  chancroid  and  gonorrhea.  We  have  ex- 
amined this  work  carefully  and  have  come  to  the 
conclusion  that  it  is  the  most  concise,  direct  and 
able  treatise  that  has  appeared  on  the  subject  of 
venereal  diseases  for  the  general  practitioner  to 


adopt  as  a  guide.  The  general  practitioner  needs 
a  few  simple,  concise  and  clearly  presented  laws, 
in  the  execution  of  which  he  cannot  fail  either  to 
cure  or  prevent  the  ravages  of  the  maladies  in 
question  and  the  direful  results  which  their  pro- 
pagation entails. — Buffalo  Medical  and  Surgi^cal 
Journal,  May,  1892. 


OORNILf    V.  f    Prof,  to  the  Faculty  of  Medicine  of  Paris,  and  Physician  to  the  Lourdne  Hasp. 

Syphilis,  its  Morbid  Anatomy,  Diagnosis  and  Treatment.  Specially 
revised  by  the  Author,  and  translated  with  notes  and  additions  by  J.  Henry  C.  Simes, 
M.  D.,  Demonstrator  of  Pathological  Histology  in  the  L'niv.  of  Pa.,  and  J.  WiiiLiAM 
White,  M.  D.,  Lecturer  on  Venereal  Diseases,  Univ.  of  Pa.  In  one  handsome  octavo 
volumie  of  461  pages,  with  84  very  beautiful  illustrations.     Cloth,  $3.75. 

The  anatomy,  the  histology,  the  pathology  and  I  perusal  without  the  feeling  that  his  grasp  of  the 
the  clinical  features  of  syphilis  are  represented  in  wide  and  important  subject  on  which  it  treats  is 
this  work  in  their  best,  most  practical  and  most  I  a  stronger  and  surer  one. — 77ie  London  Practt- 
instructive  form,  and  no  one  will  rise  from  its  1  tioner,  Jan.  1882. 

UTITCSINSON,  JONATSAN,  F.  M.  S.,  F.  JR.  C.  S., 

Consulting  Surgeon  to  the  London  Hospital. 
Syphilis.     In  one  12mo.  volume  of  542  pages,  with  8  chromo-lithographs.     Cloth, 
$2.25.     See  Series  of  Clinical  Manuals,  page  31. 

and  power  of  observation,  but  of  his  patience  and 
assiduity  in  taking  notes  of  his  cases  and  keep- 
ing them  in  a  form  available  for  such  excellent 
use  as  he  lias  put  them  to  in  this  volume. — London 


Those  who  have  seen  most  of  the  disease  and 
those  who  have  felt  the  real  difficulties  of  diagno- 
sis and  treatment  will  most  highly  appreciate  the 
facts  and  sugge.stions  which  abound  in  these 
pages.  It  is  a  worthy  and  valuable  record,  not 
only  of  Mr.  Hutchinson's  very  large  experience 


Medical  Record,  Nov.  12, 1887. 


ghoss,  s.  n.,  3i.  z>.,  ll.  d.,  n.  c.  l.,  etc. 

A  Practical  Treatise  on  the  Diseases,  Injuries  and  Malformations 
of  the  Urinary  Bladder,  the  Prostate  Gland  and  the  Urethra.  Third 
edition,  thoroughly  revised  by  Samuel  AV.  Gross,  M.  D.  In  one  octavo  volume  of  574 
pages,  with  170  illustrations.     Cloth,  $4.50. 

CULZJEBIBB,  A.,  &  BV3ISTBAJy,  F.  J.,  31.1>.,  LL.D., 

Surgeon  to  the  HOpital  du  Midi.  Late  Prof,  of  Ven.  Dis.  Coll.  Phys.  and  Surg.,  N.  F. 

An  Atlas  of  Venereal  Diseases.  Translated  and  edited  by  Freejian  J.  Buit- 
stead,  M.  D.  In  one  4to.  volume  of  328  pages,  with  26  plates,  containing  about  150  figures, 
beautifully  colored,  many  of  them  the  size  of  life.     Strongly  bound  in  cloth,  $17.00. 

HILL  ON  SYPHILIS  AND  LOCAL  CONTAGIOUS  I  FORMS    OF     LOCAL     DISEASE    AFFECTING 

I  (fSORDERS.  In  one  8vo  vol.  of  479  p.  Cloth,  83.25.  !  PRINCIPALLY    THE    ORGANS    OF    GENERA- 

LEES  LECTURES  ON  SYPHILIS  AND  SOME  j  TION.    In  one  8vo.  vol.  of  246  pages.    Cloth,  S2.25. 


26  Lea  Brothers  &  Co.'s  Publications — Venereal,  Skin. 

TAYLOn,  BOBJEBT  W.,  A, 31.,  M.D.. 

Clinical  Professor  of  Genifo-  Urinary  Diseases  in  the  College  of  Physicians  and  Surgeons,  New  York  ; 
Surgeon  to  the 'Department  of  Venereal  and  Skin  Diseases  of  the  New  York  Hospital;  Presi- 
dent  of  the  American  Dermatological  Association. 

A  Clinical  Atlas  of  Venereal  and  Skin  Diseases :  Including  Diagnosis, 
Prognosis  and  Treatment.  In  eight  large  folio  parts,  measuring  14  x  18  inches,  and 
comprising  58  beautifully  colored  plates  with  213  figures,  and  431  pages  of  text  with  85 
engravings.  Complete  work  just  ready.  Price  per  part,  $2.50.  Bound  in  one  volume, 
half  Eussia,  $27  ;  half  Turkey  Morocco,  $28.  For  sale  by  subscription  only.  Specimen 
plates  sent  on  receipt  of  10  cents.     A  full  prospectus  sent  to  any  address  on  application. 

It  would  be  hard  to  use  words  which  would  per- 
spicuously enough  convey  to  the  reader  the  great 
value  of  this  Clinical  Atlas.  This  Atlas  is  more 
complete  even  than  an  ordinary  course  of  clinical 
lectures,  for  in  no  one  college  or  hospital  course 
is  it  at  all  probable  that  all  of  the  diseases  herein 
represented  would  be  seen.  It  is  also  more  ser- 
viceable to  the  majority  of  students  than  attend- 
ance upon  clinical  lectures,  for  most  of  the 
students  who  sit  on  remote  seals  in  the  lecture 
hall  cannot  see  the  subject  as  well  as  the  office 


student  can  examine  these  true- to-life  chromo-lith- 
ographs.  Comparing  the  text  to  a  lecturer,  it  is 
more  satisfactory  in  exactness  and  fulness  than 
he  would  be  likely  to  be  in  lecturing  over  a  single 
case.  Indeed,  this  Atlas  is  invaluable  to  the  gen- 
eral practitioner,  for  it  enables  the  eye  of  the 
physician  to  make  diagnosis  of  a  given  case  of 
skin  manifestation  by  comparing  the  case  with 
the  picture  in  the  Atlas,  where  will  be  found  also 
the  text  of  diagnosis,  pathology,  and  full  sections 
on  treatment. —  Virginia  Medical  Monthly,  Dec.  1889. 


SABDAWAT,  W,  A.,  M.  J>., 

Professor  of  Skin  Diseases  in  the  Missouri  Medical  College,  St.  Louis. 
Manual  of  Skin  Diseases.     With  Special  Reference  to  Diagnosis  and  Treat- 
ment.    For  the  use  of  Students  and  General  Practitioners.     12mo.,  440  pp.    Cloth,  $3. 

embraces  all  essential  points  connected  with  the 
diagnosis  and  treatment  of  diseases  of  the  skin, 
and  we  have  no  hesitation  in  commending  it  as 
the  best  manual  that  has  yet  appeared  in  this 


Dr.  Hardaway's  large  experience  as  a  teacher 
and  writer  has  admirably  fitted  him  for  the  diffi- 
cult task  of  preparing  a  book  which,  while  suffi- 
ciently elementary  for  the  student  is  yet  suffi- 
ciently thorough  and  comprehensive  to  serve  as  a 
book  of  reference  for  the  general  practitioner.    It 


department  of  Medicine.— JournoZ  of   Cutaneous 
and  Genito-  Urinary  Diseases. 


JBTYDE,  J,  JS'BVINS,  A,  M.,  M.  D., 

Professor  of  Dermatology  and  Venereal  Diseases  in  Rush  Medical  College,  Chicago. 

A  Practical  Treatise  on  Diseases  of  the  Skin.  For  the  use  of  Students  a,nd 
Practitioners.  Second  edition.  In  one  handsome  octavo  volume  of  676  pages,  with 
2  colored  plates  and  85  beautiful  and  elaborate  illustrations.  Cloth,  $4.50;  leather,  $5.50, 


His  treatise  is  like  his  clinical  instruction, 
admirably  arranged,  attractive  in  diction,  and 
strikingly  practical  throughout.  No  clearer  de- 
scription of  the  various  primary  and  consecutive 
lesions  of  the  skin  is  to  be  met  with  anywhere. 
Dr.  Hyde  has  shown  himself  a  comprehensive 
reader  of  the  latest  literature,  and  has  incorpo- 
rated into  his  book  all  the  best  of  that  which 


the  past  years  have  brought  forth.  The  prescrip- 
tions and  formula  are  given  in  both  common  and 
metric  systems.  Text  and  illustrations  are  good, 
and  colored  plates  of  rare  cases  lend  additional 
attractions.  Altogether  it  is  a  work  exactly  fitted 
to  the  needs  of  a  general  practitioner,  and  no  one 
will  make  a  mistake  in  purchasing  it. — Medical 
Press  of  Western  New  York,  June,  1888. 


JAMIJESOW,  W.  AZLAJV,  M.  D., 

lecturer  on  Diseases  of  the  Skin,  School  of  Medicine,  Edinburgh. 
Diseases  of  the   Skin.     A  Manual  for  Students  and  Practitioners.       Third 
edition,  revised  and  enlarged.      In  one  octavo  volume  of  656  pages,  with  woodcut  and 
nine  double-page  chromo- lithographic  illustrations.     Cloth,  $6.00.     Just  ready. 

In  common  with  other  special  departments  in  I  This  volume  by  Dr.  Jamieson  is  a  valuable  one  for 
medicine,that  of  dermatology  is  rapidly  approach-  practitioners  and  students,  as  it  is  both  full  and 
ing  an  exactness  in  diagnosis  and  treatment  which  !  concise  without  being  unwieldy  and  voluminous. — 
fairly  places  it  at  the  front  among  the  specialties.  !  The  Jour,  of  the  Amer.  Med.  Asso.,  March  19, 1892. 

FOX,  T,,  M.  D.,  F,B.  C.  JP.,  and  FOX,  T.  C,  B,A,,  M.B,  C.S., 

Physician  to  the  Department  for  Skin  Diseases,  Physician  for  Diseases  of  the  Skin  to  the 

University  College  Hospital,  London.  Westminster  Hospital,  London. 

An  Epitome  of  Skin  Diseases.  With  Formulae.  For  Students  and  Prac- 
titioners. Third  edition,  revised  and  enlarged.  In  one  12mo.  vol.  of  238  pp.  Cloth,  $1.25. 
We  cordially  recommend  Fox's  Epitome  to  those  for  all  one  has  to  know  is  the  name  of  the  disease, 
whose  time  is  limited  and  who  wish  a  handy  and  here  are  its  description  and  the  appropriate 
manual  to  lie  upon  the  table  for  instant  reference,  treatment  at  hand,  ready  for  instant  application. 
Its  alphabetical  arrangement  is  suited  to  this  use, 


JACKSON,  GEOBGE  TaOMAS,  M.D., 

Professor  of  Dermatology,  Women's  Medical  College,  New  York  Infirmary. 

A  Handbook  of  Skin  Diseases.  For  Students  and  Practitioners.  By  George 
Thomas  Jackson,  M.  D.    In  one  12mo.  volume  of  450  pages,  with  illustrations.    Shortly. 

PTE-SMITS,  P.  JBT.,  Jf.  !>.,  F.  B.  S., 

Physician  to  Guy's  Hospital,  London. 

A  Handbook  of  Diseases  of  the  Skin.  By  Philip  H.  Pye-Smith,  M.  D., 
F.  R.  S.,  Physician  to  Guy's  Hospital,  London.  In  one  octavo  volume  of  450  pages, 
with  illustrations.    Preparing. 

HILLIER'S  HANDBOOK  OF  SKIN  DISEASES;  I  WILSON'S  STUDENT'S  BOOK  OF  CUTANEOUS 
for  Students  and  Practitioners.  Second  Ameri-  MEDICINE  AND  DISEASES  OF  THE  SKIN, 
can  edition.  In  one  12mo.  volume  of  353  pages,  In  one  handsome  small  octavo  volume  of  535 
with  plates.    Cloth,  S2.25.  I      pages.    Cloth,  f3.50. 


Lea  Brothers  &  Co.'s  Publications — Dis.  of  Women.    . 


27 


The  American  Systems  of  Gynecology  and  Obstetrics. 

Systems  of  Gynecology  and  Obstetrics,  in  Treatises  by  American 
Authors,  (gynecology  edited  by  Matthew  D.  Mann,  A.M.,  M.D.,  Professor  of  Oltstetrics 
and  Gynecology  in  the  Medical  Department  of  the  University  of  Eiift'alo;  and  Ob.stet- 
ric-s  edited  by  Barton  Cooke  Hirst,  M.  D.,  Associate  Professor  of  Obstetrics  in  the 
University  of  Pennsylvania,  Philadelphia.  In  four  very  handsome  octavo  volumes,  con- 
taining 3612  pages,  1092  engravings  and  8  plates.  Complete  work  nov)  ready.  Per  vol- 
ume: Cloth,  $5.00;  leather,  $6.00;  half  Russia,  $7.00.  For  sole  by  subscription  only. 
Address  the  Publishers.     Full  descriptive  circular  free  on  ai)plication. 

LIST  OF   CONTRIBUTORS. 


WILLIAM  H.  BAKER,  M.  D., 
ROBERT  BATTEY,  M.  D., 
SAMUEL  C.  BUSEY,  M.  D., 
JAMES  C.  CAMERON,  M.  D., 
HENRY  C.  COE,  A.  M.,  M.  D., 
EDWARD  P.  DAVIS,  M.  D., 
G.  E.  De  SCHWEIMTZ,  M.  D., 
E.  C.  DUDLEY,  A.  B.,  M.  D., 
B.  McE.  EMMET,  M.  D., 
GEORGE  J.  ENGELMANN,  M.  D., 
HENRY  J.  GARRIGUES,  A.  M.,  M.  D., 
WILLIAM  GOODELL,  A.  M.,  M.  D., 
EGBERT  H.  GRANDIN,  A.  M.,  M.  D., 
SAMUEL  W.  GROSS,  M.  D., 
ROBERT  P.  HARRIS,  M.  D., 
GEORGE  T.  HARRISON,  M.  D., 
BARTON  C.  HIRST,  M.  D. 
STEPHEN  Y.  HOWELL,  M.  D., 
A.  REEVES  JACKSON,  A.  M.,  M.  D., 
W.  W.  JAGGARD,  M.  D., 
EDWARD  W.  JENKS,  M.  D.,  LL.  D., 
These  volumes  are  the  coutributions  of  the  most 
eminent  gentlemen  of  this  country  in  these  de- 
partments of  the  profession.   Each  contributor  pre- 
sents a  monograph  upon  his  special  topic,  so  that 
everything  in  the  way  of  history,  theory, methods, 
and  results  is  presented  to  our'fullest  need.    As  a 
vrork  of  general  reference,  it  will  be  found  remarka- 
bly full    and    instructive    in    every    direction    of 
inquiry. — The  Obstetric  Gazette,  September,  1889. 

One  is  at  a  loss  to  know  what  to  say  of  this  vol- 
ume, for  fear  that  just  and  merited  praise  maybe 
mistaken  for  flattery.  The  papers  of  Drs.  Engel- 
mann,  Martin,  Hirst,  Jaggard  and  Reeve  are  incom- 
parably beyond  anything  that  can  be  found  in 
obstetrical  works. — Journal  of  the  American  Medical 
Aswciation,  Sept.  8, 1888. 

In  our  notice  of  the  "System  of  Practical  Medi- 
cine by  American  Authors,"  we  made  the  follow- 
ing statement: — "It  is  a  work  of  which  the  pro- 
fession in  this  country  can  feel  proud.  Written 
exclusively  by  American  physicians  who  are  ac- 
quainted with  all  the  varieties  of  climate  in  the 


D., 


HOWARD  A.  KELLY,  M.  D., 
CHARLES  CARROLL  LEE,  M.  D., 
WILLIAM  T.  LUSK,  M.  D.,  LL.  D., 
J.  HENDRIE  LLOYD,  M.D., 
MATTHEW  D.  MANN,  A.  M.,  M.  D., 
H.  NEWELL  MARTIN,  F.  R.  S.,  M, 
RICHARD  B.  MAURY,  M.  D., 
CD.  PALMER,  M.D., 
ROSWELL  PARK,  M.  D., 
THEOPHILUS  PARVIN,  M.  D.,  LL.  D., 
R.  A.  F.  PENROSE,  M.  D.,  LL.  D., 
THADDEUS  A.  REAMY,  A.  M.,  M.  D., 
J.  C.  REEVE,  M.  D., 
A.  D.  ROCKWELL,  A.  M.,  M.  D., 
ALEXANDER  J.  C.  SKENE,  M.  D., 
J.  LEWIS  SMITH,  M.  D., 
STEPHEN  SMITH,  M.  D., 
R.  STANSBURY  SUTTON,  M.  D..  LL.D., 
T.  GAILLARD  THOMAS,  M.  D.,  LL.  D., 
ELY  VAN  DE  WARKER,  M.  D., 
W.  GILL  WYLIE,  M.  D. 
United  States,  the  character  of  the  soil,  the  man- 
ners and  customs  of  the  people,  etc.,  it  is  pecul- 
iarly adapted  to  the  wants  of  American  practition- 
ers of  medicine,  and  it  seems  to  us  that  every  one 
of  them  would  desire  to  have  it."     Every  word 
thus  expressed  in  regard  to  the  "American  Sys- 
tem of  Practical  Medicine"  is  applicable  to  the 
"System  of    Gynecology  by  American  Authors." 
It,  like  the  other,  has  been  written  exclusively 
by  American  physicians  who  are  acquainted  with 
all  the  characteristics  of  American  people,  who  are 
well  informed  in  regard  to  the  peculiarities  of 
American  women,  their  manners,  customs,  modes 
of  living,  etc.     As  every  practising  physician  is 
called  upon  to  treat  diseases  of  females,  and  as 
they  constitute  a  class  to  which  the  family  phy- 
sician must  give  attention,  and  cannot  pass  over 
to  a  specialist,  we  do  not  know  of  a  work  in  any 
department  of  medicine  that  we  should  so  strongly 
recommend  medical  men  generally  purchasing. — 
Cincinnati  Med.  News,  July,  1887. 


EMMBT,  TS03IAS  ADDIS,  M,  2>.,  LL,  D., 

Surgeon  to  the  Woman's  Hospital,  New  York,  etc. 

The  Principles  and  Practice  of  Gynaecology ;  For  the  use  of  Students  and 
Practitioners  of  Medicine.  Third  edition,  thoroughly  revised.  In  one  large  and  very 
handsome  octavo  volume  of  880  pages,  with  150  illustrations.  Cloth,  $5 ;  leather,  $6. 
We  are  in  doubt  whether  to   congratulate  the  j  the  privilege  thus  offered  them  of  perusing  the 


author  more  than  the  profession  upon  the  appear- 
ance of  the  third  edition  of  this  well-known  work. 
Embodying,  as  it  does,  the  life-long  experience  of 
one  who  has  conspicuously  distinguished  himself 
as  a  bold  and  successful  operator,  and  who  has 
devoted  so  much  attention  to  the  specialty,  we 
feel  sure  the  profession  will  not  fail  to  appreciate 


views  and  practice  of  the  author.  His  earnestness 
of  purpose  and  conscientiousness  are  manifest. 
He  gives  not  only  his  individual  experience  but 
endeavors  to  represent  the  actual  state  of  gynae- 
cological science  and  art. — British  Medical  Jour- 
nal, May  16,  1885. 


UniS,  ARTBUR  TF.,  M.  D,,  Land.,  F,It.  C.  J».,  31,  B,  C.S,, 

Assist.  Obstetric  Physician  to  Middlesex  Hospital,  late  Physician  to  British  Lying-in  Hospital. 
The  Diseases  of  Women.     Including  their  Pathology,  Causation,  Symptoms, 
Diagnosis  and  Treatment.     A  Manual  for  Students  and  Practitioners.     In  one  handsome 
octavo  volume  of  576  pages,  with  148  illustrations.     Cloth,  $3.00 ;  leather,  $4.00. 

The  special  qualities  which  are  conspicuous  I  among  the  more  common  methods  of  treat- 
are  thoroughness  in  covering  the  whole  ground,  I  ment,  and  yet  very  little  is  said  about  them  in 
clearness  of  description  and  conciseness  of  state-  i  man^'  of  the  text-books.  The  book  is  one  to  be 
ment.  Another  marked  feature  of  the  book  is  warmly  recommended  especially  to  students  and 
the  attention  paid  to  the  details  of  many  minor  !  general  practitioners,  who  need  a  concise  but  com- 
surgical  operations  and  procedures,  as,  for  j  plete  j-esi^ni*  of  the  whole  subject.  Specialists,  too, 
Instance,  the  use  of  tents,  application  of  leeches,  will  find  many  useful  hints  in  its  pages.— Boston 
and    use    of    hot   water    injections.      These    are  1  Med.  and  Surg.  Joum.,  March  2, 1882. 


HODGE  ON  DISEASES  PECULIAR  TO  WOMEN. 
Including  Displacementsof  the  Uterus.  Second 
edition,  revised  and  enlarged.  In  one  beauti- 
fully printed  octavo  volume  of  519  pages,  with 
original  illustrations.    Cloth,  S4.50. 


WEST'S  LECTURES  ON  THE  DISEASES  OF 
WOMEN  Third  American  from  the  third  Lon- 
don edition.  In  one  octavo  volume  of  543  pages. 
Cloth,  S3.75;  leather,  S4.75. 


28 


Lea  Brothers  &  Co.'s  Publications — Diseases  of  Women. 


TMOMAS,  T,  GAILLABD,  and  MVNDE,  PAUZ  F,, 

31.  D.,  LL.  D,,  M.  !>., 

Emeritus  Professor  of  Diseases  of  Women  in  the  College  Professor  of  Gynecology  in  the  New    York 

of  Physicians  and  Surgeons,  N.  F.  Polyclinic. 

A  Practical  Treatise  on  the  Diseases  of  Women.  New  (sixth)  edition, 
thoroughly  revised  and  rewritten  by  Dr.  Mtjnde.  In  one  large  and  handsome  octavo 
volume  of  824  pages,  with  347  illustrations,  of  which  201  are  new.     Cloth,  $5 ;  leather,  $6, 


Probably  no  treatise  ever  written  by  an  Ameri- 
can author  on  a  medical  topic  lias  been  accepted 
by  more  practitioners,  as  a  standard  text-book,  or 
read  with  pleasure  and  profit  by  more  medical 
students  than  Thomas  on  the  diseases  of  women. 
Next  lo  the  indescribable  charm  of  listening  to 
Dr.  Thomas'  lectures  and  clinics,  which  have  in 
them  the  element  of  a  captivating  and  inspiring 
personality—which  must  be  heard  and  felt  to  be 
properly  appreciated — is  this  volume,  which  in 
classic  excellence,  elegance  of  diction  and  scholar- 


ly and  scientific  statement  must  remain  what  it 
long  has  been,  a  standard  text-book  both  for  prac- 
titioner and  student,  at  home  and  abroad,  and  an 
enduring  pride  to  American  gynecologists.  In  a 
field  by  no  means  new  or  wanting  in  honorable 
achievement,  Dr.  Mund§  has  added  to  his  already 
enviable  reputation  by  the  manner  in  which  he 
has  acquitted  himself  in  an  undertaking  at  once 
so  delicate  and  difficult  and  for  which  he  will 
receive,  at  the  hands  of  the  profession,  their  ac- 
knowledgment.—  The  Brooklyn  Med.  Jour.,  Max.  '92. 


TAIT,  LAWSON,  F.B,  C,  S,, 

Professor  of  Oynmcology  in  Queen's  College,  Birmingham;  late  President  of  the  British  Gyne- 
cological Society ;  Fellow  American  Gynecological  Society. 

Diseases  of  Women  and  Abdominal  Surgery.    In  two  octavo  volumes. 
Volume  I.,  554  pages,  62  engravings  and  3  plates.     Cloth,  $3.     Volume  II.,  preparing. 


The  plan  of  the  work  does  not  indicate  the  regu- 
lar system  of  a  text- book,  and  yet  nearly  every- 
thing of  disease  pertaining  to  the  various  organs 
receives  a  fair  consideration.  The  description  of 
diseased  conditions  is  exceedingly  clear,  and  the 
treatment,  medical  or  surgical,  is  very  satisfactory. 


Much  of  the  text  is  abundantly  illustrated  with 
cases,  which  add  value  in  showing  the  results  of 
the  suggested  plans  of  treatment.  We  feel  con- 
fident that  few  gynecologists  of  the  country  will 
fail  to  place  the  work  in  their  libraries. — The 
Obstetric  Gazette,  March,  1890. 


SUTTON,  J,  BZAWD,  F.  M.  C.  S., 

Assistant  Surgeon  to  the  Middlesex  Hospital,  London. 

Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,  including 
Tubal  Pregnancy.  In  one  crown  octavo  volume  of  544  pages  with  119  engravings 
and  5  colored  plates.     Cloth,  $3.     Just  ready. 

To  gynecologists  the  name  of  Mr.  Sutton  has  that  the  writer  has  to  say  is  stated  in  a  clear, 
long  been  familiar  as  that  of  a  conscientious  practical  way.  The  author's  style  is  singularly 
vrorker  in  pelvic  pathology,  as  well  as  a  compara-  conciHe — almost  epigrammatic.  Statements  which 
tive  anatomist  of  wide  reputation.  The  present  in  a  less  weighty  authority  might  appear  too  dog- 
voiume  contains  the  substance  of  valuable  papers  matic  gather  force  by  the  positive  manner  in 
which  have  been  scattered  throughout  journals  which  they  are  made.  We  have  no  hesitation  in 
and  society  reports  during  the  past  five  or  six  '  pronouncing  it  the  best  monograph  of  the  kind 
years,  and  deserves  the  careful  attention  of  gen-  ,  which  has  yet  appeared. — Medical  Record,  New 
eral  readers  as  well  as  of  specialists.    Everything  |  York,  May  21, 1892. 


DAVEJSTFORT,  F,   S.,  31.  D., 

Assistant  in  Gynaecology  in  the  Medical  Department  of  Harvard  University,  Boston. 

Diseases  of  Women,  a  Manual  of  Non-Surgical  Gynaecology.  De- 
signed especially  for  the  Use  of  Students  and  General  Practitioners.  New  (second) 
edition.  In  one  handsome  12mo.  volume  of  314  pages,  with  107  illustrations.  Cloth, 
$1.75.     Just  ready. 

A  notice  of  the  previous  edition  is  appended.  , 


There  is  not  even  a  paragraph  of  useless  matter. 
Everything  is  of  the  newest,  freshest  and  most 
practical,  so  much  so  that  we  have  recommended 
it  to  our  class  of  gynecology  students.  What  the 
author  advises  in  the  way  of  treatment  has  all 


been  practically  tested  by  himself,  and  each 
method  receives  only  so  much  commendation  as  he 
has  found  that  it  deserves.  We  are  sure  that 
these  good  qualities  will  command  for  it  a  large 
sale. — Canada  Medical  Record,  Dec.  1889. 


31  AT,   CJEEABLES  M.,  31.  n., 

Late  Souse  Surgeon  to  Mount  Sinai  Hospital,  New  York. 
A  Manual  of  theDiseases  of  Women.   Being  a  concise  and  systematic  expo- 
sition of  the  theory  and  practice  of  gynecology.      Second  edition,  edited  by  L.  S.  Rau, 
M.  D.,  Attending  Gynecologist  at  the  Harlem  Hospital,  N.  Y.     In  one  12mo.  volume  of 
3t)0  pages,  with  31  illustrations;     Cloth,  $1.75  ^-^,-%s»d^^^ 


Tnis  is  a  manual  of  gynecology  in  a  very  con- 
densed form,  and  the  fact  that  a  second  edition 
has  been  called  for  indicates  that  it  has  met  with 
a  favorable  reception.  It  is  intended,  the  author 
tells  us,  to  aid  the  student  who  after  having  care- 
fully perused  larger  works  desires  to  review  the 
subject,  and  he  adds  that  it  may  be  useful  to  the 
practitioner  who  wishes  to  refresh  his  memory 


rapidly  but  has  not  the  time  to  consult  larger 
works.  We  are  much  struck  with  the  readiness 
and  convenience  with  which  one  can  refer  to  any 
subject  contained  in  this  volume.  Carefully  com- 
piled indexes  and  ample  illustrations  also  enrich 
the  work.  This  manual  will  be  found  to  fulfil  its 
purposes  very  satisfactorily. — The  Physician,  and 
Surgeon,  June,  1890. 


Lea  Brothers  &  Co.'s  Publications — Obstetrics,  Dis.  of  Worn.   29 


PARVIK,  THEOPHILVS,  M,  D.,  ii.  !>., 

Prof,  of  Obstetrics  ami  the  Diseases  of  Women  and  Ctdldren  m  Jefferson  Med.  Coll.,  Phila. 
The  Science  and  Art  of  Obstetrics.     Second  edition.     In  one  liandsome  8vo. 
volume  of  701  pages,  with  239  engravings  and  a  colored  plate.     Cloth,  $4.25;  leather,  $5.25. 

The  second  edition  of  thiy  work  i.s  fully  up  to  the  I  ob.stetric  literature  can  be  found  a  work  which  is 
present  state  of  advancement  of  the  obstetric  art.  so  comprehensive  and  yet  compact  and  practical. 
The  author  has  succeeded  exceedingly  well  in  j  In  such  respect  it  is  essentially  a  text  book  of  the 
incorporating  new  matter  without  apparently  in-  first  merit.  The  treatment  of  the  subjects  gives  a 
creasing  the  size  of  his  work  or  interfering  with  '  real  value  to  the  worb — the  individualities  of  a 
the  smoothness  and  grace  of  its  literary  construe-  j  practical  teacher,  a  skilful  obstetrician,  a  close 
tion.  He  is  very  felicitous  in  hi-s  descriptions  of  thinker  and  a  ripe  scholar. — Medical  Record,  Jan. 
conditions,  and  proves  himself  in  this  respect  a  17,  1891. 
scholar  and  a  master.     Rarely  in  the  range  of  I 


JPLAYFAIB,  W.  S.,  M.  D.,  F.  JR,  C,  P., 

Professor  of  Obstetric  Medicine  in  King's  College,  London,  etc. 

A  Treatise  on  the  Science  and  Practice  of  Midwifery.  Fifth  Amer- 
ican, from  the  seventh  English  edition.  Edited,  with  additions,  by  Kobert  P.  Harris, 
M.  D.  In  one  handsome  octavo  volume  of  664  pages,  with  207  engravings  and  5  plates, 
aoth,  $4.00 ;  leather,  $5.00. 


Truly  a  wonderful  book ;  an  epitome  of  all  ob- 
stetrical knowledge,  full,  clear  and  concise.  In 
thirteen  years  it  has  reached  seven  editions.  It 
is  perhaps  the  most  popular  work  of  its  kind  ever 
presented  to  the  profession.  Beginning  with  the 
anatomy  and  physiology  of  the  organs  concerned, 
nothing  is  left  unwritten  that  the  practical  ac- 
coucheur should  know.  It  seems  that  every 
conceivable  physiological  or  pathological  condi- 


tion from  the  moment  of  conception  to  the  time 
of  complete  involution  has  had  the  author's 
patient  attention.  The  plates  and  illustrations, 
carefully  studied,  will  teach  the  science  of  mid- 
wifery. The  reader  of  this  book  will  have  before 
him  the  very  latest  and  best  of  obstetric  practice, 
and  also  of  all  the  coincident  troubles  connected 
therewith. — Southern  Practitioner,  Dec.  1889. 


KING,  A,  F,  A,,  M.  D,, 

Professor  of  Obstetrics  and  Diseases  of  Women  in  the  Medical  Department  of  the  Columbian  Univer- 
sity, Washington,  D.  C,  and  in  the  University  of  Vermont,  etc. 

A  Manual  of  Obstetrics.     New  (Fifth)  edition.     In  one  very  handsome  12mo. 
volume  of  about  450   pages,  with  about  150  illustrations.     Preparing. 
A  notice  of  the  previous  edition  is  appended. 


Dr.  King,  in  the  preface  to  the  first  edition  of 
this  manual,  modestly  states  that  "its  purpose  is 
to  furnish  a  good  groundwork  to  the  student  at 
the  beginning  of  his  obstetric  studies."  Its  pur- 
pose is  attained;  it  toi7;  furnish  a  good  ground- 
work to  the  student  who  carefully  reads  it;  and 
further,  the  busy  practitioner  should  not  scorn  the 
volume  because  written  for  students,  as  it  con- 
tains much  valuable  obstetric  knowledge,  some 
of  which  is  not  found  in  more  elaborate  text- 
books. The  chapters  on  the  anatomy  of  the 
female  generative  organs,  menstruation,  fecunda- 


tion, the  signs  of  pregnancy,  and  the  diseases  of 
pregnancy,  are  all  excellent  and  clear ;  but  it  is  in 
the  description  of  labor,  both  normal  and  abnor- 
mal, that  Dr.  King  is  at  his  best.  Here  his  style 
is  so  concise,  and  the  illustrations  are  so  good, 
that  the  veriest  tyro  could  not  fail  to  receive  a  clear 
conception  of  labor,  its  complications  and  treat- 
ment. Of  the  141  illustrations  it  may  be  safely 
said  that  they  all  illustrate,  and  that  the  engraver's 
work  Is  excellent.  From  every  standpoint  we  can 
most  heartily  recommend  the  book  both  to  practi- 
tioner and  student. —  The  Medical  News,  Dec.  7, 1889. 


BABNFS,  nOBEBT,  31.  B,,  and   FANCOUBT,  M.  B., 

Phys.  to  the  General  Lying-in  Hosp.,  Land.  Obstetric  Phys.  to  St.  Thomas'  Hosp.,  Lond. 

A  System  of  Obstetric  Medicine  and  Surgery,  Theoretical  and  Clin- 
ical. For  the  Student  and  the  Practitioner.  The  Section  on  Embryology  by  Prof.  Milnes 
Marshall.      In  one  8vo.  volume  of  872  pp.,  with  231  illustrations.    Cloth,  $5 ;  leather,  $6. 


The  immediate  purpose  of  the  work  is  to  furnish 
a  handbook  of  obstetric  medicine  and  surgery 
for  the  use  of  the  student  and  practitioner.  It  is 
not  an  exaggeration  to  say  of  the  book  that  it  is 
the  best  treatise  in  the  English  language  yet 
published,  and  this  will  not  be  a  surprise  to  those 
who  are  acquainted  with  the  work  of  the  elder 
Barnes.      Every  practitioner  who  desires  to  have 


the  best  obstetrical  opinions  of  the  time  in  a 
readily  accessible  and  condensed  form,  ought  to 
own  a  copy  of  the  book. — Journal  of  the  American 
Medical  Association,  June  12, 1886. 

The  Authors  have  made  a  text-book  which  is  in 
every  way  quite  worthy  to  take  a  place  beside  the 
best  treatises  of  the  period. — JVew  York  Medical 
Journal,  July  2,  1887. 


BVNCAW,  J.  MATTSFWS,  M.B,,  LZ.  B.,  F.  B,  S.  F.,  etc. 

Clinical  Lectures  on  the  Diseases  of  Women ;  Delivered  in  Saint  Bar- 
tholomew's Hospital.     In  one  handsome  octavo  volume  of  175  pages.     Cloth,  $1.50. 

They  are  in  every  way  worthy  of  their  author;  rule,  adequately  handled  in  the  text-books;  others 
indeed,  we  look  upon  them  as  among  the  most  of  them,  while  bearing  upon  topics  that  are  usually 
valuable  of  his  contributions.  They  are  all  upon  treated  of  at  length  in  such  works,  yet  bear  such  a 
mattersof  great  interest  to  the  general  practitioner,  stamp  of  individuality  that  they  deserve  to  be 
Some  of  them  deal  with  subjects  that  are  not,  as  a    widely  read. — N.  Y.  Medical  Journal,  March,  1880. 


WINCKEL,  F. 

A  Complete  Treatise  on  the  Pathology  and  Treatment  of  Childbed. 

For  Students  and  Practitioners.     Translated,  with  the  consent  of  the  Author,  from  the 
second  German  edition,  by  J.  K.  Chadwick,  M.  D.    Octavo  484  pages.    Cloth,  $4.00. 


30 


Lea  Brothers  &  Co.'s  Publications — Obstet.,  Ois.  Childn. 


SMITS,  J,  LEWIS,  M,  D., 

Clinical  Professor  of  Diseases  of  Children  in  the  Bellevue  Hospital  Medical  College,  N.  Y. 

A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  New  (severitli) 
edition,  thoroughly  revised  and  rewritten.  In  one  handsome  octavo  volume  of  881 
pages,  with  51  illustrations.     Cloth,  $4.50 ;  leather,  |5.50. 

We  have  always  considered  Dr.  Smith's  book  as 
one  of  the  very  best  on  the  subject.  It  has  always 
been  practical — a  field  book,  theoretical  where 


theory  has  been  deduced  from  practical  experi- 
ence. He  takes  his  theory  from  the  bedside  and 
the  pathological  laboratory.  The  very  practical 
character  of  this  book  has  always  appealed  to  us. 
It  is  characteristic  of  Dr.  Smith  in  all  his  writings 
to  collect  whatever  recommendations  are  found  in 
medical  literature,  and  his  search  has  been  wide. 
One  seldom  fails  to  find  here  a  practical  suggestion 
after  search  in  other  works  has  been  in  vain.  In 
the  seventh  edition  we  note  a  variety  of  changes 
in  accordance  with  the  progress  of  the  times.  It 
still  stands  foremost  as  the  American  text-book. 
The  literary  style  could  not  be  excelled,  its  advice 


is  always  conservative  and  thorough,  and  the 
evidence  of  research  has  long  since  placed  its 
author  in  the  front  rank  of  medical  teachers. — 
The  American  Journal  of  the  Medical  Sciences,  Dee. 
1891. 

In  the  present  edition  we  notice  that  many  of 
the  chapters  have  been  entirely  rewritten.  Full 
notice  is  taken  of  all  the  rece"nt  advances  that 
have  been  made.  Many  diseases  not  previously 
treated  of  have  received  special  chapters.  The 
work  is  a  very  practical  one.  Especial  care  has 
been  taken  that  the  directions  for  treatment  shall 
be  particular  and  full.  In  no  other  work  are  such 
cartful  instructions  given  in  the  details  of  infant 
hygiene  and  the  artificial  feeding  of  infants. — 
Montreal  Medical  Journal,  Feb.  1891. 


LANDIS,  SENRY  G,,  A,  M.,  M,  J>., 

Professor  of  Obstetrics  and  the  Diseases  of  Women  in  Starling  Medical  College,  Columbus,  O. 

The  Management  of  Labor,  and  of  the   Lying-in  Period.     In 

handsome  12mo.  volume  of  334  pages,  with  28  illustrations.     Cloth,  $1.75. 


The  author  has  designed  to  place  in  the  hands 
of  the  young  practitioner  a  book  in  which  he  can 
find  necessary  information  in  an  instant.    As  far 


as  we  can  see,  nothing  is  omitted.    The  advice  is 
sound,  and  the  procedures  are  safe  and  practical. 
Centralblatt  filr  Gynakologie,  December  4, 1886. 


SEBMAJSr,  G,  EBNEST,  M,  B,,  F,  B,  C.  P., 

Obstetric  Physician  to  the  London  Hospital. 

First  Lines  in  Midwifery:  a  Guide  to  Attendance  on  Natural  Labor 
for  Medical  Students  and  Midwives.    In  one  12mo.  volume  of  198  pages  with 

80  illustrations.     Cloth,  $1.25.     Just  ready.     See  Student's  Series  of  Manuals,  below. 

This  work  is  designed  to  give  such  elementary  student  and  the  educated  midwife.  The  work 
knowledge  as  may  be  needed  by  a  midwife  or  is  written  in  a  plain,  simple  style,  and  is  as 
student  in  the  care  of  their  first  cases  of  normal  much  as  possible  devoid  of  technical  terms.  It 
labor,  and  it  presents  that  knowledge  in  a  clear  will  prove  valuable  to  the  beginner  in  midwifery 
and  practical  way. —  The  American  Journal  of  Ob-  and  could  be  read  with  advantage  by  the  majority 
stetrics,  April,  1892.  of  practitioners,    old   and    young. — The    Medical 

This  is  a  little  book,  intended  for  the  medical    Fortnightly,  April  15, 1892. 


OWEJSr,  EDMUJS^JD,  M.  B.,  F.  B.  C.  S,, 

Surgeon  to  the  Children's  Hospital,  Great  Ormond  St.,  London. 


Surgical  Diseases  of  Children. 

chromo-lithographic  plates  and  85  woodcuts, 
page  31. 

One  is  immediately  struck  on  reading  this  book 
with  its  agreeable  style  and  the  evidence  it  every- 
where presents  of  the  practical  familiarity  of  its 
author   with   his   subject.      The   book    may   be 


In  one  12mo.  volume  of  525  pages,  with  4 
Cloth,  $2.     See  Series  of  Clinical  Manuals, 

honestly  recommended  to  both  students  and 
practitioners.  It  is  full  of  sound  information, 
pleasantly  given. — Annals  of  Surgery,  May,  1886. 


STUDEWT'S  SEBIES  OF  MAJSTTALS. 

A  Series  of  Fifteen  Manuals,  for  the  use  of  Students  and  Practitioners  of  Medicine  and  Surgery, 
written  by  eminent  Teachers  or  Examiners,  and  issued  in  pocket-size  12mo  volumes  of  300-540  pages, 
richly  illustrated  and  at  a  low  price.  The  following  volumes  are  now  ready :  Herman's  First  Lines  in 
Midwif ery,  $1.25 ;  Treves'  Manual  of  Surgery,  by  various  writers,  in  three  volumes,  each,  $2;  Bell's  Com- 
parative  Anatomy  and  Physiology,  $2;  GovLiJ's  Surgical  Diagnosis.  92;  'Robb'r'ison's  Physiological  Physics, $2; 
Brtjoe's  Materia  Medica  and  Therapeutics  (ith  edition),  $1.50 ;  Power's  Human  Physiology  (2d  edition), 
S1.50;  Clarke  and  Lockwood's  Diisectors'  Manual,  $1.50;  Ealfe's  Clinical  Chemistry,  $1.50;  Treves' 
Surgical  Applied  Anatomy,  $2;  Pevv^r's  Surgical  Pathology,  $2;  and  Klein's  Elements  of  Histology  (ith 
edition),  $1.75.  The  following  is  in  press:  Pepper's  Forensic  Medicine.  For  separate  notice's  see 
index  on  last  page. 


CONDIE'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  OF  CHILDREN.  Sixth  edition,  re- 
vised and  augmented.  In  one  octavo  volume  of 
779Dages.    Cloth.  85.25;  leather.  8fi.2fi 

LEISHMAN'S  SYSTEM  OF  MIDWIFERY,  IN- 
CLUDING THE  DISEASES  OF  PREGNANCY 
AND  THE  PUERPERAL  STATE.  Fourth  edi- 
tion.   Octavo. 

WEST  ON  SOME  DISORDERS  OP  THE  NERV- 
OUS SYSTEM  IN  CHILDHOOD.  In  one  small 
12mo.  volume  of  127  pages.    Cloth,  $1.00. 

PARRY  ON  EXTRA-UTERINE  PREGNANCY" 
Its  Clinical  History,  Diagnosis,  Prognosis  and 
Treatment.    Octavo,  272  pages.    Cloth,  $2.50. 

CHURCHILL  ON  THE  PUERPERAL  FEVER 
AND  OTHER  DISEASES  PECULIAR  TO  WO- 
MEN.   In  one  8vo.  vol.  of  464  pages.    Cloth,  S2.50. 

TANNER  ON  PREGNANCY.  Octavo,  490  pages, 
colored  plates,  16  cuts.    Cloth,  $4.25. 


ASHWELL'S  PRACTICAL  TREATISE  ON  THE 
DISEASES  PECULIAR  TO  WOMEN.  Third 
American  from  the  third  and  revised  London 
edition.    In  one  8vo.  vol.,  pp.  520.    Cloth,  $3.50. 

MEIGS  ON  THE  NATURE,  SIGNS  AND  TREAT- 
MENT OF  CHILDBED  FEVER.  In  one  8vc. 
volume  of  346  pages.     Cloth.  82.00. 

RAMSBOTHAM'S  PRINCIPLES  AND  PRAC- 
TICE OF  OBSTETRIC  MEDICINE  AND 
SURGERY.  In  reference  to  the  Process  of 
Parturition.  A  new  and  enlarged  edition,  thor- 
oughly revised  by  the  Author.  With  additions 
by  W.  V.Keating,  M.  D.,  Professor  of  Obstetrics, 
etc.,  in  the  Jefferson  Medical  College  of  Phila- 
delphia. In  one  large  and  handsome  imperial 
octavo  volume  of  640  pages,  with  64  full  page 
plates  and  43  woodcuts  in  the  text,  containing  in 
all  nearly  200  beautiful  figures.  Strongly  bound 
in  leather,  with  raised  bands,  $7. 


Lea  Brothers  &  Co.'s  Publications — Med.  Juris.,  Miscel. 


31 


SERIES  OF  CLINICAL  MANUALS, 

In  arranging  for  this  Series  it  has  Vjeen  the  design  of  the  jiublishers  to  provide  the  profession  with 
a  collection  of  authoritative  monogniplis  on  important  clinical  subjects  in  a  cheap  and  portable  form. 
The  volumes  will  contain  about  .'■i50i)uges and  will  be  freely  illustrated  by  chromo-lithographs  and  wood- 
cuts. The  following  volumes  are  now  ready:  Yeo  on  Food  in  Health  and  Disense,  ^1;  Broaciient  on 
the  Pu?se,  $1.75;  Carter  &  Frost's  Ophthalmic  Surgery,  82.2,';;  Hutchinson  on  Syphilis,  $i.'iry,  Ball  on 
the  Rectum  and  Atius,  $2.25;  Marsh  on  the  .Joints,  $2;  Owen  on  Surgical  Diseases  of  Children,  $2; 
Morris  on  Surgical  Diseases  of  the  Kidney,  $2.25;  Pick  on  Fractures  and  Dislocations,  $■>;  Butlin  on 
the  Tongue,  $A.50;  Treves  on  Intestinal  Obstruction,  $2;  and  Savage  on  Insanity  and  Allied  Neuroses,  $2. 
The  following  is  in  active  preparation:  Lucas  on  Diseases  of  the  Urethra.  For  separate  notices  see 
index  on  last  page. 

TATLOM,  ALFRED  S.,  M.  !>., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  m  Ouy's  Hospital,  London. 

Poisons  in  Relation  to  Medical  Jvirisprudence  and  Medicine.  Third 
American,  from  the  third  and  revised  English  edition.  In  one  large  octavo  volume  of  788 
pages.    Cloth,  $5.50 ;  leather,  $6.50. 

By  the  Same  Author. 
A  Manual  of  Medical  Jxirisprudence.     Eighth  American  from  the  tenth  Lon- 
don edition,  thoroughly  revised  and  rewritten.     Edited  by  John  J.  Reese,  M.  D.    In  one 
large  octavo  volume. 

FEFFEM,  AUGUSTUS  J.,  M.  S,,  M,  B.,  F.  M,  C.  S., 

Examiner  in  Forensic  Medicine  at  the  University  of  London. 
Forensic  Medicine.    In  one  pocket-size  12mo.  volume.    Preparing.    See  StudenU^ 
Series  of  Manuals,  below. 

LEA,  HENRY  C,  LL.  JD. 

Chapters  from  the  Religious  History  of  Spain.— Censorship  of  the 
Press. — Mystics  and  Illuminati. — The  Endemoniadas. — El  Santo  Nino 
de  la  Guardia. — Brianda  de  Bardaxi.  In  one  12mo.  volume  of  522  pages. 
Cloth,  $2.50. 


The  width,  depth  and  thoroughness  of  research 
which  have  earned  Dr.  Lea  a  high  European  place 
as  the  ablest  historian  the  Inquisition  has  yet 
found  are  here  applied  to  some  side-issues  of  that 
great  subject.  We  have  only  to  say  of  this  volume 
that  it  worthily  complements  the  author's  earlier 
studies  in  ecclesiastical  history.  His  extensive 
and  minute  learning,  much  of  it  from  inedited 
manuscripts  in  Mexico,  appears  on  every  page. — 
London  Antiquary,  Jan.  1891. 

After  attentively  reading  the  work  one  does  not 
know  whether  the  author  is  a  Catholic,  a  Protestant 


or  a  free-thinker.  This  moderation  deprives  the 
indictment  of  none  of  its  force.  The  facts  and 
the  documents,  of  which  the  number  and  novelty 
attest  a  patient  erudition,  are  grouped  in  luminous 
order  and  produce  on  the  reader  an  effect  all  the 
more  powerful  in  that  it  seems  the  less  designed. 
When  we  add  that  the  style  is  in  every  way  excel- 
lent, that  it  is  clear,  sober  and  precise,  we  do  full 
justice  to  a  work  which  reflects  the  highest  honor 
on  the  talents  of  the  writer  and  on  the  method  of 
the  modern  school  of  history. — Revue  Critique 
d^Hiitoire  et  de  Liiteraiure,  Paris,  Jan.  1891. 


By  the  same  Author. 
Superstition  and  Force :  Essays  on  The  Wager  of  Law,  The  Wager  of 
Battle,    The   Ordeal  and  Torture.     Third  revised  and  enlarged  edition.     In  one 
handsome  royal  12mo.  volume  of  552  pages. 


Mr.  Lea's  curious  historical  monographs,  of 
which  one  of  the  most  important  is  here  produced 
in  an  enlarged  form,  have  given  him  a  unique 
position  among  English  and  American  scholars. 
He  is  distinguished  for  his  recondite  and  affluent 
learning,  his  power  of  exhaustive  historical  analy- 


sis, the  breadth  and  accuracy  of  his  researches 
among  the  rarer  sources  of  linowledge,  the  gravity 
and  temperance  of  his  statements,  combined  with 
singular  earnestness  of  conviction,  and  his  warm 
attachment  to  the  cause  of  freedom  and  intellect- 
ual progress. — jY.  Y,  Tribune,  August  0, 1878. 


By  the  Same  Author. 
Studies  in  Church  History.    The  Rise  of  the  Temporal  Power— Ben- 
efit of  Clergy— Excommunication— The  Early  Church  and  Slavery.    Sec- 
ond and  revised  edition.     In  one  royal  octavo  volume  of  605  pages.    Cloth,  $2.50. 

complex  or  conflicting  forces. — Boston  Traveller. 
It  is  some  years  since  we  read  the  first  edition 
of  this  work  by  Mr.  Lea,  and  the  impression  made 
by  it  on  us  at  the  time  is  confirmed  by  reperusal 
of  it  in  this  enlarged  and  improved  form ;  namely, 
that  it  is  a  book  of  great  research  and  accuracy, 
full  of  varied  information  on  very  interesting 
phases  of  church  life  and  history.  It  discusses 
each  subject  with  a  rare  fulness  of  dates  and  in- 
stances, and  a  curious  conscientiousness  of  veri- 
fication and  citation  of  authorities.— JE'dinburgrA 
Scotsman. 


The  author  is  preeminently  a  scholar;  he  takes 
up  every  topic  allied  with  the  leading  theme  and 
traces  it  out  to  the  minutest  detail  with  a  wealth 
of  knowledge  and  impartiality  of  treatment  that 
compel  admiration.  The  amount  of  information 
compressed  into  the  book  is  extraordinary,  and 
the  profuse  citation  of  authorities  and  references 
maizes  the  work  particularly  valuable  to  the  student 
who  desires  an  exhaustive  review  from  original 
sources.  In  no  other  single  volume  is  the  develop- 
ment of  the  primitive  church  traced  with  so  much 
clearness  and  with  so  definite  a  perception  of 


By  the  Same  Author. 
An  Historical  Sketch  of  Sacerdotal  Celibacy  in  the  Christian 
Church.  Second  edition,  enlarged.  In  one  octavo  volume  of  685  pages.  Cloth,  $4.50. 
This  subject  has  recently  been  treated  with  very  I  more  light  on  the  moral  condition  of  the  Jliddle 
great  learning  and  with  admirable  impartiality  by  Ages,  and  none  which  is  more  fitted  to  dispel  the 
an  American  author,  Mr.  Henry  C.  Lea,  in  his  His-  '  gross  illusions  concerning  that  period  which  posi- 
tory  of  Sacerdotal  Celibacy,  which  is  certainly  one  five  writers  and  writers  of  a  certain  ecclesiastical 
of  the  most  valuable  works  that  America  has  pro-  ,  school  have  conspired  to  sustain. — Lechy's  History 
duced.  Since  the  great  history  of  Dean  Milman,  of  European  Morals,  Chap.  V. 
I  know  no  work  in  English  which  has  thrown  I 


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15 
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20 
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20,31 
16 
29 
16 
24 
7,30 

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19 

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13 

17,31 

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17 

11,30 

12 

21 

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23 

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7 

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16 

8 
10 
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10 

6 


Abbott's  Bacteriology  .  . 

Allen's  Anatomy  .  •  .  . 

American  Journal  of  the  Medical  Sciences 
American  Systems  of  Gynecology  and  Obstetrics 
American  System  of  Practical  Medicine  . 
American  System  of  Dentistry 
Asbliurst's  Surgery        .... 

Ashwell  on  Diseases  of  Women 

Attfield's  Chemistry 

Ball  on  the  Rectum  and  Anus 

Barlow's  Practice  of  Medicine 

Barnes'  System  of  Obstetric  Medicine 

Bartholow  on  Electricity       .  .     '     . 

Basham  on  Kenal  Diseases    . 

Bell's  Comparative  Anatomy  and  Physiology 

Bellamy's  Surgical  Anatomy 

Berry  on  the  Eye  .... 

Billings'  National  Medical  Dictionary     . 

Blandford  on  Insanity 

Bloxam's  Chemistry      .... 

Bristowe's  Practice  of  Medicine 

Broadbent  on  the  Pulse 

Browne  on  Koch's  Remedy  . 

Browne  on  the  Throat,  Nose  and  Ear 

Bruce's  Materia  Medica  and  Therapeutics 

Brunton's  Materia  Medica  and  Therapeutics 

Bryant's  Practice  of  Surgery  . 

Bumstead  and  Taylor  on  "Venereal.    See  Taylor. 

Burnett  on  the  Ear 

Butlin  on  the  Tongue    . 

Carpenter  on  the  Use  and  Abuse  of  Alcohol 

Carpenter's  Human  Physiology 

Carter  &  Frost's  Ophthalmic  Surgery 

Chambers  on  Diet  and  Regimen 

Chapman's  Human  Physiology 

Charles'  Physiological  and  Pathological  Chem, 

Churchill  on  Puerperal  Fever 

Clarke  and  Lockwood's  Dissectors'  Manual 

Classen's  Quantitative  Analysis 

Cleland's  Dissector        .... 

Clouston  on  Insanity    . 

Clowes'  Practical  Chemistry 

Coats'  Pathologj' 

Cohen  on  the  'Throat 

Cohen's  Applied  Therapeutics 

Coleman's  Dental  Surgery      . 

Condie  on  Diseases  of  Children 

Cornil  on  Syphilis  .... 

Cullerier  &  Bumstead  on  Venereal 

Culver  &  Hayden  on  Venereal  Diseases  . 

Dalton  on  the  Circulation 

Dalton's  HumanPhysiology 

Davenport  on  Diseases  of  Women  . 

Davis'  Clinical  Lectures  .  .  .16 

Draper's  Medical  Physics       ....         7 

Druitt's  Modern  Surgery         ....       20 

Duncan  on  Diseases  of  Women        ...       29 
Dungllson's  Medical  Dictionary 
Edes'  Materia  Medica  and  Therapeutics  .       11 

Edis  on  Diseases  of  Women  ....       27 

Ellis' Demonstrations  of  Anatomy  .  .         7 

Emmet's  Gynsecology  .  .  .       27 

Erichsen's  System  ot  Surgery  ...       21 

Farquharson's  Therapeutics  and  Mat.  Med.       .       12 
Pinlayson's  Clinical  Diagnosis         .  .  .15 

Flint  on  Auscultation  and  Percussion      .  .       17 

Flint  on  Phthisis  .....       13 

Flint  on  Respiratory  Organs  ...       17 

Flint  on  the  Heart        .  ...       13 

Flint's  Essays      .  .  ....       13 

Flint's  Practice  of  Medicine  .         .  .13 

Folsom's  Laws  of  U.  S.  on  Custody  of  Insane   .       19 
Foster's  Physiology       .....         8 

Fothergill's  Handbook  of  Treatment       ,  .       15 

Fownes'  Elementary  Chemistry      ...         9 
Fox  on  Diseases  of  the  Skin  ....       26 

Frankland  and  Japp's  Inorganic  Chemistry 

Fuller  on  the  Dungs  and  Air  Passages     .  .       16 

Gant's  Student's  Surgery       ....       20 

Gibbes'  Practical  Pathology  .  .  .18 

Gould's  Surgical  Diagnosis     .  .  .  .  20,  30 

Gray's  Anatomy     .        .  .  .  .  .5 

Gray  on  Nervous  Diseases      .  .  .  .19 

Green's  Pathology  and  Morbid  Anatomy  .       IS 

Greene's  Medical  Chemistry  ....         9 

Griffith's  Universal  Formularj'       ...       11 
Gross  on  Foreign  Bodies  in  Air-Passages  .       17 

Gross  on  Impotence  and  Sterility    ...       25 
Gross  on  Urinary  Organs  ,  .       25 

Gross  System  of  Surgery 
Habershon  on  the  Abdomen  .         .       15 

Hamilton  on  Fractures  and  Dislocations  .       22 

Hamilton  on  Nervous  Diseases       .  .  .19 

Hare's  Practical  Therapeutics         .  .  .12 

Hare's  System  of  Practical  Therapeutics  .       12 

Hardaway  on  the  Skin  .  .  .  .26 

Hartshorne's  Anatomy  and  Physiology  .  .         6 

Hartshorne's  Conspectus  of  the  Med.  Sciences  .        3 
Hartshorne's  Essentials  of  Medicine         .  .       13 

Herman's  First  Lines  in  Midwifery        .  .       30 

Hermann's  Experimental  Pharmacology  .       11 

Hill  on  Syphilis 25 

Hillier's  Handbook  of  Skin  Diseases         .  .       26 

Hirst  &  Piersol  on  Human  Monstrosities  .        6 

Koblyn's  Medical  Dictionary  ...         3 

Hodge  on  Women  ....       27 

Hofimann  and  Power's  Chemical  Analysis      .       10 
Holden's  Landmarks    .  .  .  .  .         5 

Holland's  Medical  Notes  and  Reflections  .       16 

Holmes'  Principles  and  Practice  of  Surgery     .       22 
Holmes'  System  of  Surgery  ,  .  .21 

Horner's  Anatomy  and  Histology  .  .         6 

Hudson  on  Fever  .  ...       15 

Hutchinson  on  Syphilis  .  .  ,25,31 

Hyde  on  the  Diseases  of  the  Skin    .  .  .26 

Jackson  on  the  Skin    ...  .26 


Jamieson  on  the  Skin  ....       26 

Jones  (C.  Handfleld)  on  Nervous  Disorders      ,       19 
Juler's  Ophthalmic  Science  and  Practice  ,      23 

King's  Manual  of  Obstetrics  .  .  .  .29 

Klein's  Histology  ,  .  .17, 30 

Landis  on  Labor  .  ...       30 

La  Roche  on  Pneumonia,  Malaria,  etc.    .  .       16 

La  Roche  on  Yellow  Fever    ....       15 

Laurence  and  Moon's  Ophthalmic  Surgery        .       23 
Lawson  on  the  Eye,  Orbit  and  Eyelid       .'         .       23 
Lea's  Chapters  from  Religious  History  of  Spain      31 
Lea's  Sacerdotal  Celibacy       .  .  .  .31 

Lea's  Studies  In  Church  History      .  .  .31 

Lea's  Superstition  and  Force  .  -  31 

Lee  on  Syphilis    .  .  ...       25 

Lehmann's  Chemical  Physiology    ...         7 
Leishman's  Midwifery  ....       30 

Lucas  on  Diseases  of  the  Urethra  .  .  .24,30 

Ludlow's  Manual  of  Examinations  .  .         3 

Lyman's  Practice  of  Medicine        .  .  .15 

Lyons  on  Fever  ......       15 

Maisch's  Organic  Materia  Medica  .  .  .11 

Marsh  on  the  Joints  .  .  .22,31 

May  on  Diseases  of  Women   .  .  .  .28 

Medical  News      ......        1 

Medical  News  Visiting  List  ....         3 

Medical  News  Physicians'  Ledger  ...         3 
Meigs  on  Childbed  Fever        .  .  .  .30 

Miller's  Practice  of  Surgery   ....       20 

Miller's  Principles  of  Surgery  .  .  20 

Morris  on  Diseases  of  the  Kidney  .  .  .  24, 31 

Musser's  Medical  Diagnosis  .  .  .  .15 

National  Dispensatory  .  .  .       11 

National  Medical  Dictionary  ...         4 

Nettleship  on  Diseases  of  the  Eye  .  .  .23 

Norrls  and  Oliver  on  the  Eye  .  .  .23 

Owen  on  Diseases  of  Children         .  .  .30, 31 

Parrlsh's  Practical  Pharmacy  .  .  .10 

Parry  on  Extra-Uterine  Pregnancy  .  .       29 

Parvin's  Midwifery       .  ....       29 

Pavy  on  Digestion  and  its  Disorders         .  .       16 

Payne's  General  Pathology    ....       18 

Pepper's  System  of  Medicine  .  .  .       14 

Pepper's  Forensic  Medicine  .  .  .  .  30, 31 

Pepper's  Surgical  Pathology  .  .  .  17, 30 

Pick  on  Fractures  and  Dislocations  .  .  22, 31 

Pirrie's  System  of  Surgery    .  ...       20 

Playfair  on  Nerve  Prostration  and  Hysteria     .       19 
Playfair's  Midwifery     .....       29 

Power's  Human  Physiology  .  .  .  .7.30 

Purdy  on  Bright's  Disease  and  Allied  A  flections      24 
Pye-Smlth  on  the  Skin  .  .  .  .26 

Ralfe's  Clinical  Chemistry  .  .  .  10, 30 

Ramsbotham  on  Parturition  .  .  .       30 

Bemsen's  Theoretical  Chemistry    .  .  .10 

Reynolds'  System  of  Medicine         .  .  .13 

Richardson's  Preventive  Medicine  .  .       16 

Roberts  on  Diet  and  Digestion        .  .  .24 

Roberts  on  Urinary  Diseases  .  .  .24 

Roberts'  Compend  of  Anatomy     ...         7 
Roberts'  Surgery  .  ...       20 

Robertson's  Physiological  Physics  .  .7,30 

Ross  on  Nervous  Diseases      ....       19 

Savage  on  Insanity,  including  Hysteria  .  .  19,31 

Schafer's  Essentials  of  Histology,  .  .       17 

Schrelber  on  Massage   .  ...       16 

Seller  on  the  Throat,  Nose  and  Naso-Pharynx        17 
Senn's  Surgical  Bacteriology  .  .  .       18 

Series  of  Clinical  Manuals      ....       30 

Simon's  Manual  of  Chemistry         ...         8 
Slade  on  Diphtheria      .  ....       16 

Smith  (Edward)  on  Consumption   .  .  .16 

Smith  (J.  Lewis)  on  Children  ...       30 

Smith's  Operative  Surgery  .  .  .22 

Stille  on  Cholera  .  ...       13 

Stills  &  Maisch's  National  Dispensatory  .       11 

StlllS's  Therapeutics  and  Materia  Medica  .       11 

Stimson  on  Fractures  and  Dislocations  .       22 

Stimson's  Operative  Surgery  .  .  "       P 

Students'  Series  of  Manuals  .  .  •  .30 

Sturges'  Clinical  Medicine     .  .  .  .16 

Sutton  on  the  Ovaries  and  Fallopian  Tubes     .       28 
Tait's  Diseases  of  Women  and  Abdom.  Surgery      28 
Tanner  on  Signs  and  Diseases  of  Pregnancy     .       30 
Tanner's  Manual  of  Clinical  Medicine     .  .       15 

Taylor's  Atlas  of  Venereal  and  Skin  Diseases         26 
Taylor  on  Venereal  Diseases  .  .  .       25 

Taylor  on  Poisons  .  ...  .31 

Tavlor's  Medical  Jurisprudence      .  .  .31 

Thomas  &  Munde  on  Diseases  of  Women  .       28 

Thompson  on  Stricture  .  ...       24 

Thompson  on  Urinary  Organs         .  .  .24 

Todd  on  Acute  Diseases  .  ...       16 

Treves'  Operative  Surgery    ...  21 

Treves' Manual  of  Surgery    .  .  .  .21,30 

Treves' Surgical  Applied  Anatomy  .  .6,30 

Treves  on  Intestinal  Obstruction    .  .  .  21 ,  31 

Tuke  on  the  Influence  of  Mind  on  the  Body      .       19 
Vaughan  &  Novy's  Ptomaines  and  Leucomaines    10 
Visiting  List,  The  Medical  News    ...        3 
Walshe  on  the  Heart    .  .  .  .  .16 

Watson's  Practice  of  Physic  ....       13 

Wells  on  the  Eye  .  .  .  .23 

West  on  Diseases  of  Women  .  .  .27 

West  on  Nervous  Disorders  in  Childhood  .       30 

Wharton's  Minor  Surgery  and  Bandaging         .       21 
Whitla's  Dictionary  of  Treatment  .  .       15 

Williams  on  Consumption     ....       16 

Wilson's  Handbook  of  Cutaneous  Medicine       .       26 
Wilson's  Human  Anatomy   ....         6 

Winckel  ou  Pathol,  and  Treatment  of  Childbed       29 

Wohler's  Organic  Chemistry  ...         7 

i  Woodhead's  Practical  Pathology    .  .  .17 

I  Year-Books  of  Treatment  for  86,  '87,  '90,  '91,  '92.       16 

Yeo  on  Food  In  Health  and  Disease  .  .  16,30 

1  Young's  Orthopaedic  Surgery  .  .  .20 


